1. Hernias
Prof.Dr.Gamal Karrouf

2. Definition
• It is the protrusion of a portion of the abdominal
contents through an aperture (congenital or normal
physiologioal opening or an acquired opening) in
the wall of the abdomen to lay beneath the skin
which remains intact. Or A hernia comprises the
protrusion of an organ or part of an organ through
the wall of the cavity normally containing it.

3. Classification of hernias
: hernia may be classified as direct or indirect,
internal or external. A direct hernia occurs
through a rent or tears whereas an indirect
hernia occurs through natural passage such
as the inguinal canal or umbilicus

4. • 1- External hernias: it occurs through the
body wall producing a visible and palpable
swelling covered by skin as umbilical H.
and Ventral H
• 2- Internal hernias: it occur within the
abdominal cavity. As diaphragmatic H.

5. 3-Incisional or postoperative
hernias:
• encountered relatively frequently following
abdominal surgery. Improper closure of the
incision, suture breaking or tearing through
tissues, postoperative wound infection, are
contributory factors. The weakened
abdominal wall undergoes loss of continuity
and a hernia develops often a delay of
several weeks or months

6. Parts of the hernia: surgically,
a hernia consists of
1- Hernial opening or ring or orifice: it may be
accidental rupture in the abdominal wall (ventral
H) or a persistent prenatal opening (umbilicus) or
normal passage (inguinal canal). The size of the
opening varies from that which admits the passage
of a finger to about 4 fingers, or may be much
larger. Its shape may be round, oval, slitlike or
irregular or in the form of a passage (inguinal H)

7. • 2- Hernial swelling:
• The size varies from that of a grap to that of a
man's head or rarely much larger. The shape may
be hemispherical, cylindrical or conical. It
comprises of two parts:
• a. Hernial sac: it encloses the hernial contents
and is formed of skin, perhaps some few muscular
fibres, fibrous tissue and the parietal layer of the
peritoneum and the later may be absent, if it is
ruptured by the causal agent. The sac has a neck,
body and a fundus.

8. • The neck is the nearest portion to the
abdominal wall, the fundus is the lowest
part and the body is the intervening region.
The inner surface is smooth and thus greatly
favours the passage of the abdominal
viscera into the cavity and it throwns into
folds at its neck

9. • b. Hernial contents: these usually
comprise a loop of the bowel with its
ingensta and mesentric attachment
(enterocele), or omentum (epiplocele) or
both (entero-epiplocele) or rarely the
stomach (gastrocele) or bladder (vesciocele)

10. Fig.2: Umbilical hernias inFig.2: Umbilical hernias in
buffalo calf (A) and cowbuffalo calf (A) and cow
calf (B) and closure of thecalf (B) and closure of the
hernial ring by a series ofhernial ring by a series of
interrupted horizontalinterrupted horizontal
mattress sutures using ofmattress sutures using of
Polyglycolic acid (C) .Polyglycolic acid (C) .

11. Fig.3: Umbilical herniaFig.3: Umbilical hernia
in foal (A), afterin foal (A), after
dissection and freeing ofdissection and freeing of
the hernial sac 1cmthe hernial sac 1cm
peripheral to the hernialperipheral to the hernial
ring (B). Herniorrhaphyring (B). Herniorrhaphy
was obtained by a serieswas obtained by a series
of interrupted horizontalof interrupted horizontal
mattress sutures using ofmattress sutures using of
silk (C) .silk (C) .

12. Fig.9: Umbilical hernias in buffalo calf (A) and cow
calves (B&C) and closure of the hernial ring by a
series of interrupted horizontal mattress sutures
using of silk (D) .

13. Fig.4: Large umbilical hernia repaired with a hernial
tape.

14. Types of hernia:
• hernia is classified as follows
• 1. According to their situation: e.g.
umbilical H. (omphalocele or exomphalos),
inguinal H. (bubonocele), scrotal H.
(oscheocele), or ventral H., femoral H. and
perineal hernia.

15. • 2. According to the nature of the hernial
contents: e.g. that containing the bowel
with the mesentry (enterocele), omentum
(epiplocele) and bladder (vesicocele).

16. • 3. According to the condition of the
hernial contents:
• This may be: 1. Reducible or mobile hernia
(more common)
• In which the hernial contents can be
returned to the abdominal cavity through
the hernial ring.

17. • 2. Irreducible hernia: in which the
contents can not be returned to their normal
location. It comprises three types:-
• A- Incarcerated hernia: is one in which
the passage of the ingesta through the
protruding loop of intestine is arrested. The
blood flow in its wall, however is
maintained

18. • B- Strangulated hernia: is one in which both
irreducible and incarcerated and in which the
blood circulation is also arrested and the lumen of
the bowel is obstructed resulting in gangrene
within 24 hours unless speedy relief is afforded..
• C- Hernia with adhesion: inflammatory
adhesions may have united the contents to the
lining of the sac. They prevent the complete
reduction of the hernia and may cause
strangulation by constricting the bowel.

19. • Aetiology: I- Predisposing causes:
• 1- Congenital or herditary as umbilical and
inguinal hernias .
• 2- Weak abdominal wall e.g. imperfect occlusion
of the umbilicus.
• 3- Deep wounds, contusions and abscesses.
• 4- Increased intra-abdominal pressure e.g.
straining from constipation or diarrhoea or
parturition, fits of coughing or intestinal tympany.

20. II. Exciting causes:
• 1- Mainly increased intra-abdominal
pressure with rupture of the rigid muscles
tends to force the viscera via weak points in
the abdminal wall.
• 2- Violent impact against a blunt object
with rupture of the muscle while the skin is
intact.

21. • Symptoms Physical symptoms
• 1- It is due to the presence of hernial swelling
which varies in shape and size.
• 2- In enterocele, it is elastic and in epiplocele it is
doughy to feel; manipulation of the former may
produce a gurgling sound.
• 3- If the herniated portion of the intestine is
distended with gses, it will be tympanic on
percussion and if it is containing a quantity of
fluid it will fluctuate on palpation.

22. • 4- In entero-epiplocele there is a combination of
the foregoing characters.
• 5- In the vast majority of cases, gentle pressure on
the protruding swelling will reduce the hernia,
allowing identification of the hernial ring, which
should be assessed for size, shape and rigidity.
Reduction of the bowel is more easily and sudden
than the reduction of other organs.

23. • 6- Incarcerated hernias present as tense,
painful swelling which are usually
irreducible occasionally gas in the
entrapped. Intestine may have been
dispersed during transport to a surgical
facility or by gentle pressure allowing
reduction to be achieved

24. • Umbilical hernia 'omphalocele-
exomphalos'
• Definition: an umbilical hernia is that one
which its hernial ring is formed by the
umbilicus.

25. • Occurrence: it occurs in all animals .
• Aetiology: the condition may either
congenital due to failure of abdominal wall
to close or develop at 3-4 weeks of age.
Excessive straining to defecate or micturate
and infection of the umbilicus may be
causative factor

26. Symptoms
• An umbilical hernia usually shows an oval
localized soft not painful compressible and mostly
reducible swelling vary in size from one to several
centimeters in diameter. At the depth of the hernia
one can easily detect the hernial ring which is
passable for 2-3 fingers.
• Course: the majority of small hernias close
spontaneously as the animal get older; and it has
customary to wait until the animal is 6-12 months
old before attempting surgery. Large defects show
little tendency to spontaneous closure.

27. Fig.3: Umbilical hernia inFig.3: Umbilical hernia in
foal (A), after dissectionfoal (A), after dissection
and freeing of the hernialand freeing of the hernial
sac 1cm peripheral to thesac 1cm peripheral to the
hernial ring (B).hernial ring (B).
Herniorrhaphy wasHerniorrhaphy was
obtained by a series ofobtained by a series of
interrupted horizontalinterrupted horizontal
mattress sutures using ofmattress sutures using of
silk (C) .silk (C) .

28. • Diagnosis: hernia may confuse with an
abscess at the navel, confirmation is done
through an exploratory puncture, the
presence of the hernial ring and reducibility.
It must be differntiated also from the
tumours in the region of the umbilicus and
urachal cysts as the forementioned abscess
formation in the said region by the
exploratoy puncture.

29. Ventral hernia
• A ventral hernia is one that occurs through any
part of the abdominal wall other than the
umbilical or inguinal canal.
• Aetiology: they may be traumatic in origin or
incisional kicks, collisions with blunt objects and
straddling gates are common cause
• It may develop from rupture of the abdominal
muscles e.g. the rectus abdominis as may happen
in cases of advanced pregnancy

30. • Occasionally the abdominal wall may be so
weakaned by an abscess that, following its
evacuation, a hernia froms. This fact must
be taken into consideration when opening
abdominal wall's abscesses. Here the hernial
sac consists only of the skin and parts of the
subcutis since to peritoneum is usually
ruptured together the musculature

31. • In recent lesions there is a swelling often covered
by a haematoma. The hernial ring is often not
palpable until after regression of the haematoma
and tissue reaction caused by the trauma.
• In small hernias, the hernial contents usually
consist of omentum or intestine but a large tear
will allow a large mass of viscera (e.g. large
colon) to escape from the abdomen, but the size of
the swelling is not necessarily an indication of the
size of the defect because a considerable length of
small intestine can escape through a small rent

32. • When the acute symptoms have
disappeared, it is usually possible to palpate
the hernial ring as a slit or very often as a
tear with irregular edges (diagnostic).
• Size: Varies from that of a fist to a man's
head and may be larger.

34. Diagnosis
• Is confirmed as soon as the hernial ring has been found,
the ability to reduce the hernial parts further confirms the
diagnosis (Reducibility). Sometimes adhesion between the
sac and the contents of the hernia may interfere with the
process of reduction of the later. In doubtful cases it may
be necessary to carry out an exploratory puncture with
a fine bore trocar under aseptic precautions.
• In may cases, rectal examination may also be of great
value. It must be remembered that haematoma and
abscesses may cover and completely mask a traumatic
ventral hernia.

35. Treatment
• The aim of treatment is to replace and then to
ensure retention of the hernial contents. In dogs
and cats, it is ensured with the use of a bandage. In
cattle and horses, this is done by a gauze pressure-
cushion which is fixed in position with a purse
string suture placed as deeply in the tissue as
possible.

36. • In both small and large animals operative
interference is contra-indicated between the
first to the tenth day of development of the
hernia when the hernia is not accompanied by
signs of intestinal obstruction, it is advisable to
delay surgery for 3-6 weeks until some swelling
has subsided and deposition of collagen has
increased the tensile strength of the damaged
tissues as one cannot expect sutures to hold in
the infiltrated tissues surrounding it

37. • The rent in the abdominal wall is closed
by overlapping the edges with a heavy
suture material and the technique is same as
described for umbilical hernia. Interrupted
sutures can be placed between the
overlapping sutures for reinforcement.

38. • When the defect is very large or its
edges are too rigid to appose by suture,
satisfactory repair may be achieved using
mesh. Following closure of the peritoneum
and transverse muscle by suture, a piece of
polypropylene mesh is sutured to the deep
face of the internal oblique aponeurosis.

39. • N.B. When the hernia is apparently harmless,
herniorrhaphy is elective and not an emergency
operations while signs of depression, abdominal
discomfort and cessation of defecation indicate
intestinal obstruction requiring prompt
intervention.
• Postoperative management: the amount of feed
should be reduced to half for about a week after
surgery. A supportive bandage may be placed
around the abdomen to relieve tension on the
healing tissue