Hernia
Tulane University Department of Surgery
What is a Hernia?
• Congenital or Acquired defect in the abdominal wall
• Herniorrhaphy is one of the most commonly performed
operations in all of surgery
• Incidence ~ 1-5%
Physical Exam Characteristics
• Reducible: hernia returns to anatomical location
• Incarcerated: fixed hernia +/- intestinal obstruction
• Strangulated: s/s of ischemia and obstruction
Abdominal Wall Anatomy
9 Layers
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Skin
Subcutaneous fat
Camper’s fascia
Scarpa’s fascia
External Oblique
Internal Oblique
Transversus Abdominus
Transversalis fascia
Peritoneum
Types
1. Inguinal
2. Femoral
3. Umbilical
4. Epigastric
5. Sliding
6. Littre’s
7. Internal
8. Obturator
9. Petit’s
10. Gryngelt’s
11. Coopers
12. Pantaloon
13. Richters
14. Incisional
15. Ventral
16. Hiatal
17. Parastomal
18. Etc.
What is the most common Type?
Types
1. Inguinal
2. Femoral
3. Umbilical
4. Epigastric
5. Sliding
6. Littre’s
7. Internal
8. Obturator
9. Petit’s
10. Gryngelt’s
11. Lumbar
12. Pantaloon
13. Richters
14. Incisional
15. Ventral
16. Hiatal
17. Parastomal
18. Etc.
What is the most common Type?
Differential Diagnosis (Inguinal Hernias)
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Lymphadenopathy
Varicocele
Undescended testicle
Hematoma/Pseudoaneursym
Sarcoma
Lipoma
Contents of Spermatic Cord
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Vas deferans
Spermatic vessels
Genital branch of gentiofemoral nerve
Cremasteric vessels
Inguinal Repairs
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Marcy
Bassini
McVay
Shouldice
LICHTENSTEIN – Tension Free
Acquired Causes
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Increased abdominal pressure
Obesity
Chronic cough
Ascites
Pregnancy
Hesselbach’s Triangle
Indirect (50%) >> Direct (25%)
Indirect Hernia
Operative Repair—Mesh, Mesh, Mesh
Incisional Hernias
• Up to 11% of pts with previous laparotomy will develop hernia
• Previous hernia is a risk for development of future hernia
• Chances of successful closure decrease with each successive
repair attempt
Incisional Hernia Repairs
Repair
Recurrence
3yr
Recurrence
10yr
Complication
Suture
42%
63%
8%
Mesh
24%
32%
17%
Abdominal Wall Reconstruction
Paradigm for Repairs
1900- Silver Filigree Mesh
Stainless Steel Cloth
Shift 1
1940- Tantalum Mesh (metal)
1944- Nylon Mesh
1958- Marlex (Polyethylene)
1962- Prolene (Polypropylene)
1984- Mersilene (Polyester)
Shift 2
1985- Component Separation
Shift 3
- Bioprosthetics
Component Separation
• Defined anatomic planes and range of advancement of
rectus-internal/transversus muscle block
Alloderm
• Acellular Human Dermis
• Epidermis and all cellular
compenents are removed
• Initially used in burn patients as a
scaffolding for STSG
• Minimal inflammatory response
cost $/cm2
30
26.38
25
20
15
10
5
0
8.33
4.8
3.4
S u rgi s i s
4.29
0.65
Pe rm acol
PTFE Du al
Prol e n e
Al l ode rm
Vi cryl
Conclusion
• Hernias REQUIRE SURGERY to prevent further
complications (intestinal obstruction and infarction)
– If reducible----elective
– If incacerated----semi-elective
– If strangulated----emergent
Questions?
According to the National Center for Health Statistics,
approximately five million Americans have an
abdominal hernia, but only a fraction of those seek
treatment.
Hernias do not go away and, if left untreated, may
worsen over time, causing complications.