Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Hernias
Ákos SZŰCS M.D.
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Pathomorphology
Each abdominal hernia consists of
• hernia gate
• hernia sac
• hernia contents
Hernia sac forms by outpouching of parietal
peritoneum and can contain small intestine and
omentum. Sometimes it containes other organs:
large intestine, urinary bladder, ovary, and
appendix.
• The main parts of the hernia pouch are neck, body
and fundus.
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Common Presentations
A lump
• Comes and goes
• Appears on straining /coughing
A pain
• Dragging pain/ Pain on exertion
Incidental finding on examination/ imaging
Presenting as a complication
• Incarceration/ Intestinal obstruction
.
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Common Presentations
Dg:
•Anamnesis and physical examination
–Inspection may reveal an obvious swelling in the inguinal
area. If he has a small hernia, the affected area may simply
appear full.
–As part of your inspection, have the patient lie down. If the
hernia disappears, it's reducible
–Auscultation should reveal bowel sounds. The absence of
bowel sounds may indicate incarceration or strangulation.
–Palpation helps to determine the size of an obvious hernia. It
also can disclose the presence of a hernia in a male patient.
•Sonography of the hernia pouch.
•Plain X-ray for suspected bowel obstruction
•Common blood analysis.
•Common urine analysis.
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Inguinal hernia
Anatomy:
Anatomy:
•„Corona Mortis”
• Hernias are divided into two main
groups: congenital and acquired.
The main reason of congenital hernias
is malformation. Thus, inguinal hernia
arose in case of no closure of the
process of peritoneum, which passes
by inguinal channel during descending
the testis. On such hernias testis is
located in the hernia pouch. Acquired
inguinal hernia has hernia pouch and
testis located outside it.
–is an anatomical variant, an
anastomosis between the obturator
and the external iliac or inferior
epigastric arteries or veins
–It is located behind the superior
pubic ramus at a variable distance
from the symphysis pubis
–The name "corona mortis" or
crown of death testifies to the
importance of this feature, as
significant hemorrhage may occur if
accidentally cut and it is difficult to
achieve subsequent hemostasis
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Inguinal hernia
Th:
•Bassini repair
•Shouldice repair (tension free technique)
•Lichtenstein repair (using a mesh)
•Laparoscopic hernia repair
–(TEP – totally extraperitoneal)
–(TAPP - transabdominal preperitoneal)
–(IPOM - intraperitoneal onlay mesh)
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Femoral hernia
Etiology:
•Accounts for 4% of Groin Hernias
•More common in elderly women
•Gender predisposition: Female by 3 to 1 ratio
Pathophysiology:
•Associated with increased intraabdominal pressure
•Hernia sac bulges into femoral canal
–Femoral canal lies immediately medial to femoral vein
–The femoral canal is the way that the femoral artery, vein, and nerve leave the
abdominal cavity to enter the thigh.
–Although normally a tight space, sometimes it becomes large enough to allow
abdominal contents (usually intestine) into the canal.
•This hernia causes a bulge below the inguinal crease in roughly the
middle of the thigh.
•Rare and usually occurring in women, these hernias are particularly at risk
of becoming irreducible and strangulated.
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Umbilical hernia
Etiology:
•These common hernias (10-30%) are often noted at birth as a
protrusion at the bellybutton (the umbilicus).
•This is caused when an opening in the abdominal wall, which
normally closes before birth, doesn’t close completely.
•Even if the area is closed at birth, these hernias can appear
later in life because this spot remains a weaker place in the
abdominal wall.
•They most often appear later in elderly people and middleaged women who have had children
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Incisional hernia
Etiology:
•Abdominal surgery causes a flaw in the abdominal wall that must
heal on its own.
•This flaw can create an area of weakness where a hernia may
develop.
•This occurs after 2-10% of all abdominal surgeries, although some
people are more at risk
•Risks for postoperative hernia development
–Vertical scar more commonly affected than horizontal
–Wound infection
–Wound dehiscence
–Malnutrition
–Obesity
–Tobacco abuse
•After surgical repair, these hernias have a high rate of returning
(20-45%).
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Umbilical and incisional hernia
Th:
•Mayo repair:
–After the Mayo method defect of anterior abdominal wall
in the umbilical ring is sutured by U-shaped stitches in
transversal direction
•Repair using a mesh:
–After the Mayo method defect of anterior abdominal wall
in the umbilical ring is sutured by U-shaped stitches in
transversal direction and placed a mesh
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Rare hernias
Spigelian hernia
Obturator hernia
Richter hernia
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Complications of hernia
Incarceration - strangulation
•Signs and sympthoms
–Clinical Features
–Physical Findings
•Dg:
–CBC (complete blood count) and electrolytes
–Abdominal x-ray series
–CT scan
•Th - Surgery:
–Resection is not needed (no irreversible damage)
–Resection is needed (irreversible damage)
Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Complications of hernia repair
•Nerve injury (n. ilioinguinalis, n. genitofemoralis)
•Vessel injuy (a.,v. femoralis, epigastrica inferior,
spermatica)
•Injury of the ductus deferens
•Injury of the bladder
•Bowel injury
•Infections
–Wound infection
–Infection of the implanted mesh