TYPES OF HERNIA AND

ITS MANAGEMENT

ROWENA
 OVERVIEW
 DEFINITION

 TYPES & CLASSIFICATION

 INGUINAL HERNIAS

 FEMORAL HERNIA

 PARAUMBILICAL HERNIA

 INCISIONAL HERNIA

 EPIGASTRIC HERNIA

 OTHER RARE HERNIAS

 DEFINITION

A HERNIA IS A PROTRUSION OF A VISCUS OR

PART OF A VISCUS THROUGH AN ABNORMAL
OPENING IN THE WALLS OF ITS CONTAINING
CAVITY.
 T YPES OF HERNIA

 GROIN HERNIA
-Inguinal hernia
Direct inguinal hernia
Indirect inguinal hernia
-Femoral hernia

 PELVIC HERNIA
-obturator hernia
-sciatic hernia
-gluteal hernia
 ANTERIOR ABDOMINAL WALL HERNIAS
-Umbilical hernia
-paraumbilical hernia
-epigastric hernia
-Spigelian hernia

 POSTERIOR ABDOMINAL WALL HERNIAS

-superior lumbar hernia
-inferior lumbar hernia
 CLASSIFICATION

 Reducible – if contents can be returned to abdomen

 Irreducible – if contents cannot be returned but there
are no other complications
 Obstructed – if bowel in the hernia has good blood
supply but bowel is obstructed.
 Strangulated – if blood supply of bowel is obstructed.
 Inflamed – if contents of sac have become inflammed
 Incarcerated – if the portion of the colon occupying a
hernial sac is blocked with faeces
INGUINAL HERNIA
 INGUINAL HERNIAS

Protrusion of peritoneal sac through an

abnormal opening in the inguinal region.
Broadly classified as indirect and direct.
 INDIRECT INGUINAL HERNIA

Congenital
Patent processus
vaginalis
Passes through the
inguinal canal
Higher risk of
strangulation than
direct
INDIRECT INGUINAL HERNIA
INDIRECT INGUINAL HERNIA
INDIRECT INGUINAL HERNIA
 DIRECT INGUINAL HERNIA

Within the floor of

hesselbach’s
triangle
Acquired defect
Do not descend to
scrotum
Less chances of
strangulation
DIRECT INGUINAL HERNIA
 ETIOLOGIES

 Multifactorial

1) Increased abdominal pressure

- Cough
- Constipation
- Urinary trouble
- Acsites
- Intraabdominal malignancies
- pregnancy
2) Weakness of abdominal wall
a) Congenital
- Patent processus vaginalis
- Patent canal of nuck in female
b) Acquired
- Obesity
- Surgical incision
- Connective tissue disorder (Marfan’s syndrome)
 COMPOSITION OF HERNIA

 A hernia consists of three parts :

- The sac
- Coverings of sac
- Contents of sac
 The sac is a diverticulum of peritoneum, consists :
- Mouth
- Neck
- Body
- fundus
 CONTENTS

 Omentum = omentocoele
 Intestine = enterocele
 A portion of the circumference of the intestine=
Richter’s hernia
 A portion of the bladder
 A Merkel’s diverticulum = a Littre’s hernia
 Fluid, as part of ascites or peritoneal fluid.
 LAYERS
 Skin & subcutaneous fat.
 Campers fascia.
 Scarpa’s fascia.
 External oblique fascia.
 Cremaster muscle.
 Spermatic cord (male) or Round ligament (female).
 Internal oblique & Transversus abdominis.
 Transversalis fascia.
 Preperitoneal tissues.
 Peritoneum.
 ANATOMY OF INGUINAL CANAL
 4cm in length.
 Extends between superficial and deep rings.
 Deep/ internal ring is ‘U’ shaped in the fascia
transversalis which lies 1.25cm above the mid inguinal
point
 Superficial/ External ring is in the external oblique
aponeurosis situated just above and lateral to the
pubic crest.
INGUINAL CANAL
BOUNDARIES OF INGUINAL CANAL
 CONTENTS OF THE INGUINAL CANAL

 Ilioinguinal nerve
 Spermatic cord (in males)
 Round ligament (in females)
 SPERMATIC CORD COVERINGS

 External spermatic fascia

derived from external
oblique aponeurosis and
attached to the margins of
the superficial inguinal ring
 Cremasteric fascia derived
from the internal oblique
muscle
 Internal spermatic fascia
derived from fascia
transversalis and attached
to the margins of the deep
inguinal ring
 SPERMATIC CORD CONTENTS
 3 arteries
Testicular artery
Ductus deferens artery
Cremasteric artery
 3 nerves
Cremasteric nerve
Genital branch of genitofemoral
nerve
Ilioinguinal nerve
 3 other things
Ductus deferens
Pampiniform plexus
Lymphatics
 NERVE INNERVATION IN GROIN
 Major nerves in the region are ilioinguinal,
iliohypogastric & genitofemoral nerves.
 Ilioinguinal nerve provides sensory to pubic
region, upper labia, scrotum. Most commonly
injured especially during appedicectomy.
 Iliohypogastric nerve provides sensory to skin
superior to the pubis.
 Genitofemoral nerve provides sensory to scrotum
and thigh.
BOUNDARIES OF HESSELBACH TRIANGLE
 NYHUS CLASSIFICATION OF
HERNIA
 TYPE I: Indirect hernia, normal internal ring,
(children or young adults).
 TYPE II: Indirect hernia, dilated internal ring.
 TYPE III: posterior wall defects,
A : Direct hernia,
B : Indirect hernia, dilated internal ring,
massive scrotal swelling,
Sliding hernia.
C: Femoral hernia.
 TYPE IV: Recurrent herniae (post-hernia repair).
 HISTORY
 A “bulge” or expansile swelling in groin
 Pain or dull dragging sensation.
 Extrainguinal symptoms
- Change in bowel habit
- Urinary symptoms
 Pressure on nerves
-local sharp pains
-referred pain to scrotum, testis or inner thigh
 Precipitating factors
 PHYSICAL EXAMINATION

 INSPECTION
- Best done in standing postion
- Site
- Size
- Surface
- Margin
- Shape
- Extension
- Visible cough impulse
 PALPATION
- Tenderness
- Warmth
- Site – relation to pubic tubercle
- Size
- Shape
- Extension
- Consistency
- Can get above swelling?
- Palpation of spermatic cord and testis
- Cough impulse on palpation
 REDUCIBILIT Y TEST
 DEEP RING OCCLUSION TEST
 SEARCH FOR PREDISPOSING FACTORS :

1) ABDOMEN EXAMINATION
-ABDOMINAL MASS

2)PER RECTAL EXAMINATION

-BPH
-PROSTATIC CARCINOMA
-CONSTIPATION
 DIFFERENTIAL DIAGNOSIS

 Femoral hernia
 Lipoma
 Femoral aneurysm
 Saphena varix
 Inguinal lymphadenopathy
 Psoas abscess
 Ectopic testis
 Spermatocoele
 Vaginal hydrocoele
 IMAGING FOR INGUINAL HERNIA

 Imaging modalities
- Ultrasound
- CT scan
- MRI
 Indications for imaging in inguinal hernia:
- Vague groin swelling and diagnostic uncertainty
- Poor localization of swelling (hidden in thick fat)
- Intermittent swelling which is not present at the time
of examination
- Other groin complaints without swelling.
ULTRASOUND IMAGING
COMPUTED TOMOGRAPHY (CT SCAN)
 CT abdomen and pelvis is a good
imaging modality to assess for
abdominal hernia, especially when
there is concern for acute
incarceration or strangulation.

 CT findings include a “z one of

transition” depicting a change in
diameter of small bowel from
dilated to a normal or decreased
diameter such as the “pinc h point ”
seen in the case image.

 Signs concerning for strangulation

include engorged vessels within
incarcerated hernia, fat stranding
and thic kened bowel wall
(Strange).
 SURGICAL TREATMENT
 HERNIOTOMY
-Usually done in children

 HERNIORRHAPHY
-Bassini repair
-Shouldice repair
-Mc Vay repair

 HERNIOPLASTY
- Lichtenstein repair
- Plug and patch repair

 Laparoscopic repair
- TEP (total extra peritoneal)
- TAPP (trans abdominal preperitoneal )
 COMPLICATIONS

1. INCARCERATION : A reducible hernia becomes

irreducible . No intestinal obstruction or strangulation.

2. OBSTRUCTION
Clinicalfeatures of Small or Large bowel obstruction.

3. STRANGULATION
-S/S of Intestinal obstruction, with severe abdominal
pain & constitutional symptoms - if gut is strangulated.
 OTHER GROIN HERNIAS
Sliding hernia: large bowel “slides” through
internal ring, lateral to cord.
Richter’s hernia: portion of wall of small bowel
inside hernia sac.
Littre’s hernia: Meckel’s diverticulum in hernia
sac.
Maydl’s hernia: W shaped hernia
Amyand’s hernia: hernia containing appendix
FEMORAL HERNIA
 FEMORAL HERNIA

 Herniation of intra abdominal contents through

femoral canal.
 Sex: common in females
 Side: right side 2x more common than left side
 ANATOMY OF FEMORAL TRIANGLE

 It’s a triangular hollow in the upper 1/3 rd of the

anterior thigh.
 Boundaries :
- Superior : inguinal ligament
- Lateral : medial border of sartorius
- Medial : lateral border of adductor longus
- Roof : fascia lata
- Floor : adductor brevis muscle
 CONTENTS OF FEMORAL TRIANGLE

Femoral nerve
Femoral artery
Femoral vein
Femoral sheath
Femoral canal
Deep inguinal lymph
nodes
Fat tissue
 ANATOMY OF FEMORAL SHEATH

 It is a funnel shaped sheath that surrounds upper 1/3 rd

of the femoral vessels
 The anterior wall is the downward prolongation of the
fascia transversalis of the anterior abdominal wall.
 The posterior wall is the downward prolongation of the
fascia iliac of the posterior abdominal wall.
 Contents of femoral sheath :
- Femoral artery
- Femoral vein
- Femoral branch of genitofemoral nerve
- Femoral canal
 ANATOMY OF FEMORAL CANAL &
FEMORAL RING

 It is conical in shape and 1 ½ cm in length.

 Extends from the femoral ring to the saphenous ring.
 About 1 ½ inches below and lateral to the pubic
tubercle.
 Innermost compartment of femoral sheath
 Boundaries of femoral ring :
- Anterior : inguinal ligament
- Posterior : ligament of Cooper, iliopectineal ligament
- Medial : lacunar ligament
- Lateral : femoral vein
 CONTENTS OF FEMORAL CANAL :

- Fat
- Facsia
- Lymphatics : lymph
node of Cloquet
 Causes of femoral hernia
- Pregnancy : increased intraabdominal pressure
- Wide femoral canal
 Coverings of femoral hernia :
- Skin
- Superficial fascia
- Cribriform fascia
- Transversalis fascia
- Fat and lymphoid tissue
- Sac
 CLINICAL FEATURES

 Local symptoms :
1) Pain if adhered to greater omentum
2) Swelling:
- apparent on standing and straining, disappear upon lying
down.
- Situated below and lateral to the pubic tubercle.

 General symptoms :
- If obstructed, colicky abdominal pain, vomiting, abdominal
distention.
- If strangulated, sudden pain at local side which then spreads
to whole abdomen.
 Specific examination:
- Swelling below and lateral to pubic tubercle
- Reducible
- Expansile cough impulse often not present due to
narrow inguinal canal
- Consistency : firm and doughy ( omentum or
extraperitoneal fat)
 DIFFERENTIAL DIAGNOSIS

 Inguinal hernia
 Saphena varix
 Femoral aneurysm
 Enlarged femoral lymph node
 Lipoma
 Psoas abscess
 MANAGEMENT

 Surgery is a must in all cases due to high risk of

strangulation.
 Basic principle : approximation of inguinal ligament
with Cooper’s ligament.
3 surgical approaches :
a) Lotheissen’s operation
- Incision in made through the inguinal canal
b) High approach of Mc Evedy
- Incision is made over femoral canal and continued above inguinal
canal.
- Useful in strangulated and irreducible hernias
c) Low operation of Lockwood
- Incision made below the inguinal ligament via groin crease
incision.
- Indicated in uncomplicated cases
- Does not prevent inguinal hernia
PARAUMBILICAL HERNIA
 PARAUMBILICAL HERNIA

 Hernia occurs either above or below the umbilicus,

through linea alba
 Common in females
 Causes:
- Obesity
- Repeated pregnancy
- Ascites
 CLINICAL FEATURES

 Swelling over the umbilical region which increases in

size on coughing and straining.
 Positive expansile cough impulse
 Reducibility can be present
 Dragging pain if adhered to omentum.
 Consistency : firm or granular mass
 MANAGEMENT

 Mayo’s repair
-a curvilinear incision made below the umbilicus
-skin flaps are raised
-sac is dissected all around and the defect in the linea
alba is identified
-contents are reduced
-defect in the linea alba is extended laterally and then
upper and lower aponeurotic flaps are sutured together
by using double breasting technique.
MAYO’S REPAIR
INCISIONAL HERNIA
 INCISIONAL HERNIA

 Hernia which occurs through an acquired scar in the

abdominal wall usually caused by previous surgical
operation or an accidental trauma.
 Also called ventral hernia or post operative hernia.
 Etiology :
- Infection
- Incision wrongly placed
- Improper suture material
- Increased intra-abdominal pressure.
INCISIONAL HERNIA
 MANAGEMENT

 There are various operations for treatment of incisional

hernias depending upon the size of the defect,
anatomical location of incision and the presence of
precipitating factors.
 1) laparoscopic mesh repair
EPIGASTRIC HERNIA
 EPIGASTRIC HERNIA

 Hernia which occurs in the epigastrium through linea

alba which extends between the xiphoid process and
umbilicus.
 Precipitated by sudden straining or heavy exercises
resulting in the tear of few fibres of linea alba.
 Treatment :
- Small incision made over the swelling.
- If hernial sac is present, it is opened, the contents are
reduced and the defect is closed using non - absorbable
sutures.
EPIGASTRIC HERNIA
RARE EXTERNAL HERNIAS
 SPINGELIAN HERNIA

 An interstitial hernia which occurs through the

Spingelian fascia.
 This is a thin strip of fascia which runs parallel to the
outer border of rectus sheath from the tip of the 9 th
costal cartilage to the pubic tubercle.
 A reducible swelling located just below and lateral to
the umbilicus.
 Precipitated by pregnancies, advancing age, obesity,
sudden straining due to cough or weight lifting.
 Treatment : sac is excised after reducing the content
and the defect is repaired .
SPINGELIAN HERNIA
 LUMBAR HERNIA

 It is the herniation either

through superior or inferior
lumbar triangle.
 Treatment:
-small defects can be closed with
simple sutures.
-large defects need to be closed
with or without mesh .
LUMBAR HERNIA
 OBTURATOR HERNIA

 Hernia which occurs through the obturator canal.

 Common in females
 Precipitated by repeated pregnancies and older women
who have recently loss lots of weight.
 Common presentation is acute intestinal obstruction
with strangulation.
 Pain is referred along the obturator nerve to the knee.
 Treatment :
- Closure if the obturator opening is done by stitching the
broad ligament over the opening or by using the
monofilament nylon with or without mesh.
OBTURATOR HERNIA
 REFERENCES

 MANIPAL MANUAL OF SURGERY ( 3 rd EDITION)

 DOCTRINE PERPETUA
 GOOGLE IMAGES