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ABDOMINAL HERNIAE

ABDOMINAL HERNIAE. LIDIA IONESCU 3 rd .Surgical Unit. DEFINITION. HERNIA= a protrusion of an organ through its containing wall Herniation of the muscle through its fascial covering Herniation of the brain through a fracture of the skull

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ABDOMINAL HERNIAE

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  1. ABDOMINAL HERNIAE LIDIA IONESCU 3rd.Surgical Unit

  2. DEFINITION • HERNIA= a protrusion of an organ through its containing wall • Herniation of the muscle through its fascial covering • Herniation of the brain through a fracture of the skull • Herniation of an intra-abdominal organ through a defect in the abdominal wall, pelvis or diaphragm-the term “hernia” is used to describe an abnormal opening in a patient’s muscle that will allow tissue or organs to pass through the opening in the muscle

  3. Abdominal herniae • Before an organ can herniate through its retaining wall – there must be a weakness in that wall: • Normal- related to the anatomical configuration • Abnormal weakness - congenital abnormality - acquired as a result of trauma or disease

  4. Types of hernias • Common types: • Inguinal • Umbilical • Femoral • Incisional hernia • Less common types: • Epigastric • Spigelian • Obturator

  5. Types of abdominal hernia

  6. BE AWARE • FAILURE TO DIAGNOSE ANY TYPE OF STRANGULATED HERNIA COMMON OR RARE MAY LEAD TO THE PATIENT’S DEATH

  7. Complications • Irreducibility- bowel obstruction- incarcerated bowel • Strangulation – bowel obstruction + necrotic bowel  

  8. Relation to gender • Inguinal hernia is common in men • Femoral hernia is more common in women

  9. Certain physical signs • Occur at weak spots in the abdominal wall • Reduce on lying down or with direct manual pressure • Expansive cough impulse

  10. Etiology • Defects in the abdo wall: • Structures pass through: indirect inquinal, epigastric • Muscles fail to overlap: spigelian, lumbar • No muscles, only scar tissue: umbilical hernia • Loss of tissue strength: • Direct inquinal hernia • Increased intra-abdo pressure • Trauma

  11. He had his hernia repaired

  12. Inguinal hernia • This type of hernia accounts for the vast majority of hernia surgical repairs. • An inguinal hernia is located in the inguinal region of the body where the thigh meets our pelvis. • The most common types of inguinal hernias are either direct or indirect hernias and these are found more often by far in men rather than women.

  13. Inguinal hernia

  14. Inguinal and femoral hernia • It is possible to develop three types of hernia in, or close to the inguinal region: direct inguinal; indirect inguinal; femoral. • Each opening (the deep and superficial inguinal rings) is visible and “protected” by two of the muscle layers. • The muscles and their aponeuroses were clearly defined and two of them (internal oblique and transversus abdominis) could be seen arching over the canal to form its roof and then its posterior wall (conjoint tendon).

  15. Inguinal hernia

  16. Inguinal herniaPre and post-op. aspect

  17. Descriptive terms • Reducible hernia- hernia content can be pushed back into the abdomen • Irreducible hernia-incarcerated hernia- hernia content cannot be pushed back • Obstructing hernia- hernia containing a loop of bowel that is kinked and therefore obstructed • Strangulated hernia-the tissue contained in the hernia is ischemic due to interruption of the blood supply • Sliding hernia-when the wall of the hernia sac in part formed by the wall of another intra-abdominal organ( colon, bladder) • Richter’s hernia-one side of the bowel wall is trapped in the hernia

  18. Complications • Intestinal obstruction- a loop of bowel passes through the abdo. wall defect and becomes mechanically obstructed. • Intestinal strangulation with gangrene/perforation – vascular pedicle to the herniated loop of bowel is also interrupted

  19. Inguinal herniaAnatomy of the inguinal region • Superficial inguinal ring- triangular defect in the aponeurosis of the EOM and the pubic crest • Deep inguinal ring- an oval opening in the fascia transversalis, 1,3 cm. above the mid-inguinal ligament. • Medially- inf. epigastric vessels • Inguinal canal- oblique passage through the lower part of the anterior abdominal wall • Spermatic cord • Round ligament

  20. Inguinal canal • 1. Inguinal canal • 2. Spermatic cord • 3. Testis • 4. Uterus • 5. Round ligament • 6. Lymph vessels • 7. Superficial inguinal nodes • 8. Deep inguinal ring • 9. Superficial inguinal ring

  21. Inguinal canal • 4 cm. long, between deep and superficial rings • Anterior wall- EOM aponeurosis • Inferior wall- inguinal ligament • Superior wall- conjoint tendon • Posterior wall- transversalis fascia • Hesselbach’s triangle- within the posterior wall: inf.epi.art.- inguinal lig.-lateral border of the rectus sheath

  22. Types of inguinal herniae • Indirect inguinal herniae • Passes through the deep inguinal ring, down the inguinal canal • May extend into the scrotum • 5 times commoner than direct hernia • Direct inguinal hernia • Passes through the Hesselbach triangle • Posterior to the spematic cord • Does not pass into the scrotum • Less often associated with strangulation

  23. Symptoms and signsInguinal hernia • Gender- all ages • Occupation- heavy works • Local symptoms- dragging sensation in the groin • Systemic symptoms- obstructive hernia- vomiting, distension, colicky abdominal pain, absolute constipation

  24. Inguinal herniaPhysical examination • Position- above the inguinal ligament • Tenderness- if strangulated • Shape- “pear-shaped” with the “stalk” at the external inguinal ring • Composition- soft-gut, firm-omentum. • Cough impulse • Reducibility

  25. Inguinal herniaGeneral examination • Look for causes of a raised intra-abdominal pressure: • Chronic bronchitis- caughing • Chronic retention of urine- difficulty in micturition • Chirrhosis - ascites • Intra-abdominal masses Look for signs of intestinal obstruction: - Abdominal distention - Visible peristalsis - High-piched bowel sounds

  26. Inguinal herniaDifferential diagnosis • Femoral hernia • Vaginal hydrocele • Undescended testis • Lipoma

  27. Femoral herniaAnatomy • Femoral canal – space containing lymphatic and fat tissue • Femoral ring: inguinal ligament, Cooper’s ligament, pectineal line, femoral vein

  28. Femoral canal

  29. Femoral hernia

  30. Femoral hernia • Femoral ring is rigid- strangulation more likely • The bulge can be palpated in inguinal crease, below inguinal ligament • Obese patients- difficult to palpate • Think to a complicated femoral hernia in an obese patient with painful femoral area and bowel obstruction symptoms • More common in women • Related with physical effort

  31. Femoral canal

  32. Symptoms and signsFemoral hernia • Age - uncommon in kids • Gender -women more affected • Position - below and lateral to the pubic tubercle • Tenderness - not tender unless complicated • Shape and size - spherical, small • Surface - smooth • Reducibility- firm pressure • Cough impulse - tight ring- less likely

  33. Differential diagnosisFemoral hernia • Inguinal hernia • Enlarged lymph nodes • Sapheno-varix • Ectopic testis • Psoas abscess • Lipoma

  34. Umbilical hernia

  35. Umbilical hernia • This type of hernia occurs at the level of the naval and are usually the result of the failure of the abdominal wall defect to close after the patients umbilical cord falls off as an infant. Most of these hernias defects will close in childhood by the age of 3-5. • Remaining umbilical hernias however can enlarge over time and require repair in the adult patient.

  36. Congenital umbilical hernia • 90% of cases, defects are closed by the age of one year • 99% by 2 years of age • Surgery is contraindicated below the age of 3 years

  37. Acquired umbilical hernia • Adult hernia through the umbilical scar • Secondary to a raised intra-abdominal pressure

  38. Umbilical hernia • Congenital umbilical hernia • Acquired umbilical hernia • Para-umbilical hernia

  39. Para-umbilical hernia • Acquired umbilical hernia • Appears through a defect that is adjacent to the umbilical scar

  40. Umbilical hernia

  41. Marked ascites and an umbilical hernia, which had ruptured a few days before the photograph, in a patient with cirrhosis and portal hypertension secondary to hepatitis C.

  42. Spigelian hernia • This type of hernia  is a rare form of hernia defect that can occur at the level of the umbilicus but actually lateral to it. • These hernias are often difficult to diagnose

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