Overview of Hernias with special emphasis on Inguinal Hernias. Management of obstructed, strangulated hernia, Bassini repair, McVay's repair, Tanner's slide
3. INTRODUCTION
Hernias are among the oldest recorded “afflictions”
of mankind.
They are a significant cause of small bowel
intestinal obstruction and other life threatening
complications, especially in our environment
where patients do not present for treatment early,
either due to financial reasons, or because
according to them, it is not “paining” them.
3
4. DEFINITION
A hernia is defined as the protrusion of a viscus or
part of a viscus through a point of weakness or
defect in the wall of its containing cavity.
For example, the area of weakness in direct
inguinal hernias is the Hesselbach’s triangle,
whereas for indirect inguinal hernias, the defect is
the deep ring, both in the inguinal region.
4
5. CLASSIFICATION
Anatomical classification
Internal hernias: Protrusion of a viscus
through an anatomic foramen or a congenital or
acquired defect in the peritoneum or mesentery
with the organ remaining within the body. They
include:
Diaphragmatic hernia
Hiatal hernia
Sigmoid mesocolon hernia
Winslow hernia
Paracaecal hernia
Paraduodenal hernia
Foramen magnum hernia (coning) 5
7. External hernias: These communicate with,
and can be seen at the exterior as a bulge or
swelling. They include:
Groin hernias
• Inguinal hernia
• Femoral hernia
Ventral hernias
• Incisional hernia
• Umbilical hernia
• Paraumbilical hernia
• Epigastric hernia
• Spigelian hernia
• Lumbar hernias
For the purpose of this presentation, we will be more
concerned about the external hernias which happen to
be commoner.
7
9. EPIDEMIOLOGY
The prevalence of external hernias is
estimated to be about 11-12% of the
population.
Hernias as a whole, are commoner in
males, manual labourers and with
advancing age.
Inguinal hernia is the commonest type of
hernia – 80-92%. It is equally common in all
communities, and is the commonest type
of hernia in both males and females. 9
10. Femoral hernia in turn, makes up 2-5% of all
hernias. It is much more common in Europe
and North America than in Black Africa, and is
present in females than in males
Others include umbilical hernias (2%),
epigastric hernias (1%) and incisional
hernias (1 – 6%)
Internal hernias on the other hand are rare.
The overall incidence is <1%, and a substantial
percentage remain asymptomatic.
10
11. AETIOPATHOGENESIS
There are two factors implicated in
hernia development:
Predisposing factors: These cause
a defect or weakness in the
abdominal wall
Precipitating factors: These lead to
repeated increased intra-abdominal
pressure which leads to the
protrusion of the viscus. 11
12. The Predisposing factors include:
Normal anatomic defects e.g. deep
inguinal ring
Embryological defects e.g. patent
processus vaginalis
Surgical defects
Nerve injury
Advancing age
Connective tissue disorders
Cigarette smoking
Obesity 12
13. The Precipitating factors include:
Chronic cough
Chronic constipation
Bladder outlet obstruction
Heavy manual labour
Multiple pregnancies
Abdominal mass
Ascites
Peritoneal dialysis
13
14. PATHOLOGY
Most hernias comprise of the sac, its coverings
and its contents
The sac is a diverticulum of peritoneum with
mouth, neck, body and fundus.
Note:
Hernia without neck: Those hernias with larger
mouth lack neck, e.g. direct inguinal hernia,
incisional hernia.
Hernia without sac: Epigastric hernia—it is
protrusion of extra-peritoneal pad of fat.
The coverings are the layers of the abdominal wall
the sac carries along with it as it passess through
the defect in the abdominal wall.
14
18. o Contents of the sac
Omentocoele—omentum.
Enterocoele—intestine.
Cystocoele—urinary bladder.
Littre’s hernia—Meckel’s diverticulum.
Amyand hernia – vermiform appendix
Maydl’s hernia (hernia-en-W) – a bowel loop in the
shape of the letter “W”
Sliding hernia (hernia-en-glissade) – extraperitoneal
bowel or urinary bladder
Richter’s hernia—part of the bowel wall.
18
19. A – Richter’s
B – Pantaloon’s
C – Amyand’s
D – Sliding
E – Littre’s
F – Maydl’s
19
20. COMPLICATIONS
Note that, a hernia is described as reducible
if its contents return completely into the
abdomen when the patient lies down or when
pressure is applied on it. Usually, reducible
hernias are uncomplicated.
Irreducible (incarcerated) hernia:
Contents cannot be returned to the
abdomen due to a narrowed neck or
adhesions.
Irreducibility predisposes to obstruction and
strangulation. 20
22. Obstructed hernia:
It is an irreducible hernia with a stoppage
in the onward flow of intestinal
contents, but blood supply to the bowel
is not interfered.
It eventually may lead to strangulation.
Note that features of intestinal obstruction
may be absent in case of omentocele,
Richter’s hernia, Littre’s hernia
22
23. Strangulated hernia:
It is an irreducible hernia with obstruction to blood flow.
This causes ischaemia, gangrene and consequently
peritonitis
The swelling is tense, tender, with absent cough
impulse and with features of intestinal obstruction.
Overlying skin is dark or purplish
Other complications of hernias include:
Inflamed hernia
Rupture
Peritonitis
Fistula formation
23
25. SURGICAL ANATOMY OF THE
INGUINAL CANAL
The superficial inguinal ring is a triangular opening in
the external oblique aponeurosis and is 1.25 cm above
the pubic tubercle.
The deep inguinal ring is a U-shaped condensation of
the transversalis fascia, lies 1.25 cm above the
midpoint of the inguinal ligament.
The inguinal (Poupart’s) ligament is formed by the
lower border of the external oblique aponeurosis which
is thickened and folded backwards on itself, extending
from anterior superior iliac spine to pubic tubercle.
25
27. The inguinal canal is an oblique
passage in lower part of abdominal wall,
4 cm long, situated above the medial ½
of inguinal ligament, extending from deep
inguinal ring to superficial inguinal ring.
The inguinal canal in females is known
as the ‘canal of Nuck.’
Contents of the inguinal canal
Spermatic cord in males
Round ligament in females
Ilio-inguinal nerve 27
28. The spermatic cord comprises of:
Three fascia coverings
Internal spermatic fascia derived from
fascia transversalis
Cremasteric fascia derived from internal
oblique aponeurosis
External spermatic fascia derived from
external oblique aponeurosis
Three arteries
Testicular artery
Artery to vas
Cremasteric artery 28
30. Three veins
Pampiniform plexus of veins
Vein of vas
Cremasteric vein
Three nerves
Genital branch of genitofemoral nerve
Sympathetic plexus (T10 – T11) around the
artery to vas
Parasympathetic nerve fibres
Three other structures
Vas deferens
Lymphatics of the testis
Remains of processus vaginalis 30
31. Boundaries of the inguinal canal
Anterior wall: Skin, subcutaneous tissue,
external oblique aponeurosis (medial two-thirds)
and internal oblique muscle (lateral one-third).
Posterior wall: Fascia transversalis (lateral half)
and conjoined tendon (medial half).
Roof: Arched fibres of internal oblique, and
transversus abdominis.
Inferiorly: Inguinal ligament, and lacunar
ligament (medially) 31
33. The ‘Hesselbach’s triangle’ is a weak point
in the anterolateral abdominal wall,
susceptible to direct inguinal hernias.
It is bounded:
Medially by the lateral border of rectus
muscle,
Laterally by the inferior epigastric artery,
Inferiorly by the iliopubic tract
33
35. CLASSIFICATION
Anatomical classification:
Indirect hernia. It comes out through the internal ring
along with the cord. It is lateral to the inferior
epigastric artery.
Direct hernia. It occurs through the posterior wall of the
inguinal canal through the ‘Hesselbach’s triangle.’ Sac
is medial to the inferior epigastric artery.
Saddle-bag or pantaloon hernia has got both medial
and lateral (direct and indirect components).
35
40. HISTORY
Biodata:
Age: Indirect hernias are congenital in majority
of cases and are commoner in children
whereas direct hernias are usually acquired
and hence, are commoner in adults.
Occupation: Manual jobs
Presenting complaint – a groin or scrotal
swelling;
that was initially or is still reducible
(spontaneously or manually),
that is precipitated or aggravated by standing,
straining or coughing
40
41. History of Aetiology:
The risk factors that predispose to or precipitate
hernia formation may be elicited in the history
It is important to also rule in/out possible
differential diagnoses such as inguinal
lymphadenopathy, saphenous varices, etc.
NB: Most differentials are excluded via
physical examination.
History of Complications:
Hernia may have become irreducible
Colicky abdominal pain, bilious vomiting,
abdominal distension and constipation –
intestinal obstruction
Severe, constant pain, fever –
strangulation, gangrene, peritonitis 41
42. PHYSICAL EXAMINATION
Examination of an inguinal hernia is done in both
the standing and the supine positions.
Inspection is done in the standing position,
while palpation involves both standing and lying
down.
Inspection: First, compare contralateral side.
Then examine for site, size, shape, extent,
nature of skin over swelling, visible cough
impulse, transillumination, inspect the
surrounding.
42
43. Palpation (standing position): Differential
temperature, tenderness, surface, extent (try to get
above/below it), consistency, feel for the testis,
palpable cough impulse, palpate the contralateral
hemiscrotum.
Palpation (supine position):
Hernia may reduce spontaneously, but, if not,
attempt is made to reduce manually or ask the
patient to help
If reducible, deep ring occlusion test is done
with the index finger
Note the relationship in position between the
hernia and the pubic tubercle.
Examine the abdominal muscle tone –
Magaigne bulges 43
45. NB:
The deep ring is located 1.25cm (a finger
breadth) superior to the midpoint of the
inguinal ligament
The deep ring occlusion test is positive when
no impulse or hernia bulge is seen medial to
the deep inguinal ring on coughing suggestive
of an indirect inguinal hernia. Otherwise, it is
a direct inguinal hernia
45
46. Other examinations
General examination – examine patient’s general
state, check for fever, dehydration, etc
Respiratory examination – respiratory pathologies
Abdominal examination – examine for scars,
abdominal distension, ascites, masses, other hernia
orifices, bowel sounds
Urogenital examination – examine for urethral
induration
Rectal examination – examine for haemorrhoids,
enlarged prostate, rectal masses 46
47. Examination findings for normal/complicated
hernias
Reducible hernia:
Good general state
Inguinal swelling,
Positive cough impulse.
Normal overlying skin
Soft
Reducible
No differential warmth
Irreducible (incarcerated) hernia:
Inguinal swelling
Absent cough impulse
Skin may be oedematous
Firm
Non-reducible
Tenderness may be elicited
47
49. Strangulated hernia:
General examination:
Toxically ill looking
Fever
Dehydration, shock
Groin swelling:
Overlying skin, purplish or dark; may be
hyperaemic in early stages
Absent cough impulse
Differential coldness
Tense
Tender
Irreducible 49
50. Abdominal examination
Abdominal distension
Rebound tenderness
Bowel sounds may be hyperactive
NB: Most strangulated hernias are also
obstructed, exceptions are Richter’s
hernia, hernias in which the content is not
a bowel.
50
51. Differential diagnoses
Femoral hernia – inferolateral to the pubic tubercle
Encysted hydrococoele of the cord – transilluminates,
may get above and below
Vaginal hydrocoele – transilluminates, can get above
it
Saphena varix – no cough impulse, may be
associated with varicose veins
Varicocoele – feels like a bag of worms
51
52. Lipoma of the cord – lobulated surface, slipping
sign, no cough impulse
Inguinal undescended testis – only one testis
palpated in the scrotum, cough impulse may be
present
Enlarged inguinal lymph node – no cough
impulse
Inguinal abscess – no cough impulse
Femoral artery aneurysm – pulsatile,
compressible
52
53. INVESTIGATIONS
Diagnosis of inguinal hernias is clinical
However, specific investigations may be done
as indicated
Chest X-ray: Tuberculosis, COPD
Abdominal USS: Masses, prostate
Urethrogram: Urethral stricture
Abdominal X-ray, erect and supine: Intestinal obstruction
Routine investigations
Serum E/U/Cr
FBC
Hepatitis screening
RVS 53
54. TREATMENT
REDUCIBLE HERNIA
Treatment is operative, and it is elective.
Precipitating factors must be addressed first before
surgery to correct the hernia.
Surgeries
Children – Herniotomy
Herniotomy – Sac is excised after reduction of contents
Lytle’s repair may be done to narrow the deep ring if
wide
Adults – Herniorrhaphy, Hernioplasty
Herniorrhaphy – Sac is excised, and the posterior wall
reinforced with non-absorbable sutures
Hernioplasty – Sac is excised, and an artificial material
such as prolene mesh is applied 54
58. Indications for mesh repair
Recurrent hernias
Incisional hernias
Massive hernias
Old age
Weak abdominal muscle tone
Sliding hernias
Direct hernias
Connective tissue disorders e.g. Ehlers
syndrome, Marfan syndrome
58
59. IRREDUCIBLE HERNIA
Reduction of the hernia is attempted under
sedation and muscle relaxant
If reduction is successful, do herniorrhaphy
or hernioplasty later (24-48hrs later) when
oedema subsides
If hernia remains irreducible, emergency
surgery is done.
59
60. OBSTRUCTED/STRANGULATED HERNIA
Adequate resuscitation and optimization of
patient for surgery
Fluid resuscitation
Nasogastric intubation to rest the bowel
Urethral catheterization to monitor urine output
Intravenous broad spectrum antibiotics
Correction of electrolyte deficits
When patient is fit for surgery, a groin
exploration is done
60
61. During the surgery, it is important not to
reduce the content of the sac until it is
examined to be viable.
Viable bowel is/has
Pinkish/reddish
Glistening
Peristalsis
Pulsation of the mesenteric arteries
Resect non-viable bowel and do end-to-
end anastomosis 61
62. Non-viable bowel is/has
Gangrenous
Lustereless
No peristalsis
No pulsation in the mesenteric arteries
For omentum, the affected part is
excised.
Then, inguinal herniorrhaphy is done
62
67. CONCLUSION
In an environment like ours where majority of
patients only show up for care in the midst of the
raging storm, it is important as physicians that we
are well grounded on how to weather these storms.
And this we can do by possessing a sound
knowledge of what hernias are, how they are
diagnosed, and the life-saving ways to manage
them.
67
69. REFERENCES
Baja’s Principles and Practice of Surgery (including
Pathology in the Tropics) 5th ed; E.Q. Archampong
et al
SRB’s Manual of Surgery 5th ed; Sriram Bhat M
Browse’s Introduction to the Signs and Symptoms
of Surgical Disease 4th ed; Norman L. Browse et al
Clinical Surgery Tutorial Manual 2nd ed; Omoigiade
E. Udefiagbon
MBBS Undergraduate Notes; Osaigbovo
Uhunmwagho, Omoigiade E. Udefiagbon
emedicine.medscape.com 69
