Hernia
Hernia
Hernia
Inguinal hernia
Umbilical hernia
Hernia in cicatrice
Sports hernia
Internal hernia
Diaphragmal hernia
TYPES OF HERNIA
ANATOMY
The inguinal canal is 4-6 cm long.
The inguinal canal starts in the abdomen from the point that the
spermatic cord crosses the internal/deep inguinal ring in the
transversalis fascia (in women the Round ligament).
The most common inguinal hernia in women and in men is the indirect
inguinal hernia.
Femoral hernia in the elderly and in those who had a previous hernia
repair is more common.
A) Congenital
B) Acquired
A) Congenital Hernia:
ii.In the descent of the testes from the abdomen to the scrotum in the third trimester, a part of the peritoneum descends with it
which is called the processus vaginalis.
i.Lack of closure of processus vaginalis results in a patent processus vaginalis which is a reason for the high prevalence of
inguinal hernia in the preterm neonates.
i.A lot of the process vaginalises close in a few months after birth and its patency does not necessarily mean that a hernia will
be formed.
ETIOLOGY
B) Acquired Hernia:
:It seems that most cases of hernia come from an acquired defect in the abdominal wall and the reason for its formation is multifactorial
1- Strenuous physical activity can be a factor but it is not known whether the hernia is just from physical activity or in the setting of a
patent processus vaginalis.
4- Collagen deficiency associated diseases like collagen type I deficiency relative to type III.
Being overweight is to some extent protective (maybe it is from the more difficult diagnosis of hernia)
SYMPTOMS
The symptoms are variable from a hernia with no symptoms to one
with strangulation.
The feeling of pressure and weight on the inguinal region especially after a daily
activity is common.
A sharp pain indicates nerve entrapment and does not have anything to do with
physical activity.
Usually the patient can reduce the hernia but the bigger the hernia, the
less likely it is to reduce.
B) We examine the contralateral side and compare the two sides to each
other.
The extent of bulging on the two sides can be a criteria for the
diagnosis of hernia on one or both sides.
PHYSICAL EXAM
The differentiation between a direct and an indirect inguinal hernia in
the physical exam:
- If the finger is inside the inguinal canal and the patient exerts
pressure or coughs and the hernia comes in contact with the tip of the
finger it is a direct hernia.
- If with closure of the internal ring with the finger while the patient
strains (coughs) the hernial sac does not bulge out the hernia is an
indirect one, and if the hernial sac bulges the hernia is a direct one.
PHYSICAL EXAM
the examination of the femoral hernia is difficult. This hernia
presents under the inguinal ligament and the presence of too much
or too little fat in the inguinal region can cause an error in the
diagnosis. (Femoral Psuedohernia)
Imaging in hernia:
1- Overwieght individuals
2- Recurrent hernia
3- Hernias that are not found in the physical exam
Mesh is the golden standard because less tension is produced and there is less recurrency.
Because of the very good results of mesh the initial tissue repair is not used any more.
Laparascopic surgery is used in bilateral and recurrent conditions or when another surgery
like prostate surgery has to take place at the same time.
The laparascopic procedure is not different from the open surgery method in the recurrency rate.
It has less post-op complications and a sooner return to work. Intestinal obstruction and ileus
is seen more often after a laparascopic procedure.
TREATMENT
Contraindications of laparascopy:
1- A previous surgery in the area (a surgery that the surgeon entered the
abdomen such as prostatectomy)
2-Primary medical condition
In recurrent cases, dissection in the scar tissue should not be made (due
to inability in exactly differentiating the anatomic parts.
Obstruction
When bowel is extruded through a hernia and becomes so tight that
food cannot pass through that segment
Causes severe pain, nausea, vomiting
Requires URGENT surgery
COMPLICATIONS
Strangulation
When hernia contents – especially bowel – become stuck so
tightly
that adequate blood flow cannot reach these contents
Causes necrosis (death) of the strangulated contents
Eventually results in perforation, peritonitis, sepsis, and death
Requires EMERGENT surgery
EMERGENCY SURGERY
Strangulated Hernia: NO TAXIS
1-Fever
2-Leukocytosis
3- Hemodynamic instability
4- Tender and warm hernia contents
5- Erythema in hernial sac
1-Cord lipoma
2-Seroma
3-Weakness of external oblique muscle
4-Cough
COMPLICATIONS OF
HERNIA SURGERY
1-Pain
4-Wound infection
5-Seroma
6-Urinary Retention
SPORTSMAN’S HERNIA
Occult hernia, pubic pain in sportsmen, sportsmen’s hernia
Due to repetitive movement in lower extremity such as skiing, hockey, or
American football, usually hernia is not found in physical exam other than the time
of surgery.
Symptoms: Acute or chronic pain that gets worse with movement, coughing or
sneezing and can reduce the sportsman’s function. In the physical exam no
bulging or evidence of hernia is seen and pain and tenderness in the inguinal canal
and the external ring is present.
Prevalence of hernia is higher in, premature and LBW and on the right side.
Treatment: to some extent emergency even if with no symptoms. In premature neonates inguinal hernia repair before
hospital discharge.
Important Point: Method of exploring the opposite side is somewhat controversial. Now laparascopy is mostly used. But sonography has also been used.
HERNIA IN CICATRICE
Occur mostly after laparotomy in the middle line
Mesh Sublay
Plug in
IPOM – laparoscopic
- open
HIATAL HERNIA
It mostly occurs when the upper part of stomach pushes through an
opening in diaphragm and up in to the chest.