Abdominal Wall Hernia

1. Back to Department of Surgery Trinity College Dublin Abdominal Wall Hernia Essentials MA MURPHY FRCSI

2. Objectives • Understand the term hernia • Basic anatomical knowledge • Clinical features of common hernia • Complications of hernias • Examination of a hernia • Differential diagnoses of a lump in the groin • Management of hernia

3. Hernia • A protrusion of an organ or tissue outside its’ normal compartment

4. Common External Hernias • ABDOMINAL WALL & GROIN • Midline • Umbilical • Para- umbilical • Epigastric • Inguinal • Direct/ Indirect/ Combined • Femoral • Incisional

6. 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

7. Inguinal Hernia • Commonest external hernia • Male preponderance • Infant / adult • Direct / indirect / combined • Weakness / increased pressure • Cause pain / discomfort • Carry risk of complications • Treated surgically

8. Inguinal Hernia - History OBJECTIVES • Establish differential diagnoses • Identify risk factors and significant co-morbid pathologies • (e.g. increased intra-abdominal pressure due to ascites or chronic airways disease)

9. Inguinal Hernia - History • Onset • Duration • Symptoms • Other hernia(e) • Irreducibility • Gastrointestinal system • Respiratory system • Surgery / anaesthesia

10. Inguinal Hernia - Examination • Surface markings • Anterior superior iliac spine • Pubic tubercle • Midpoint of inguinal ligament

12. Inguinal Hernia - Examination OBJECTIVES • Confirm diagnoses • Out rule differentials • Establish type • Determine contents • Reducibility • Identify co-morbid pathologies

13. Direct Post wall Less common Older Smaller Hesselbachs Medial Lower risk Indirect Deep ring 70% Congenital Scrotal Deep ring Lateral Strangulate Direct V’s Indirect

14. Inguinal Hernia • Examination • Standing / Lying Supine • Cough impulse • Reducibility • Contents • Bowel sounds • Scrotal contents

15. Differential • Direct /Indirect/Combined • Femoral hernia • Hydrocele • Lipoma • Lymph node • Testicular tumour • Saphenous varix

16. Inguinal Anatomy • The inguinal canal represents the oblique passage through the anterior abdominal wall of the vas deferens (round ligament) • It is 5cm long and lies directly above the medial half of the inguinal ligament

17. Inguinal Anatomy • Floor • Transversalis fascia • Medially the conjoint tendon • Roof • External oblique aponeurosis • Laterally the conjoint tendon • Skin and superficial fascia • Above • Conjoint tendon • Below • The inguinal ligament

18. Inguinal Anatomy • Three nerves • Ilio-inguinal (on not in) • Sympathetic fibers • Genitofemoral • Three layers of fascia • Internal spermatic (transversalis f.) • Cremasteric (conjoint tendon) • External spermatic (ext. oblique)

19. Inguinal Anatomy • Three arteries • Testicular (from the aorta) • Artery of the vas (external iliac) • Cremasteric (inferior epigastric) • Three other structures • The vas deferens • The pampniform plexus of veins • Lymphatics (to aortic nodes)

20. TESTIS CORD STRUCTURES

21. Inguinal Anatomy

22. Hernia Anatomy

23. Indirect Hernia

24. Direct Inguinal Hernia

25. Hernia Complications • Incarceration • Strangulation • Intestinal obstruction

26. Varieties of Hernias • Maydls • W loop of intestine • Richters • Partial inclusion of intestinal wall • Sliding hernia • Bladder • Sigmoid colon/ appendix

27. Richters’ Hernia

28. Maydls’ Hernia

29. Hernia Management • Investigations • None required for routine uncomplicated case • Plain X-ray for suspected bowel obstruction • Ultrasound in case of diagnostic uncertainty • Herniogram rarely used • Routine pre-op investigations

30. Hernia Treatment • Surgery • To relieve symptoms • To prevent complications • Operations • Open hernia repair • Laparoscopic hernia repair • Pre-peritoneal • Intra- abdominal

31. Open Hernia Repair • Day-case surgery • Anaesthesia • General • Local • Operations • Tension free Mesh repair (Lichtenstien) • Darn repairs (Shouldice, Bassini)

32. Open Hernia Repair • Incision above medial half of inguinal ligament • External oblique opened from external ring to expose the cord and overlying ilioinguinal nerve • Internal (deep) ring exposed • Hernial sac identified and reduced • Prolene mesh inserted to reinforce posterior wall and deep ring

33. Open Hernia Repair

34. Open Hernia Repair

35. Open Hernia Repair

36. Open Hernia Repair

42. Open Hernia Repair

43. Laparoscopic Repair

44. Laparoscopic Repair

45. Laparoscopic Repair

46. Surgery Complications • Trauma • Nerve • Artery (testicular atrophy) • Intestine • Haemorrhage • Haematoma (infection) • Infection • Wound infection • Chest Infection

47. Femoral Hernia • Herniation through femoral canal • Appears below and lateral to pubic tubercle • Relatively uncommon • Commoner in females • Contains omentum or small intestine • High risk of strangulation • Repaired surgically

48. Femoral Hernia

49. Femoral Hernia Repair

50. Summary • Inguinal hernia is the commonest external hernia • Indirect hernias have a higher risk of strangulation • Hernias are treated by surgery, to relieve symptoms and prevent complications • Femoral hernias have a high risk of strangulation