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Abdominal Wall Hernia
Essentials
MA MURPHY FRCSI
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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
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Hernia

A protrusion of an organ or tissue outside
its’ normal compartment
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Common External Hernias

ABDOMINAL WALL & GROIN

Midline
• Umbilical
• Para- umbilical
• Epigastric

Inguinal
• Direct/ Indirect/ Combined

Femoral

Incisional
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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
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Inguinal Hernia

Commonest external hernia

Male preponderance

Infant / adult

Direct / indirect / combined

Weakness / increased pressure

Cause pain / discomfort

Carry risk of complications

Treated surgically
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Inguinal Hernia - History
OBJECTIVES

Establish differential diagnoses

Identify risk factors and significant comorbid pathologies

(e.g. increased intra-abdominal
pressure due to ascites or chronic
airways disease)
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Inguinal Hernia - History

Onset

Duration

Symptoms

Other hernia(e)

Irreducibility

Gastrointestinal system

Respiratory system

Surgery / anaesthesia
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Inguinal Hernia - Examination

Surface markings

Anterior superior iliac spine

Pubic tubercle

Midpoint of inguinal ligament
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asis
midpoint of inguinal liagament
pubic tubercle
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Inguinal Hernia - Examination
OBJECTIVES

Confirm diagnoses

Out rule differentials

Establish type

Determine contents

Reducibility

Identify co-morbid pathologies
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Direct V’s Indirect

Direct

Indirect

Post wall

Deep ring

Less common

70%

Older

Congenital

Smaller

Scrotal

Hesselbachs

Deep ring

Medial

Lateral

Lower risk

Strangulate
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Inguinal Hernia

Examination

Standing / Lying Supine

Cough impulse

Reducibility

Contents

Bowel sounds

Scrotal contents
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Differential

Direct /Indirect/Combined

Femoral hernia

Hydrocele

Lipoma

Lymph node

Testicular tumour

Saphenous varix
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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
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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
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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)
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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)
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TESTIS CORD STRUCTURES
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Inguinal Anatomy
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Hernia Anatomy
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Indirect Hernia
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Direct Inguinal Hernia
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Hernia Complications

Incarceration

Strangulation

Intestinal obstruction
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Varieties of Hernias

Maydls
• W loop of intestine

Richters
• Partial inclusion of intestinal
wall

Sliding hernia
• Bladder
• Sigmoid colon/ appendix
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Richters’ Hernia
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Maydls’ Hernia
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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
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Hernia Treatment


Surgery

To relieve symptoms

To prevent complications
Operations

Open hernia repair

Laparoscopic hernia repair
 Pre-peritoneal
 Intra-
abdominal
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Open Hernia Repair

Day-case surgery

Anaesthesia


General

Local
Operations

Tension free Mesh repair
(Lichtenstien)

Darn repairs (Shouldice, Bassini)
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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
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Open Hernia Repair
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Open Hernia Repair
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Open Hernia Repair
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Open Hernia Repair
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Open Hernia Repair
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Laparoscopic Repair
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Laparoscopic Repair
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Laparoscopic Repair
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Surgery Complications

Trauma
• Nerve
• Artery (testicular atrophy)
• Intestine


Haemorrhage
• Haematoma (infection)
Infection
• Wound infection
• Chest Infection
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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
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Femoral Hernia
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Femoral Hernia Repair
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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
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Recommended Reading

Ellis H. Clinical Anatomy

www.vesalius.com