Abdominal Wall Hernias

1. Abdominal Wall Hernias

2. Hernia • Definition:A hernia is an abnormal protrusion of a viscus through the wall of a cavity which normally contains it. • It may be through a congenital/acquired opening • in the presence of continued or repeated  intra-abdominal pressure

3. Direct inguinal hernia Indirect inguinal hernia Femoral hernia Obturator hernia Sciatic hernia Perineal hernia Umbilical hernia Paraumbilical hernia Epigastric hernia Hiatus hernia Diaphragmatic hernia Incisional hernia Spigelian hernia Types of Hernias

4. Development of a hernia • In young age group: congenital potential space • In old age group: gradual onset and slow enlargement due to weakness in the abdominal wall

5. Predisposing factors • Congenital defect, e.g. • persistence of processus vaginalis • incomplete obliteration of umbilicus • persistent communication between abd. and thorax • Acquired defect, e.g • surgical incisions • muscle weakness due to ageing/ nerve injury and wasting/ fatty infiltration/ pregnancy

6. Precipitating factors • Chronic cough • constipation • straining at micturition • childbirth • vomiting • severe muscular effort • ascites - fluid may increase the size of an existing sac

7. Contents in a Hernia • Usual: omentum, small bowel • Sliding hernia: content with partial peritoneal cover such as: sigmoid colon, urinary bladder • Ritcher’s hernia: part of the small bowel wall was in the hernia with perforation but no obstruction

8. The contents of the sac • Reducible • irreducible • obstructed, or • strangulated

10. SACRUM ILIUM ILIUM The inguinal ligament runs from the anterior superior iliac spine to the pubic tubercle Anatomy

11. Site / Origin • Inguinal • Inguino-scrotal • Isolated in scrotum

12. Groin hernias • indirect inguinal • direct inguinal • femoral

13. Nyhus Classification • Type I--indirect inguinal hernia • Internal inguinal ring normal (i.e. paediatric hernia) • Type II--indirect inguinal hernia • Dilated internal inguinal ring with posterior inguinal wall intact • Type III--posterior wall defects • Direct inguinal hernia • Indirect inguinal hernia: dilated internal ring with large medial encroachment on the transversalis fascia of the Hesselbach's triangle (i.e. massive scrotal, sliding hernia) • Femoral hernia • Type IV--recurrent hernia

14. Inguinal Hernias - Anatomy

16. Indirect inguinal hernia • most common in young males • enters the inguinal canal through the deep ring • the sac often extends, following the line of the spermatic cord (over the pubic crest) into the scrotum • the neck of the sac is narrow

19. Direct inguinal hernia • Common in older men with weak abdominal muscles • Often bilateral • the sac bulges forward thro’ the posterior wall of the inguinal canal, medial to the inferior epigastric vessels • Does not extend into scrotum • the neck of the sac is wide

21. Femoral hernia • Less common than inguinal hernias • occur more frequently in females • the sac descends thro’ the femoral ring and canal, thro’ the saphenous opening of the fascia lata. • Blunts the groin crease • (both types of inguinal hernia increase the crease) • it has a narrow neck

23. Main Points in History • Age: young or old? • Factors for increase abdominal pressure • Started with a smaller swelling • Disappears on lying down • Gurgling noise inside the swelling • Pain and dragging discomfort • Intestinal obstruction

24. Physical Examination Three important steps MUST be taken • Patient standing for the examination - cough impulse and cannot get above the swelling • Lying down to reduce the hernia by patient • Try to hold back the hernia with the thumb at the internal ring while standing will distinguish direct from indirect inguinal hernia

25. Anatomical Landmarks • Anterior superior iliac spine • Pubic tubercle • Inguinal ligament • Mid-inguinal point • Interrnal inguinal ring • To distinguish direct/indirect hernia

26. Examination of the patient with a hernia • With the patient supine look for • signs of systemic toxicity • intestinal obstruction or • inflammation of the abdominal wall • visible bulge, effect on groin crease and • a visible impulse on coughing allow the patient to attempt reduction of the hernia in the supine position

27. palpate for • cough impulse in the area of abdominal wall weakness, note any tenderness Reducible hernia; • place a finger over the deep ring and allow the patient to stand • ask the patient to hold nose and blow • if the hernia appears after release of your finger, then it is an INDIRECT inguinal hernia

28. Scrotal Masses • Can you get ABOVE the swelling? • Where is the mass arising from? • The mass itself cystic/transilluminate? • The mass hard and the surface irregular?

29. Scrotal swellings • Painful + firm • Torsion • Acute inflammation (orchitis/ epididymitis) • Painless + firm • Neoplasm • Chronic inflammation • haematoma • Soft • Varicocele • Hydrocele • Epididymal cyst

30. Varicocele • Grade 1 - palpable with Valsalva • Grade 2 - palpable without straining • Grade 3 - can be seen on inspection • Bag of worms in 15% of young man • More common on the left side • 30% infertile patients have varicocele

31. Varicocele • Usually cause discomfort after running • Spermatogenesis impaired due to hypoxia, elevated temperature and reflux of metabolites • Treatment by Ligation of the veins • Varicocele in older man may indicate left renal carcinoma with renal vein involvement

32. Torsion of Testis • To distinguish from Orchitis • Both are acute painful swelling of the testis • Treatment is different • Age, fever, venereal exposure… • Types of torsion - extra-vaginal, intra-vaginal, • Torsion of the undescended testis

33. Empty Scrotum • Undescended testis • Ectopic testis • Retractile testis

34. Hydrocele • Accumulation of fluid in the tunica vaginalis • Short history - thin wall and transilluminate • Long history - thick wall and ?previous trauma • Cystic mass, the testis is within the sac and therefore NOT palpable • Can get above the swelling • Surgery - Jaboulay’s operation

35. Trauma to the Scrotum • Haematocele of the testis • Rupture of the testis • Fracture of the penis • Trauma to the bulbous urethra • Laceration of the scrotal skin

36. Testicular Tumour • Hard and irregular swelling of the testis • Spermatic cord normal • Types - germ cell, non germ cell, secondary metastasis, paratesticular tissues • Must palpate the abdomen for central supra-umbilical masses (lymph nodes)

37. Indication for Surgery • Risk of complications such as strangulation and intestinal obstruction • Pain and mass interfere with function • Conservative treatment

38. Principles of Surgery • Reduction of the contents • Excision of the hernial sac • Repair of the defect • Difficult in case of large hernia and large defects

39. Historical developments 1700 BC: Hammurabi (Babylon) – Hernia reduction / bandaging 1363 : Guy de Chauliac – Distinguished inguinal from femoral hernia for the first time in Chirugia Magna 1. Reinforcing the anterior wall and narrowing the external ring • Eg Repair by ligation of hernial sac and cicatrization with healing by secondary intention (Caspar Stromayr, 1559) 2. Reinforcing the posterior wall and narrowing the internal ring • 1881 Splitting of external oblique + ligation of sac at internal ring (Lucas-Championnière) • 1889 Suturing of threefold layer (internal oblique, tranversus abdominis + transversalis fascia) to inguinal ligament (Bassini) • 1939 Subcutaneous shift of spermatic cord (Kirschner) • 1969 Duplication of transversalis fascia (Shearburn – as per Shouldice) • 1987 Application of alloplastic material (Lichtenstein) 3. Reinforcing the posterior wall and narrowing the internal ring from intraabdominally • 1891 During laparotomy for other indication (Tait) • 1990 Laparoscopic hernia repair (Popp)

40. Hernien Open hernia repair • Bassini • Shouldice • Lichtenstein • Robbins-Rutkow • Prolene Hernia System CHIRURGISCHE KLINIK UKBENJAMIN FRANKLIN FU BERLIN

41. Repair under Tension • 1889 Bassini - Suturing of threefold layer (internal oblique, tranversus abdominis + transversalis fascia) to inguinal ligament • Tension created during repair with recurrence rates generally around 10% • Best results reported by Shouldice using his technique in a dedicated hernia hospital – recurrence of only 0.8%

42. Hernioplastik n. Bassini Bassini CHIRURGISCHE KLINIK UKBENJAMIN FRANKLIN FU BERLIN

43. Hernioplastik n. Shouldice Shouldice CHIRURGISCHE KLINIK UKBENJAMIN FRANKLIN FU BERLIN

44. Hernioplastik n. Lichtenstein Lichtenstein CHIRURGISCHE KLINIK UKBENJAMIN FRANKLIN FU BERLIN

45. Preperitoneal Approach • Originally described by Stoppa • Mesh placed between peritoneum and abdominal wall • Precursor to laparoscopic repair techniques

46. The Lichtenstein Technique • Mesh repair popularised by Lichtenstein – published a series of 1000 patients with no recurrences in 1-5 yr follow-up • Mesh repair for ALL hernias • Local anaesthetic • Day case surgery • Same day ambulation Am J Surg, 1989. 157 (2): 188-93

47. Lichtenstein Hernia Repair

48. Local anaesthetic

50. Prolene Hernia System