الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجراحة المرحلة الرابعة

1. M.A.K الجامعة السورية الدولية الخاصة للعلوم و التكنولوجياكلية الطب البشريقسم الجراحةالمرحلة الرابعة الدكتور عاصم قبطان MD – FRCS

2. HERNIA M.A.K A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity

3. M.A.K Anatomical location of Hernias • External Hernia . • Internal Hernia .

4. M.A.K External Hernia The most frequent varieties accounting for 75% of cases being the : • Inguinal . • Femoral . • Umbilical . • Paraumbilical hernia

5. M.A.K

6. M.A.K General features common to all hernias Aetiology • Any condition that raises intra-abdominal pressure • Hernias are more common in smokers, which may be the result of an acquired collagen deficiency • the appearance of a hernia in an adult can be a sign of intra-abdominal malignancy • Stretching of the abdominal musculature because of an increase in contents, as in obesity

7. M.A.K Intra-abdominal pressure raised in • powerful muscular effort. • Whooping cough is a predisposing cause in childhood . • Chronic cough . • Straining on micturition . • Straining on defaecation .

8. M.A.K Composition of a hernia • The sac . • The covering . • The content.

9. M.A.K The sac • The sac is a diverticulum of peritoneum, consisting of mouth, neck, body and fundus . • The diameter of the neck is important . • The body of the sac varies greatly in size . • In cases occurring in infancy and childhood, the sac is gossamer thin.

10. M.A.K The covering • Coverings are derived from the layers of the abdominal wall . • In longstanding cases they become atrophied from stretching and so amalgamated that they are indistinguishable from each other.

11. M.A.K Contents • omentum • Intestine : commonly small bowel but may be large intestine or appendix. • A portion of the circumference of the intestine = Richter’s hernia. • A portion of the bladder (or a diverticulum) may constitute part of or be the sole content of a direct inguinal, a sliding inguinal or a femoral hernia • Ovary with or without the corresponding fallopian tube. • A Meckel’sdiverticulum = a Littre’s hernia; • Fluid, as part of ascites.

12. M.A.K Classification A hernia can be classified into five different types • Reducible – contents can be returned to abdomen • Irreducible – contents cannot be returned but there are no other complications . • Obstructed – bowel in the hernia has good blood supply but bowel is obstructed . • Strangulated – blood supply of bowel is obstructed . • Inflamed – contents of sac have become inflamed

13. M.A.K Reducible & Irreducible hernias Reducible Hernia Irreducible Hernia • The hernia either reduces itself when the patient lies down . • Can be reduced by the patient or the surgeon. • The intestine usually gurgles on reduction . • Omentum, in contrast, is described as doughy . • A reducible hernia imparts an expansile impulse on coughing. • The contents cannot be returned to the abdomen • It is usually due to adhesions between the sac and its contents . • Note that any degree of irreducibility predisposes to strangulation .

14. M.A.K An expansile impulse on coughing

15. M.A.K Obstructed & Incarcerated Hernia Obstructed Hernia Incarcerated Hernia • This is an irreducible hernia containing intestine that is obstructed from without or within . • The symptoms (colicky abdominal pain and tenderness over the hernia site) . • Usually there is no clear distinction clinically between obstruction and strangulation . • The safe course is to assume that strangulation is imminent and treat accordingly. • This term is correctly employed only when it is considered that portion of the colon occupying a hernial sac is blocked withfaeces. • The contents of the bowel should be capable of being indented with the finger, like putty.

16. M.A.K Strangulated hernia • A hernia becomes strangulated when the blood supply of its contents is seriously impaired . • Gangrene may occur as early as 5–6 hours after the onset of the first symptoms. • Inguinal hernia may be 10 times more common than femoral hernia . • Femoral hernia is more likely to strangulate because of the narrowness of the neck and its rigid surrounding .

17. M.A.K Pathology of Strangulated Hernia • Initially, only the venous return is impeded . • The wall of the intestine becomes congested and bright red with the transudation of serous fluid into the sac. • The intestinal pressure increases, distending the intestinal loop and impairing venous return further . • As venous stasis increases, the arterial supply becomes more and more impaired.

18. M.A.K Continue • Blood is extravasated under the serosa and is effused into the lumen . • At this stage the walls of the intestine have lost their tone and become friable. • Bacterial transudation occurs secondary and the sac fluid becomes infected. • Gangrene appears at the rings of constriction . • The colour varying from black to green depending on the decomposition of blood in the subserosa. • The mesentery involved by the strangulation also becomes gangrenous. • Perforation of the wall of the intestine occurs, either at the convexity of the loop or at the seat of constriction. • Peritonitis spreads from the sac to the peritoneal cavity.

19. M.A.K Symptoms of strangulated hernia • Sudden pain, situated over the hernia . • Generalised abdominal pain, colicky in character and often located mainly at the umbilicus. • Nausea and subsequently vomiting ensue. • The patient may complain of an increase in hernia size.

20. M.A.K Signs of Strangulated Hernia • On examination the hernia is tense, On examination the hernia is tense . • Extremely tender and irreducible . • There is no expansile cough impulse. • The spasms of pain continue until peristaltic contractions cease with the onset of ischaemia. • Paralytic ileus , peritonitis , and septicaemia develop. • Spontaneous cessation of pain may be a sign of perforation .

21. M.A.K Richter’s hernia • Is a hernia in which the sac contains only a portion of the circumference of the intestine (usually small intestine). • It usually complicates femoral hernia . • Rarely, obturator hernias.

22. M.A.K Types of Strangulated Hernia • Strangulated Richter’s hernia . • Strangulated omentocele . • Inflamed hernia .

23. M.A.K Inflamed Hernia

24. M.A.K Suffering from colicky abdo pain due to strangulated hernia

25. M.A.K Inguinal hernia Surgical anatomy • The superficial inguinal ring . • The deep inguinal ring . • The inguinal canal about 3.75 cm . The relationships of an indirect inguinal and a femoral hernia to the pubic tubercle; the inguinal hernia emerges above and medial to the tubercle whereas the femoral hernia lies below and lateral to it.

26. M.A.K

27. M.A.K Natural history of inguinal hernias • Inguinal hernias in babies are the result of a persistent processusvaginalis . • Indirect inguinal hernia is the most common hernia of all, especially in the young. • Direct inguinal hernia becomes more common in the elderly .

28. M.A.K Inguinal hernia • Indirect hernias are most common in the young . • Inguinal hernia is more common on the right side in the male. • In adult males, 65% of inguinal hernias are indirect . • In adult males, 55% are right-sided. • The hernia is bilateral in 12% of cases. • Males are 20 times more commonly affected than females.

29. M.A.K Types of indirect inguinal hernia • Bubonocele. The hernia is limited to the inguinal canal • Funicular. The processusvaginalis is closed just above the epididymis. The contents of the sac can be felt separately from the testis, which lies below the hernia. • Complete (synonym: scrotal). rarely present at birth but is commonly encountered in infancy. It also occurs in adolescence or in adulthood. The testis appears to lie within the lower part of the hernia.

30. M.A.K Differential diagnosis in the male • Vaginal hydrocele . • Encysted hydrocele of the cord. • Spermatocele; • Femoral hernia; • An incompletely descended testis in the inguinal canal . • lipomaof the cord – this is often a difficult but unimportant diagnosis and it is usually not settled until the parts are displayed by operation.

31. M.A.K Herniating bladder wall Sliding Hernias

32. M.A.K Types of Indirect (oblique ) inguinal hernia

33. M.A.K Complete Funicular

34. M.A.K Complete ( Scrotal Hernia )

35. M.A.K Indirect Inguinal Hernia in elderly woman

36. M.A.K Direct inguinal hernia • In adult males, 35% of inguinal hernias are direct. • 12% of patients will have a contralateral hernia in addition . • A direct inguinal hernia is always acquired. • The sac passes through a weakness or defect of the transversalis fascia . • Women usually never develop a direct inguinal hernia .

37. M.A.K Predisposing factors to direct inguinal hernia and features • Smoking . • Occupations that involve straining and heavy lifting. • Damage to the ilioinguinal nerve (previous appendicectomy) .

38. M.A.K Features of direct inguinal hernias • All are acquired • They are most common in older men • They rarely strangulate

39. M.A.K Preoperative treatment of strangulated inguinalhernias • Resuscitate with adequate fluids • Empty stomach with nasogastric tube • Give antibiotics to contain infection • Catheterise to monitor haemodynamic state

40. M.A.K Non-operative treatment of hernias • Only indicated in children . • Forcible reduction must never be attempted .

41. M.A.K The essentials of the differential diagnosis between a femoral and an inguinal hernia

42. M.A.K Femoral hernia • Femoral hernia is the third most common type of primary hernia. • It accounts for about 20% of hernias in women and 5% in men. • Of all hernias it is the most liable to become strangulated . • Strangulation is the initial presentation of 40% of femoral hernias .

43. M.A.K Surgical anatomy of Femoral Hernia • The femoral canal occupies the most medial compartment of the femoral sheath and extends from the femoral ring above to the saphenous opening below. • The femoral canal contains fat, lymphatic vessels and the lymph node of Cloquet .

44. M.A.K Clinical features • Femoral hernia is rare before puberty . • Between 20 and 40 years of age the prevalence rises and this continues to old age . • The right side (Fig. 57.14) is affected twice as often as the left and in 20% of cases the condition is bilateral. • Adherence of the greater omentum sometimes causes a dragging pain. • Rarely, a large sac is present.

45. M.A.K Differential diagnosis • An inguinal hernia. • A saphenavarix. • An enlarged femoral lymph node. • Lipoma. • A femoral aneurysm. • A psoas abscess. • A distended psoas bursa. • Rupture of the adductor longus with haematoma formation.

46. M.A.K Umbilical hernia (Exomphalos ) • occurs once in every 6000 births • Small defects may result in the sac being tied off with cord • it is due to failure of all or part of the midgut to return to the coelom during early fetal life. • Large defects need a staged approach • Omphaloceles may be divided into those with a fascial defect less than 4. and those with a defect greater than 4 cm cmherniation of the umbilical cord.

47. M.A.K

48. M.A.K Paraumbilical Hernia in Adult • Supraumbilical hernia • Infraumbilicalhernia

49. M.A.K Small Umbelical Hernia

50. M.A.K Large Umbelical Hernia