Lecture Contents Definitions Managment of Hernia Composition of Hernia Hernia Etiology Signs and Symptoms Types Classification of Abdominal Hernia External Internal Common - inguinal - Femoral - Umbilical - incisional Rare - Spigelian - Gluteal - Obturator - lumbar - Diaphragmatic hernia - Esophogial hernia - Paraesophogial hernia 1
Definitions - A hernia is the protrusion of an organ through a defect in its containing wall. - The term can be applied to the herniation of: muscle through its fascial covering / brain through fracture of skull or through foramen magnum into the spinal cord / intra-abdominal organ through a defect in the abdominal wall, pelvis or diaphragm. - Before an organ can herniate through its retaining wall there must be a weakness in that wall. This weakness may be: Normal weakness; found in everyone and related to the anatomical configuration of the area such a place where vessel or viscus enters or leaves the abdomen / where there are no muscles, only scar tissue (e.g. umbilicus) / muscles fail to overlap Abnormal weakness; congenital or acquired as a result of trauma or disease. - We are only going to talk about Abdominal Hernias in this lecture. Composition of a Hernia 1. The sac 2. The covering of the sac 3. The content of the sac 2
1. The sac : It is a diverticulum of peritoneum and is made up of three parts : The mouth, The neck and The body of the sac. 2. The covering: Coverings are derived from the layers of abdominal wall through which the sac pass 3. Contents: can be Omentum = omentocle Intestine = enterocele Portion of circumference of intestine = Richter s hernia Portion of the bladder Ovary(with or without oviduct) Meckel s diverteculum =Littre s hernia 3
Etiology Any condition that raises intra-abdominal pressure, such as a powerful muscular effort, may produce a hernia. 1. Whooping cough is a predisposing cause in childhood 2. Chronic cough, straining on micturition or straining on defecation, heavy lifting may precipitate a hernia in an adult. 3. Smoking and aging, leading to acquired collagen deficiency. 4. intra-abdominal malignancy, ascites 5. Obesity 6. Multiparity, for femoral hernias 7. Congenital defect, as indirect inguinal hernia (processus vaginalis) Types of Hernias (variations) Reducible contents can be returned to abdomen Irreducible contents cannot be returned but there are no other complications Obstructed bowel in the hernia has good blood supply but bowel is obstructed Strangulated blood supply of bowel is obstructed Inflamed contents of sac have become inflamed Incarcerated * Reducible Vs Irreducible: - Reducible This is the one which the contents of the sac reduced spontaneously or can be pushed back manually. A reducible hernia imparts an expansile impulse on coughing. 4
- Irreducible This one whose contents cannot be returned to the peritoneal cavity either because there are: 1. adhesions between the sac and contents, or 2. Because of the narrow neck of the sac. 3. Overcrowding within the sac * Irreducible hernia can be: 1. Incarcerated: there are adhesions between the sac and the contents, but there is no obstruction or interference with blood supply. the hernia simply will not reduce 2. Obstructed: a hollow viscus is trapped within the sac and obstruction occurs. The blood supply remains intact. This is a common cause of small bowel obstruction. 3. Strangulated :the arterial blood supply to the contents of the sac is compromised, in such a hernia unless surgical relief is undertaken the contents of the sac will become gangrenous. Present with local then general abdominal pain and vomiting. ( tense + tender + no impulse on coughing) 5
Classification Abdominal Hernias External Internal Common - inguinal - Femoral - Umbilical - incisional Rare - Spigelian - Gluteal - Obturator - lumbar - Diaphragmatic hernia - Esophogial hernia - Paraesophogial hernia Common Hernias Rare Hernias 6
Signs and Symptoms - A lump disappears, reappears, and enlarges on straining and discomfort. - Physical Signs: Reduced. + ve cough impulse, in inspection and palpation - Investigation: Hernia is diagnosed clinically. Investigations are rarely indicated or valuable. The Basic Features of all Hernias: 1. They occur at a weak spot 2. They reduce on lying down or with direct pressure 3. They have an expansile cough impulse. BROWSE Management - Hernias should be operatively repaired both to relieve symptoms and to eliminate the complications. - Surgical techniques: 1. Herniotomy: removal of sac and closure of its neck. 2. Herniorrhaphy: involves some sort of reconstruction to: - Restore the anatomy if this is disturbed. - Increase the strength of the abdominal wall. - Construct a barrier to recurrence. Next we will list the Hernias in more details 7
Inguinal Hernia - An inguinal hernia is the protrusion of part of the contents of the abdomen through the inguinal region of the abdominal wall. To understand the inguinal hernia it's necessary to understand the anatomy of the inguinal canal. * Anatomy of the Inguinal Canal: - The inguinal canal is an oblique passage through the layers of the lower abdominal wall that transmits the spermatic cord in the male and the round ligament in the female. - The inguinal canal has 2 openings that communicates with each other; the internal and external rings. - The internal inguinal ring is an opening in the transversalis fascia lateral to the inferior epigastric vessels. - The external inguinal ring is an opening in the external oblique aponeurosis. - Walls of the inguinal canal: 1. Anterior wall : Aponeurosis of external oblique (along entire length ( + internal oblique on lateral one third 2. Posterior: Fascia transversalis + conjoint tendon on in medial one third 3. Roof: Arching lowest fibers of internal oblique + transversus abdominis 4. Floor (inferior(: Inguinal ligament+ lacunar ligament at the medial end ** For the best understanding if the inguinal region anatomy, watch this amazing video: http://www.youtube.com/watch?v=jt8-djyh0xi 8
- Inguinal Canal Contents: - Males: the spermatic cord and its coverings + the ilioinguinal nerve - Females: the round ligament of the uterus + the ilioinguinal nerve - Contents of spermatic cord in males: (the Rule of 3) - 3 Arteries: artery to vas deferens (or ductus deferens), testicular artery, cremasteric artery. - 3 Fascial layers: external spermatic, cremasteric, and internal spermatic fascia. - 3 Nerves: genital branch of the genitofemoral nerve (L1/2), sympathetic and visceral afferent fibers, ilioinguinal nerve (it's OUTSIDE spermatic cord but travels next to it). - 3 Other Structures: pampiniform plexus, vas deferens (ductus deferens), testicular lymphatics. * Epidemiology of Inguinal Hernia: - Male: Female by 9 to 1 ratio - Young adults mostly have indirect inguinal hernia. - As age of patient increases, the incidence of direct hernias increases. * Types of inguinal hernia: - Direct inguinal hernia - Indirect inguinal hernia Indirect inguinal hernias are the most common type of hernia in both men and women. They are 5 to 10 times more common in men than in women. 9
* Differences between Direct and Indirect hernias: 1. Origin and coarse: 2. Content: Direct: Develops in the area of Hasselbach's triangle. The origin is medially to the inferior epigastric vessels. Indirect: Develops at the internal ring. The origin is lateral to the inferior epigastric artery. Direct: Retroperitoneal fat. Less commonly, peritoneal sac containing bowel. Indirect: Sac of peritoneum coming through internal ring, through which omentum or bowel can enter. 3. Etiology: Direct: weakness of the posterior floor of the inguinal canal (acquired). Indirect: patent processus vaginalis (Congenital). * Hasselbach's triangle: - A triangular region in the lower aspect of the anterior abdominal wall, it's described as the area where a direct inguinal hernia will extrude from posterior to anterior. 11
- Boundaries of Hasselbach's triangle: Medially: lateral border of rectus abdominis. Laterally: inferior epigastric vessels. Inferiorly: inguinal ligament. * Signs & symptoms: - Bulge that enlarges when stand or strain, but often asymptomatic. - In general direct hernias produce fewer symptoms than indirect hernias and are less likely to complicate. - On examination: - Palpable defect or swelling may be present. - Indirect Hernia usually bulge at Internal Inguinal Ring. -Direct Hernia usually bulge at External Inguinal Ring. * Diagnosis - History - The patient usually presents (for groin hernia) with the complaint of a bulge in the inguinal region - They may describe minor pain or vague discomfort associated with the bulge - Extreme pain usually represents incarceration with intestinal vascular compromise - Paresthesia may be present if inguinal nerves are compressed - Physical exam - The patient should be standing and facing the examiner - Visual inspection may reveal a loss of symmetry in the inguinal area or bulge - Having the patient perform valsalva s maneuver or cough may accentuate the bulge - A fingertip is then placed in the inguinal canal; Valsalva maneuver is repeated 11
- Differentiation between indirect and direct hernias at the time of examination is not essential. - Incarcerated hernias sometimes can be reduced manually - Gentle continuous pressure on the hernial mass towards the inguinal ring is generally effective (Trendelenburg) * Differential diagnosis: 1. Tendonitis 2. Muscle tear 3. Lymphadenopathy 4. Lipoma 5. Varicose vein 6. Hydrocele 7. Epididymitis 8. Spermatocele 9. Lymphadenopathy * Complications: 1. Irreducibility, but without signs of obstruction or strangulation 2. Small Bowel Obstruction, Usually urgent surgical repair 3. Strangulation, Surgical emergency 50% indirect, 3-10% direct. * Pantaloon hernia: - Both types (direct and indirect inguinal hernia) may occur at the same time and straddle the inferior epigastric artery this is called Pantaloon hernia - The hernia sac passes both medially and laterally to the epigastric vessels 12
* Management: - Inguinal hernias should always be repaired (herniotomy, herniorrhaphy) unless there are specific contraindications. - The basic operation is inguinal herniotomy, which entails dissecting out and opening the hernia sac, reducing any contents and then transfixing the neck of the sac and removing the remainder. It is employed either by itself or as the first step in a repair procedure (herniorrhaphy) - If the patient presented with irreducible hernia: We give the patient analgesics and try to reduce it, and the direction of reduction is important (in alignment with the direction of inguinal canal, you have to pull down and press gently from distal to proximal), most of cases should be reduced but rarely it's irreducible. - Treatment of aggravating factors (chronic cough, prostatic obstruction, etc.) - Use of truss (appliance to prevent hernia from protruding) when a patient refuses operative repair or when there are absolute contraindications to operation - Laparoscopic Hernia Repair: Early attempts resulted in exceptionally high reoccurrence rates. ** Inguinal Hernia in Children ** * Embryological Review: The testicle will be formed in the posterior abdominal wall and start to descend, and the testicle completes its journey in 32 weeks of pregnancy, the testicle is a retroperitoneal organ and starts to go down, the blood supply will be took from that level which is the aorta and the inferior vena cava at the right side and the renal vein at the left side. The vas deferens also will be formed initially directed upward then reflected downward after the descent of the testis. So the testicle is formed behind the peritoneum, then goes through the abdominal cavity ( the peritoneum ), it will take part of the peritoneum attached to it ( peritoneum to peritoneum will not adhere ( skin to skin will not adhere ) while a raw surface to a raw surface it will adhere ), the raw surface of the testicle behind the peritoneum, and the peritoneum from behind is a raw surface, so those will attach to each other. Now the anterior surface of the posterior peritoneum is like a skin ( it will not get an adhesion ), so the testicle will sit down in the peritoneal cavity surrounded by the peritoneum, now this peritoneum is called visceral peritoneum and the Processus Vaginalis will be formed. 13
Now the testicle, the testicular artery and vein and the vas deferens are inside the abdominal cavity surrounded by the visceral peritoneum. During the descent, the testicle will reach the deep inguinal ring, the guide of the descent is called The Gubernaculum. When the testicle reaches the deep inguinal ring it will start to go through it, now there will be another layer of peritoneum which is the parietal peritoneum. So the peritoneum is faced to the peritoneum, which is skin to skin, there will be no adhesion, and this is why the testicle will go to the scrotum after the connection to the muscles, the muscles will make it mobile, and the loss of adhesion between the two layers of the peritoneum and the presence of the fluid from the peritoneum will make the area in gliding surface, the testicle will go down with the vessels and with the vas deferens, the vessels will elongate because the tract of the vessels came from above. Fouriner's gangrene : In immunocompromised elderly patients there is a disease called Fouriner's gangrene or necrotizing fasciitis, in this disease all the structures will be affected except the testes because the testes have their own blood supply. Wiki The gubernaculums (Caudal Genital Ligament) : are embryonic structures which begin as undifferentiated mesenchyme attaching to the caudal end of the gonads (testes in males and ovaries in females). As the scrotum and labia majora form in males and females, respectively, the gubernaculum aids in the descent of the gonads (both testes and ovaries). Wiki During the passage of the testicle through the internal ring it will take another layer of peritoneum with it, so two layers of peritoneum in front of each other surrounding the testicle with its vessels and the vas deferens. Note: During the descent of the testis the vessels will elongate, but the vas deferens will descend down with no elongation and that's why in the undescended testis we have long vas deferens and short vessels, because the vessels should elongate through the journey from above till below, while the vas deferens is long already at the first place, and there is no elongation of it. After the testicle passes the parietal peritoneum, it will take another layer from the first (internal) layer of the abdominal wall, which is transversalis fascia. So it will take a fascia from the transversalis fascia with it, this fascia is called internal spermatic fascia. 14
In front of the transversalis fascia is the internal oblique muscle. the testicle passes through the internal oblique muscle and will take with it muscles (not fascia), and this muscle is called now cremasteric muscle, and there is something called the cremasteric reflex. In front of the internal oblique muscle there is the external oblique fascia, so another fascia will be taken down during the descent of the testicle which is the external spermatic fascia. Note: The direction of internal oblique muscle is from down to above, this means that below is the bulk of muscle while above is the bulk of fascia. In the contrary the external oblique is directed in the opposite way, this means above is the bulk of muscle while below is the bulk of fascia, and condensation of the fascia of external oblique muscle will form the inguinal ligament. The cremasteric reflex: The cremasteric reflex is a superficial (i.e., close to the skin's surface) reflex observed in human males. This reflex is elicited by lightly stroking the superior and medial (inner) part of the thigh regardless of the direction of stroke.[1] The normal response is an immediate contraction of the cremaster muscle that pulls up the testis on the side stroked (and only on that side ) 15
We mentioned that peritoneum to peritoneum there will be no adhesion, this means that in the center of the spermatic cord there is a connection between the testicle and the peritoneal cavity, this connection should be obliterated, if the connection stays patent, then there is a patency of processus vaginalis. * Sequel of the patency of Processus Vaginalis: If the processus vaginalis stays patent that means a connection between the peritoneal cavity and the surroundings of the testicle, this will lead to: - Indirect inguinal hernia. - Communicating hydrocele if the content is fluid: but why the hydrocele will form and make a tense structure around the testicle? Why is it collecting around the testicle? Why not to empty in the peritoneal cavity? Simply because of the position and dependency. the accommodation of fluid down, then the pressure will be created and the tortuous passage of the descent from right to left then to the right, this will create a valve mechanism and this valve mechanism will hold the fluid down in the scrotum which is presented as communicating hydrocele, this hyrdrocele may get enlarged and then resorped. - Non-communicating hydrocele: if the processus vaginalis is obliterated proximally, and down till the level of testicle it's opened. - Encysted hydrocele: if the processus vaginalis is be obliterated proximally, obliterated distally, and contains a membrane which secretes fluid in between. 16
- The direction of the indirect inguinal hernia is towards the scrotum, why toward the scrotum? because it's inside the spermatic cord, and the cord is going toward the scrotum.all the tract (prossesus vaginalis) is patent, the internal ring is the site of the entrance, this means it's lateral to inferior epigastric vessels, so the hernial sac is located lateral to the inferior epigastric vessels. If it's direct that means it's not respecting the door and goes directly through the posterior inguinal wall to the inguinal canal, which is medial to the inferior epigastric vessels, the direct inguinal hernia is outside the cord, while the indirect inguinal hernia is inside the cord. * How could we treat these presentations? Treatment in the pediatric age group is by Herniotomy : Simply by creation of an adhesion at the level of the peritoneum by an operation called herniotomy. To open the hernia and ligate the peritoneum, while disconnection of the visceral and parietal layers of the peritoneum at the processus vaginalis, we slip the peritoneum out, now we are creating a raw surface to a raw surface, then there will be an adhesion, so closure, and the hernial openings will slide over each other in the future. ** Not like in elderly which is mostly direct inguinal hernia, which is due a defect in the fascia, defect in the posterior wall, and the treatment is by Reconstruction, how? by a mesh. it's like iron in the concrete, "the concrete" are the fibers of the body and "the iron" is the mesh, and the end result is a hard structure. * Incidence of the Indirect Inguinal Hernia : - The incidence is high about 1-5% in general pediatric population. - The right testicle descends later than the left testicle, and that's why the right side is affected more than the left. 17
- In premature infants the incidence is higher reaching 30%, the incidence is ten folds than the mature infants ( The Dr said ). The descent is in around 32 weeks of pregnancy, if the patient is premature, this means that the descent is recent if descended, or it will descend while the infant is outside the uterus. Inside the uterus there is no pressure on the peritoneal cavity, while outside the uterus there is pressure due to crying, then patency will be more and loss of obliteration will be more, so the incidence will be more, so prematurity will make more visible bilateral inguinal hernia, and right is more than the left. * Certain conditions come with higher incidence of inguinal hernia (Associated diseases): 1- Cystic fibrosis (15% incidence) : means more constipation, more straining, more hernia. 2- Connective tissue disease : loss of obliteration and lax of the tissue. 3- Mucopolysaccharidosis. 4- Children receiving chronic peritoneal dialysis: means fluids inside the peritoneal cavity, so pressure inside the peritoneal cavity. 5- Children with Ventriculo-Peritoneal shunts. * Direct inguinal hernia in pediatric age group is very rare, we only notice these cases in elderly with bronchial asthma, coughing, straining, constipation etc. * One third of children with direct hernias have operations for indirect hernias. * Clinical presentation of indirect inguinal hernia in children: - Usually the mother will come to you saying that I noticed my child while I'm changing the diapers of him that the child has a groin bulge, a small bulge that appears and disappears. - In females the bulge could be a herniated ovary, herniation of ovary will make a prolongation of the meso-ovarium through a narrow inguinal ring, and this will make the ovary more prone to torsion. in females almost all of the cases are ovarian!. - In male the hernial sac usually contains small bowel. - In 30% of patients there will be a complication of inguinal hernia within the first year of life, and that s why we should operate inguinal hernia immediately after diagnosis. - Irreducibility will present in about 12-17% of the patients, 30% of infants less than three months of age will present with irreducibility, 2/3 of cases occur in the first year of life. 18
- Clinical presentation if the hernia become obstructed: Pain, tense swelling, vomiting. Important Note : Time is important, if the irreducibility is relapsed after 6 hours we should think about the complication(perforation, ischemia,..), if you noticed any inflammatory reaction or peritonitis or collection of serosanguineous blood or any manifestations of perforation or ischemia, don t reduce the content, because you are shifting toxic materials from a will localized area to the peritoneal cavity which has the capacity of absorption, and the patient will enter in toxicity, and the treatment will be change - SO, if it's irreducible just give analgesia and rehydrate the patient and try to reduce it, if it's not reduced, take the patient directly to the theater and after sedation the hernia will be reduced(because the patient is paralyzed and you can reduce it simply), but if the time is elapsed, don t try to reduce it, just open and look, if the bowel is viable reduce it, and if the bowl not viable catch it and take out the fluids which are toxic and wash them out. 19
Femoral Hernia - A femoral hernia is the protrusion of extra peritoneal fat / a peritoneal sac / abdominal contents through the femoral canal. - Femoral canal: Is an anatomical compartment, located in the anterior thigh. It is the smallest and most medial part of the femoral sheath. It is approximately 1.3cm long. - It provides a space through which the femoral vein can expand. - The femoral canal contains efferent lymphatic vessels and a lymph node embedded in a small amount of areolar tissue; so it's considered as a weakness point through which abdominal contents can herniate. * Femoral Canal Anatomy: (Boundaries) Ant. inguinal ligament Post. Pubic ramus + pectineus muscle Med. Lacunar ligament + pubic bone Lat. Femoral vein - As you can notice, the femoral canal has a bone or ligament on three sides and a major blood vessel on the fourth so the femoral canal cannot be distended easily (clinical significant) so a peritoneal sac coming through the canal is therefore has a stiff, narrow neck and any content are at risk of strangulation. - The defect is in the transversalis fascia overlying the femoral ring at the entry to the femoral canal. - The hernia passes through the femoral canal and presents in the groin, below and lateral to the pubic tubercle. - It is more common in females and carries a higher risk of strangulation (as we mentioned before). 21
* Signs & symptoms - A lump occurs below and lateral to the pubic tubercle. It may be reducible. - It may not be noticed until it becomes tender and painful. - This type of hernia should be carefully sought in the obese patient who presents with signs of intestinal obstruction without an obvious cause. * DDx: 1. Inguinal Hernia 2. Enlarged inguinal LN 3. Femoral artery aneurysm 4. Saphena varix 5. Ectopic Testis 6. Psoas Abscess/bursa 7. Lipoma * Femoral hernia is able to strangle part of the wall of the bowel without occluding the lumen and causing intestinal obstruction this is called Richter's Hernia (picture below) Part of the wall of the intestine becomes trapped in the defect. This is usually the antimesenteric border of the small bowel. The lumen is intact ( No obstruction ) 21
Umbilical Hernia All hernias which appear to be closely related to the umbilicus may be called umbilical hernia. They may be congenital or acquired. All congenital umbilical hernia come through the umbilical defect itself (umbilical scar). In adults, most umbilical hernia are acquired and come through a defect adjacent to the umbilical cicatrix (scar) and should be termed "Para-umbilical" (Next page). - So the actual Umbilical Hernia are congenital; they occur in children because of incomplete closure of the umbilical orifice. - The majority close spontaneously during the first year of life.(no need for surgery) - Surgical repair should only be carried out if: 1. If the hernia has not disappeared by the age of 2 years. 2. The fascial defect is greater than 1.5cm in diameter - True umbilical hernia comes through the umbilical scar and it's not common in adults; so it's usually secondary to raised intra-abdominal pressure. 22
Para-Umbilical Hernia - It's the common acquired "umbilical" Hernia. - It appears through a defect that is adjacent (beside) to the umbilical scar, and the umbilical skin is not attached to the center of the sac. - It's a protrusion through the linea Alba - It occurs just above or just below the umbilicus, and is more common in obese females. * Predisposing factors: - Multiple pregnancies - Obesity. - The neck of the sac is usually narrow and therefore there is a high risk of strangulation. * The most common content is: - Omentum, then - Transverse colon and small intestine. 23
Epigastric Hernia - It's a protrusion through a defect in linea Alba somewhere between the xiphisternum and the umbilicus. - It consists of: - Extraperitoneal fat only, but - May contain omentum or small bowel. - The patient complains of epigastric pain localized at site of the hernia and may not notice the lump. - It may be extremely painful, probably because of trapping and ischaemia of extraperitoneal fat. - Pain may be associated with eating, so the patent calls it "indigestion" and make selfdiagnosis of peptic ulcer. 24
Incisional Hernia - It's a hernia through an acquired scar in the abdominal wall, caused by a previous surgical operation or injury. - Scar tissue is inelastic and stretches progressively if subjected to constant stress. * Etiology : Age: Wound healing is poor in the older patient. Obesity. Postoperative wound infection. Postoperative wound haematoma. Raised intra-abdominal pressure postoperatively, e.g. coughing, straining, constipation, ileus. Steroid therapy. Type of incision: Midline vertical wounds have a higher incidence than transverse incisions. Poor suturing technique: Rarely does a suture break * Sign & symptoms: A swelling protrudes through the wound. It May occur up to 5 years postoperatively. Many are large and involve the whole incision and consequently the neck of the sac is wide and the risk of strangulation rare. If the defect is small there is a greater risk of strangulation. 25
Rare Hernia 1. Spigelian hernia: This is a hernia through the linea semilunaris at the lateral border of the rectus sheath. 2. Littre's hernia: A hernia that contains a Meckel's diverticulum in the sac. 3. Obturator hernia: This hernia occurs through the obturator foramen. It is commoner in elderly females. 4. Lumbar herniae: These occur in the lumbar region (below the 12th rib & above the iliac crest). The End ** This lecture was written from the following sources: - Browse's introduction to the symptoms and signs of surgical disease. - Haya Hernia seminar / 2014 by Ahmad Shyoukh & Yara Mansour - Hope "Inguino-scrotal conditions" lecture by Dr. Ziad Bataineh. 26