Hernias of the antero-lateral wall of the abdomen -particular forms-

1. Hernias of the antero-lateral wall of the abdomen-particular forms-

2. Inguinal hernias

3. Anatomy briefing • Definition: hernias produced through a defect situated on the posterior wall of the inguinal canal • Inguinal canal: a space designed for the passage of • Testis – peritoneal diverticula present at birth • Round ligament – peritoneal diverticula present at birth (Nuck) • Major opening in the mucsculo-fascial structure of the abdominal wall

4. Inguinal canal

5. Inguinal canal - structure • Anatomic structures are dynamic – description represents a schematic view • 4 walls (anterior, posterior, superior and inferior) • 2 orifices: internal and external

6. Fascia of the external oblique muscle Fascia ends in 2 pillars Spina pubis Anterior part of pubic bone and rectus sheat Anterior wall

7. Inferior wall • Inguinal ligament • Concavity opened above • Internally – it reflects fibers towards the pectineal ridge = the triangular ligament of Gimbernat and prolonges on the pubic branch of the iliac bone forming one body with the ligament of Cooper – solid strutcture

8. Inferior wall

9. Superior wall • Inferior border of internal oblique and transversus : the conjoined ligament • Fusion of the structures is NOT the rule • The resultant structure is not fibrotic and sometimes very friable – not suitable for suturing

10. Posterior wall • Fascia transversalis in it’s way towards the vascular sheat • Ligament of Thompson (inferiorly) • 2 fibrotic structures ligaments of Henle and Hasselbach

11. Posterior wall • Weak anatomic region predisposed to hernia formation • Muscular structures are supposed to close the defect during effort • Inferior eipgastric vessels separate 3 parts • Profound inguinal orifice (external oblique hernia) • Middle part (medial to the epigastric vessels)– direct inguinal hernia • Internal part (medial to the umbilical artery) inetrnal oblique hernia

12. Orifices • Profund (lateral or internal) • Situated in fascia transversalis – the external part • A weak point of the abdominal wall • Superficial (medial or external) • Between the pillars of the fascia of the external oblique muscle • The place where a hernia engages towards the scrotum • Place to introduce finger for palpation

13. Content of the inguinal canal • Women: round ligament + vessels • Men: spermatic cord • cremaster • vas deferens • spermatic artery • deferntial artery • 2 venous plexuses • Nervous branches (ilio-hipogastric, ilioininguinal, genital)

14. Shall we all develop hernia? • There is a content passing from the abdomen to scrotum • BUT • The trajectory is oblique through muscles and during effort the structures are compressed together • Oblique muscles work as a curtain and close the defect • Internal orrifice is strangulate during effort

15. External oblique inguinal hernia • Congenital: persistentce of the peritoneal diverticula through which the testis migrated in scrotum. Frequently associated with abnormal migration of the testis. • Complete form with totaland free comunication from the peritoneum till scrotum • Incomplete forms – vaginala testicularis is separeted +/- hydrocele or cystic remnants in the spermatic cord.

16. External oblique inguinal hernia • Acuired : migration of the peritoneal sac • Herniation point • Interstitial hernia • Inguino-pubic hernia • Inguino-scrotal henria

17. Clinical signs • Common signs for all hernia • Digital exploration through the superficial orifice • Evaluation of the defect • Relations with the epigastric vessels = variety of hernia

18. Differential diagnosis • Uncomplicated interstitial hernia • Ectopic testis • Cysts of the spermatic cord • Solid tumors • Uncomplicated inguino-pubic hernia • Crural hernia (line of Malgagine) • Lypoma of labia major • Cyst of the Nuck canal • Inguino-scrotal hernia • Hydrocel • Varicocel • Testicular tumors

19. Direct inguinal hernia • A weak point hernia • The area of weakness is the middle inguinal area (between the epigastric artery and remnant of the umbilical artery) • Sac is completely separated from the spermatic cord which is pushed away

20. Particularities • Frequently in older people, associated with other hernias • Frequently bilateral • Generally small and do not descend in the scrotum, trajectory being perpendicular on the inguinal ligament. • Defect is large – unlikely to produce comlications

21. Differential diagnostic • Mostly with the external oblique hernia

22. Treatment of Inguinal Hernia • Objectives: • Resection of the hernia sac • Treatment of the defect – a solid wall to prevent hernia recurrence LARGE VARIETY OF TECHNIQUES

23. Operative principles • Incision of superficial structures and isolation of spermatic cord.

24. Isolate the hernia sac and the structure migrated with the peritoneal layer (lipomas)

25. Open the hernia sac • Control de content • Resction of the sac and suture the peritoneal defect

26. Posterior wall repair • GOAL – prevent recurrences • “Anatomical” procedures • Behind the spermatic cord (Bassini, Shouldice, McVay) • In front of the spermatic cord (Kimbarowski, Forgue) • Procedures that use a synthetic structure (mesh repair) – respect the principle of tension-free repair.

27. Behind the cord repair procedures

28. Mesh repair

29. Laparoscopic mesh repair

30. Orthopedic treatment • ONLY when the patient refuses operations or major contraindication for surgical repair

31. Femoral hernia

32. Anatomy • Through the femoral ring in the triangle of Scarpa • Femoral ring: • Inguinal ligament (ant) • pectineal fascia and ligament of Coopper (post) • lig Gimbernat (internal) • ileo-pectineal ligament (ext)

33. Variants • Herniation point – incomplete (under the cribriform fascia) – complete • Prevascular, retrovascular, external • Laugier (through the fibers of the ligament of Gimbernat) • Femuro-pectineal (under the pectineal fascia) • Multi-divericular • In combination with inguinal hernia – distension of the groin

34. Higher incidence in women • 4x more frequent in women • Diameter of the pelvic girdle is larger • Accentuated lordosis in lumbar area • Pregnancies: weakens the abdominal wall + sustained increase in intraabdominal pressure

35. Pathological particularities • Small sac, pear-like, well delimitated neck which is fibrotic • DIFFERENCES from other hernia: multiple layers like the onion skins (skin, subcutaneous tissue, cribriform fascia, properitoneal tissue, fascia transversalis) • Content: any organ, including caecum, apendix, colon, urinary baldder) • Major risk for complications, especially the strangulation – lateral pinch

36. Clinical signs - particularities • Few or no functional signs: little pain or heaviness in the groin or during extension of the hip. • +/- digestive symptoms (colicky pain, urinary symptoms) more often believed to have another sourceTYPICALLY the signs indicate and abdominal suffering and the physician does not explore the groin

37. Clinical examination • Small pseudo-tumor in the Scarpa triangle , most typical medial to the femoral vessels. INCONSTANT • Round or oval shape • Prolonged under the inguinal ligament – if the tumor can be felt • Frequently obese patients with lare subcutaneous fat layer

38. Clinical examination • Consistency is elastic or granular – atypical for a hernia • IREDUCIBLE but not associated with a loud symptomatology in the groin • IMPULSION AND EXPANSION are either absent or faint • High percentage are complicated at presentation

39. Differential diagnosis • REDUCIBLE: • Inguinal hernia (line of Malgaigne) • Varicose vein • Aneurism of the superficial femoral artery • Tuberculous (cold) abscess migrated in the Scarpa triangle

40. Differential diagnosis • IREDUCIBLE: • Strangulated inguinal hernia • Cyst of the canal of Nuck • Ectopic testis • Lypoma • Lymphnode enlargement • Venous thrombosis • Hematoma

41. Treatment • Principles same with all hernia • Access: • femoral • inguino-femoral • inguinal • Parietal reconstruction: • Closing the femroal ring by suturing the inguinal ligament to Cooper ligament and pectineal fascia • Suturing the conjoined tendon to Cooper ligament • Mesh prosthesis

42. Umbilical hernia

43. A. Congenital • Failure in the development of the abdominal wall • Embryonic form (defect appears before the 3rd month and organs are not covered by peritoneum – not real hernia • Fetal form – covered by peritoneum

44. Pathology • Translucent covering (displastic wall) without vessels and muscles • You can see abdominal viscera through the wall. Content can be as much as the whole abdominal content

45. Clinical aspects • Large ventral tumor, present at birth and surrounded by a skin ring • Transparent wall: abdominal visceraEVOLUTION: spontaneous rupture + death TRATAMENT: surgical- small defects: as in hernia- large defects: skin flaps +/- serial operations

46. B. Umbilical hernias of the child • Causes: • Weak umbilical scar (infection, distension) • High intraabdominal pressure (crying, coughing, fimosis, etc • Pathology: • Small sac with a large neck, little chances of strangulation

47. Treatment • Conservative: if • Less then 2 years • Less then 2 cm diameter • Has to be maintained reduced via a skin fold until spontaneous closure • Surgical: • Resection of the sac • Parietal repair

48. Weak point Obese women, multiple pregnancies, chronic peritoneal dyalisis, ascites. C. Umbilical hernias of the adult

49. Particularities • Direct herniation most typically (indirect machanism is possible if the ring is asymmetrically positioned) • Sac initially small may become multidiverticular + changes generated by the degenration of the sac by expnasion • Rigid neck – strangulation factor • Content: most frequent properitoneal fat, but viscus can migrate as well

50. Clinical signs • Pain on effort +/- digestive symptoms • Typical signs of hernia with a major tendency to become irreducible • If palpation of the ring is possible – large, round, rigid defect