HERNIAS .(A) .(B) 5. .(A) 7..( (Lumbar hernia),

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HERNIAS ysms91@wonju.yonsei.ac.kr 1..(B) 2..(B) 3..(A) 4. (Hesselbach's striangle).(b) 5.,.(A) 6. (Sliding hernia).(a) 7..( (Lumbar hernia), (Obturator hernia), (Sciatica hernia)).

Inguinal Canal - between the internal (deep inguinal) ring and the external (superficial inguinal) ring opening <anterior> contains either the spermatic cord or the round ligament of

1 HERNIAS 1..(B) 2..(B) 3..(A) 4. (Hesselbach's striangle).(b) 5.,.(A) 6. (Sliding hernia).(a) 7..( (Lumbar hernia), (Obturator hernia), (Sciatica hernia)).(b) Hernia = rupture of a portion of a structure A hernia is the abnormal protrusion of a peritoneal-lined sac through the musculoaponeurotic covering of the abdomen. Inguinal Canal - between the internal (deep inguinal) ring and the external (superficial inguinal) ring opening <anterior> contains either the spermatic cord or the round ligament of the uterus external oblique aponeurosis internal oblique muscle, transversus abdominis muscle Spermatic cord inguinal ligament, lacunar ligament transversalis fascia, transversus abdominis muscle <posterior>

2 Hesselbach's triangle - inferior epigastric vessels, rectus sheath, inguinal ligament External Oblique Aponeurosis, inguinal ligament = superficial border of the inguinal canal Internal Oblique Muscle, conjoin tendon = cephalad (or superior) border of the inguinal canal Transversalis Fascia, downward continuation of the transversalis muscle Iliopubic Tract, important structure in the repair of femoral hernias Cooper's Ligament, McVay's repair, laparoscopic hernia repair / Symptoms Physical examination bulge in the inguinal region. minor pain or vague discomfort associated with the groin bulge. parethesias related to irritation or compression of inguinal nerves by the hernia Extreme pain is unusual related with incarceration and intestinal vascular compromise Visual inspection of the groin - a loss of symmetry in the inguinal area or a discrete bulge. Valsalva's maneuver or cough accentuate the bulge Fingertips on the abdominal wall Bulging from lateral wall indirect inguinal over the inguinal region + repeat Bulging from deep portion direct inguinal Valsalva's maneuver Bulging below the inguinal ligament femoral hernia Incarcerated hernia Gentle pressure on the hernial mass under the Trendelenburg's position + analgesic agents Gangrenous bowel Rarely be reduced by manual reduction Patients should be followed for the development of peritoneal signs Reduction en masse Reduction of the entire hernia sac with the intestine remaining incarcerated within the sac Failure of manual reduction of Immediate operation incarcerated hernia

3 Approximately 75% of all hernias occur in the inguinal region. Approximately 50% of hernias are indirect inguinal hernias, and 24% are direct inguinal hernias. Incisional and ventral hernias account for approximately 10% of all hernias, Femoral hernias for 3%; Unusual hernias account for the remaining 5% to 10%. The vast majority of hernias occur in males =25% of males and only 2% of females will develop inguinal hernias in their lifetimes The most common hernia in males and females is the indirect inguinal hernia. Femoral hernias occur much more frequently in females than in males.. Hernias occur more commonly on the right side than the left. (1) congenital origins = The lack of obliteration of the processus vaginalis = in indirect hernia Risk factors : Prematurity and low birth weight, Congenital abnormalities such as pelvic deformities or exstrophy of the urinary bladder (2) acquired origins = wear-and-tear stresses = in direct hernia Risk factors : Straining to urinate or defecate, coughing, and heavy lifting, Smoking ( ) I know more than a hundred surgeons whom I would cheerfully allow to remove my gallbladder but only one to whom I should like to expose my inguinal canal. (Sir Henage Ogilvie) Natural course : Hernias do not resolve spontaneously or improve with time. Wearing a truss does not cure a hernia. Repair of a groin hernia can be planned electively unless incarceration or strangulation is present. Principles : High ligation of hernia sac + Posterior wall enforcement(reconstruction) Operation type = The options for reconstruction of the inguinal floor

hernias, recurrent hernias of the groin, and femoral hernias The conjoined tendon is sutured to Cooper's ligament from the pubic

4 Bassini Repair : The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal (Poupart's) ligament McVay (Cooper's Ligament) Repair : popular repair for the correction of large inguinal hernias, direct inguinal hernias, recurrent hernias of the groin, and femoral hernias The conjoined tendon is sutured to Cooper's ligament from the pubic tubercle laterally to the femoral canal Classic Halsted-Ferguson operation: transplanted the spermatic cord external to the external oblique fascial closure.

Shouldice (Canadian) Repair: multilayer, imbricated repair of the floor of the inguinal canal with running sutures, very low recurrence rates Lichtenstein (Tension-Free) Repair: tension-free

Excellent results have been achieved by those adopting Lichtenstein's technique.

5 Shouldice (Canadian) Repair: multilayer, imbricated repair of the floor of the inguinal canal with running sutures, very low recurrence rates Lichtenstein (Tension-Free) Repair: tension-free hernioplasty performed with mesh reinforcement of the inguinal floor significantly decreases the recurrence rate. Performed in an outpatient setting with local anesthesia. Excellent results have been achieved by those adopting Lichtenstein's technique. Laparoscopic Hernia Repair : highly controversial Method: transabdominal preperitoneal (TAPP) repair / totally extraperitoneal approach (TEPA). Definitive outcome and cost-effectiveness studies are not available in sufficient quantity to determine the long-term role of laparoscopic hernia repair. ( FEMORAL HERNIAS) A femoral hernia produces a mass below the inguinal ligament. Femoral hernias are more common in females than males A femoral hernia occurs through a space bounded superiorly by the iliopubic tract, inferiorly by Cooper's ligament, laterally by the femoral vein, and medially by the insertion of the iliopubic tract into Cooper's ligament.( 2 ) A femoral hernia can be repaired using a standard Cooper's ligament (McVay) repair. Viability of the intestine must be ensured when incarceration is detected at the time of hernia repair.

(UMBILICAL HERNIAS) (1) Congenital form - common in infant Surgical indication: The umbilical defect closes spontaneously by the age of 2 years in the vast majority of patients.

6 (UMBILICAL HERNIAS) (1) Congenital form - common in infant Surgical indication: The umbilical defect closes spontaneously by the age of 2 years in the vast majority of patients. Umbilical hernias that persist after the age of 5 years are frequently repaired surgically (2) Acquired form - during adulthood, risk factor : Pregnancy, ascites, or acute abdominal distention (e.g., intestinal obstruction) Incarceration and strangulation are unusual but rupture can occur. Treatment : Umbilical hernias can be repaired in a pants over vest manner or a simple transverse closure. Recurrence of umbilical hernias is extremely uncommon. (VENTRAL (INCISIONAL) HERNIA) Cause : inadequate healing of a previous incision or excessive strain at the site of an abdominal wall scar. Risk factors : The most common causative factor in the development of incisional hernias is postoperative wound infection > Postoperative pulmonary complications. Obesity, advanced age, malnutrition, ascites, postoperative hematoma, peritoneal dialysis, pregnancy Treatment : Primary repair of an incisional hernia with simple interrupted or mattress sutures. However, it is much more common to encounter an incisional hernia that requires prosthetic materials. SLIDING HERNIA A sliding inguinal hernia is defined as one in which a viscus forms a portion of the wall of the hernia sac. Common involved viscus : bowel(cecum, sigmoid colon) or urinary bladder. The primary danger associated with a sliding hernia is the failure to detect due to visceral component.

7 UNUSUAL HERNIAS (1) Epigastric Hernia Hernias of the linea alba occur more commonly above the umbilicus than below. These hernias are usually small. Patients complain of a painful, pulling sensation at the midline upon reclining. These hernias can usually be repaired with simple suture closure. (2) Richter's Hernia For a hernia to be considered a Richter hernia, the antimesenteric border of the intestine must protrude into the hernia sac, but never to the point of involvement of the entire circumference of the intestine. The most common location is at the site of a femoral hernia. Critical to the repair of a Richter hernia is an adequate evaluation of the intestine for viability. (3) Littre's Hernia ; rare The presence of a Meckel diverticulum as the sole component of the hernia sac defines a Littre hernia. (4) Spigelian Hernia A hernia through the fascia along the lateral edge of the rectus muscle at the space between the semilunar line and the lateral edge of the rectus muscle is a spigelian hernia. Most commonly, spigelian hernias occur inferior to the semicircular line of Douglas.

(5) Obturator Hernia The patient may present with evidence of compression of the obturator nerve, resulting in pain in the medial aspect of the thigh.

8 (5) Obturator Hernia The patient may present with evidence of compression of the obturator nerve, resulting in pain in the medial aspect of the thigh. (6) Lumbar (Dorsal) Hernia Hernia through the posterior abdominal wall. Grynfeltt's hernia appears through the superior lumbar triangle, Petit's hernia occurs through the inferior lumbar triangle. Cause : Iatrogenic after flank incisions for kidney operations. Simple suture repair of small hernias or mesh reinforcement, pedicle flaps, or free flaps. (7) Sciatic Hernia Extremely unusual hernias Symptom free until intestinal obstruction occurs. These hernias can be surgically repaired transabdominally or through a transgluteal approach. (8) Perineal Hernia very uncommon. occur following abdominoperineal resection, prostatectomy, or removal of the pelvic organs. A myocutaneous flap or mesh reinforcement is frequently required to repair a perineal hernia.

9 Complication rate In adult patients, complication rates from open inguinal herniorrhaphy vary from 1% to 26%, with most reports ranging from 7% to 12%. Intraoperative complications include injury or transection of spermatic cord structures, vascular injury producing hemorrhage, severance or entrapment of nerves, visceral (usually bowel or bladder) injury, and systemic complications such as cardiac arrest or death Postoperative wound complications include infection, hematoma, ecchymosis, seroma. Complications related to the scrotum and testicles include hematoma, atrophy, sterility, swelling, ecchymosis, hydrocele. Genitourinary postoperative complications include urinary retention and urinary tract infection. Nerve injuries are a well-documented complication of inguinal hernia repair. The nerves most commonly affected during an open herniorrhaphy are the ilioinguinal and iliohypogastric nerves. Sx: Cutaneous numbness, Persistent neuralgias Recurrece Reported recurrence rates vary from less than 1% to 7% for indirect inguinal hernias, from 4% to 10% for direct inguinal hernias, from 1% to 7% for femoral hernias, and from 5% to 35% for recurrent hernia repair. Recurrence may result from technical failure, inadequate fascial strength, impaired wound healing, trauma, progressive weakening of surrounding tissues, or tissue approximated under excessive tension.

Inguinal Hernia. Dr. Budi Irwan, SpB-KBD. Department of Surgery Faculty of Medicine University of North Sumatera Adam Malik National Hospital

Inguinal Hernia. Dr. Budi Irwan, SpB-KBD. Department of Surgery Faculty of Medicine University of North Sumatera Adam Malik National Hospital Inguinal Hernia Dr. Budi Irwan, SpB-KBD Division of Digestive Surgery Department of Surgery Faculty of Medicine University of North Sumatera Adam Malik National Hospital Definition Abnormal protrusion