Hernia
General Surgery, Renhe Hospital,
Three Gorges University，
Zhang-Xianlin
Hernia
Definition：
•
Protrusion of an organ (intestine ,brain)
or tissue outside its normal body cavity or
constricting sheath .
• Abdominal hernia is the protrusion of the
abdominal content outside abdominal wall.
Causes of Abdominal Hernia
1. Anatomical defect of the abdominal wall.
2. Acquired weakness of the abdominal wall .
Surgical Anatomy
rectus abdominis(腹直肌)
Rectus sheath（腹直肌鞘）
External oblique(腹外斜肌)
crural ligament
pubic symphysis
Surgical Anatomy
腹股沟解剖
inguinal groove
脐bellybutton
inner ring
outer ring
chorda spermatica
Surgical Anatomy
股管解剖femoral canal
Surgical Anatomy
Types of Abdominal Hernia
Epigastric
paraumbilical
Umbilical
lumbar
Spigelian(半月疝)
femoral
inguinal
The Basic Feature Of All
Hernias
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They occur at a weak spot .
They reduce on lying down ,or with direct pressure.
The have an expensile cough impulse.
A hernia consist of 3 parts:
1.Sac:
consist of a diverticulum of
peritoneum.
2.Contents:
Omentum, small or large
intestine, urinary bladder,
Omentum, ovaries malignant
nodules or ascetic fluid.
3.Coverings:
derived from the layers of
abdominal wall.
Complications Of Hernias
• Irreducible
• the hernia contents cannot be manipulated back into the abdominal
cavity.
• Incarcerated 
• the contents of the sac are literally inpresiond in the sac of Hernia.
• Obstruction 
• the loop of the bowel become non functioning with normal blood
supply .
• Strangulated
• cut off the blood supply to the content sac (tender).
Inguinal Hernia
Protrusion of abdominal contents through the
inguinal region
Inguinal Hernia
Differences between indirect and direct hernia
feature
indirect
direct
age
children, young people
aged people
pathway of protrusion coming down the
inguinal canal, may
enter the scrotum
pass through
Hesselbach’s triangle,
rarely enter the
scrotum
contours of sac
semispheric, wide
base
elliptic, pear-shaped
compress the internal controlled
ring after reduced
not controlled
Reduced
Upwards, laterally and
back ward
Upward and strait
backward
Relationship of sac
neck with inferior
epigastric artery
Sac neck is lateral to it
Sac neck is medial to
it
Incarcerated
incidence
high
low
Inguinal Hernia in Children
Most common is indirect hernia
•
Patent processes vaginalis
1. Inguinal hernia
2. infantile hydrocele
3. An encysted hydrocele of the
cord
•
Hydrocele Vs Hernia
•
More in premature infants
Treatment Notes
•
Incarcerated hernia in infancy can almost
always be managed by manipulative reduction
with subsequent scheduled herniotomy.
• The one exception is In baby girl because
the ovaries may be part of the sac content.
Special Varieties of Inguinal
Hernia
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Pantaloon Hernia
Maydl’s Hernia
Sliding Hernia
Richter’s Hernia
Litter’s Hernia
Femoral Hernia
Left Femoral Hernia
Femoral Hernia
• Protrusion of abdominal content through
the femoral canal .
• More common in females.
• Below and laterally to the pubic tubercle.
• Narrow neck High risk for strangulation.
CASES
Case (1) - Asymptomatic, reducible groin swelling in the elderly
A 71-year-old man, who has had two myocardial infarcts and
hypertension, presents with a groin bulge, present only when he
coughs. It has never been painful.
Case (2) - Asymptomatic reducible groin swelling
A fit 34-year-old policeman presents with a three month history of a
progressively enlarging inguino-scrotal swelling. It has not been
painful but is becoming more difficult to reduce digitally.
Case (3)- Irreducible groin swelling
This otherwise fit 92-year-old lady noticed a groin swelling six
months ago. At first it reduced spontaneously when she lay down
but for the past four weeks it has been present constantly, is
irreducible, and she now has twinges of pain.
DDx of Lump In The Groin
1.
2.
3.
4.
5.
6.
7.
8.
Inguinal Hernia
Femoral Hernia
Enlarged lymph node
Sapheno –varix
Ectopic testis
Psoas abcess
Psoass bursa
Lipoma
Ask in your History
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Lump: duration, first symptoms, associated symptoms,
progression, persistent ,other sites ,cause
Does it reduce on lying down?
Have there been episodes of pain in the swelling?
Have there been episodes of abdominal pain?
Does the patient have any febrile symptoms?
History of rectal bleeding
History of trauma or septic focus in the lower limbs
Causes of increase of intrabdominal pressure
Previous surgeries ?
Physical Exam
• Before Physical Exam,pay attention to:
• Introduce your self ,
• Take permission,
• Patients privacy ,
• Position standing up
• Exposure  bilateral inguinal region and
the groin
Physical Exam
• From in front :
1. Inspection lump: site, shape
scrotum: does it extend to the
scrotum
2. Palpation : (decide is it hernia or not)
Ask the patient about pain before you palpate
• Can you go above it
• Can you palpate the testis
• If it is a hernia  type
• Define pubic tubercle
Can you go Above it?
Physical Exam
Physical Exam
• Feel from the sides
1. Aim to examine the lump
( tenderness, temperature, size ,shape, site,
composition (
2. Reducible?? How?? Ask the pts if you couldn’t
3. Controlled when you pressure over deep
inguinal ring ?
4. Expensile cough impulse
5. Direction of reappearance
Physical Exam
Physical Exam
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Percussion of the sac
Auscultation of the sac
Feel the other side
Abdominal examination
Cardiovascular and respiratory
assessment
Treatment of groin hernias
Approach
• conservative (reassure the patient)
• a truss (now a rare treatment option)
• Operate
Treatment of groin hernias can be summarized:
• Direct inguinal hernia - rarely operate unless
there is a specific indication.
• Indirect inguinal hernia - usually operate.
• Femoral hernia - always operate unless there is
a contraindication.
Treatment of groin hernias
• Direct inguinal hernia
Most require no treatment. Patients with pure direct inguinal bulges are at
virtually no risk of complications. Most are elderly and reassurance is
usually appropriate.
• Indirect inguinal hernia
Most require operative treatment as the risks of irreducibility and obstruction
are higher. Advise repair unless the patient’s general health is such that the
risks of operation outweigh the possible benefits.
The operation for inguinal hernia may be:
1. sutured, e.g. Bassini, Shouldice
2. open mesh, e.g. Lichtenstein
3. laparoscopic mesh, e.g. TAPP (transabdominal preperitoneal), TEP (total
extra peritoneal)
4. in babies, simple herniotomy is all that is required.
Femoral hernia repair
Femoral hernia treatment :
1. high approach
2. low approach
3. inguinal approach
Left Femoral Hernia
Direct inguinal Hernia
lump
Right Indirect Inguinal
Hernia
包块lump
www.icareunit.com
Left Indirect Inguinal Hernia
Left Indirect Inguinal Hernia
Bilateral indirect inguinal
hernia
Bilateral indirect inguinal
hernia
Emergency presentation with small bowel
obstruction, tender irreducible groin swelling
A previously fit 58-year-old woman has
been aware of a groin hernia for several
years. It has recently become irreducible.
Today it has become acutely painful and
she has colicky abdominal pain,
distension and vomiting. She has now
become confused, clammy, hypotensive
and oliguric
What is you approach?
Epigastric Hernia
• It occurs through the linea alba midway
between the xiphisternum & the umbilicus.
• It is a protrusion of extraperitonial fat from the
site of entry of a small blood vessel through
the linea alba (fatty Hernia of linea alba).
• It is usually small in size, it may drag a pouch
of peritoneum to form a true hernia.
Epigastric Hernia
• The neck is usually too small to allow a hollow
viscous to enter it, consequently the sac is
empty or it contains small part of omentum.
(not true hernia )
• It is probably as a result of sudden strain that
tears the interlacing fibers of linea alba.
Epigastric Hernia
• Clinically; The patient is usually a manual
worker, 30-50y in age, symptom less,
incidentally discovered during routine exam
• Pain & tenderness is due to strangulated fat.
• Referred pain & dyspepsia is most probably
related to DU, GS etc.
• Treatment: Excision & repair of defect.
Epigastric
Hernia
Umbilical Hernia
• True umbilical Common in children.
• Intestinal obstruction extremely rare.
• Surgical repair if persisted after 3rd birthday .
Para-umbilical hernia
• Para umbilical usually middle age women
obese or multiparous
• It is a protrusion through the linea alba just
above or the umbilicus. As it enlarges it
sags downward and can attain a large
dimensions
• The neck of the sac is narrow as compared
with the size of the sac & it’s contents ( omentum, small intestine or part of the colon).
Usually loculated due to adhesions.
Para-umblical Hernia
• Clinically; more common in women, obese,
multiparous & 35-50y of age.
• It becomes irreducible due to adhesions &
strang-ulation may occur. Pain colicky or
dragging.
• The skin over it becomes reddened, smooth &
may become excoriated.
• Treated by division of adhesions. & repair of
defect “Mayo’s repair”
Para-umblical Hernia.
Para-umlical Hernia
Paraumlical Hernia
Incisional Hernia
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1.
2.
3.
4.
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Protrusion through surgical wound
Occur after 3-5% of abdominal operation
Causes
Midline ,vertical incision
Poor technique
Wound or chest infection
Obesity
Strangulation is rare but repair is advisable
Incisional hernia.
Thank You