Hernias, and
Intraperitoneal abscess
Sheng Yan MD, PhD
The First Affiliated Hospital
Zhejiang University
General consideration
 Definition
Hernia means a sprout, and protrusion.
External abdominal wall hernia is an abnormal protrusion of
intra-abdominal tissue or the whole or part of a viscera
through an opening or fascial defect in the abdominal wall.
most occur in the groin
Historical Hernias
Hernias have been
documented
throughout history
with varying success
at either reduction or
repair.
Trusses & Techniques
Camper’s
Scarpa’s Fascia
Inguinal canal
Contents: spermatic cord, round ligament, ilioinguinal nerve
anterior: skin, superficial fascia, and external ablique aponeurosis
posterior: transversalis fascia
superior: conjoined tenden
inferior: inguinal ligament
Hesselbach’s triangle
Bounded by the inguinal ligament, the inferior epigastric vessels,
and the lateral edge of rectus muscle.
scrotum
Anatomy
 Pathological anatomy
The hernia composed of:
• covering tissue: skin, subcutanous tissue
• hernial sac: protrusion of peritonum,
neck of the sac: is narrow where the sac emerges from
the abdomen body of the sac
• hernial contents: small intestine, major omentum
Etiology
1. intensity of abdominal wall decreased
common factors:
1) site that some tissues pass through the abdominal wall, eg. Spermatic
cord, round ligament of uterus
2) bad development of abdominal white line
3) incision, trauma, infection et al.
defect in collagen synthesis or turnover
2. any condition which increases intra-abdominal pressure
chronic cough, chronic constipation, dysuria, ascites, pregnancy, cry
Causes of indirect inguinal hernia
1. congenital abnormality of anatomy
due to failure of fusion of the processus vaginalis peritonei after the
testis has descended into the scrotum.
2. acquired weakness or defect of abdominal wall
 Clinical manifestation and diagnosis
Symptoms: pain, discomfort, dragging sensation
Sign: reducible or irreducible lump, expansive cough impulse
Reducing the hernia fully, compress the internal ring:
be controlled – indirect
not controlled -- direct
Hernia Exam
 Differential diagnosis
• 1 hydrocele of testis
•
•
•
•
translucent test (+)
2 communicated hydrocele
3 hydrocele of cord: not reducible
4 undescended testis
5 acute intestinal obstruction
 Clinical types
1. reducible hernia is one in which the contents of the sac return to the
abdomen spontaneously or with manual pressure when the patient is
recumbent.
2. irreducible hernia is one whose contents or part of contents cannot be
returned to the abdomen, without serious symptoms.
hernias are trapped by the narrow neck
Sliding hernia is one in which the wall of a viscus forms a portion of the
wall of the hernia sac. It is may be colon ( on the left), cecum (on the
right) or bladder (on either side).
Belongs to irreducible hernia
3. incarcerated hernia: is one whose contents cannot be returned to the
abdomen, with severe symptoms.
4. strangulated hernia: denotes compromise to the blood supply of the
contents of the sac.
incarcerated hernia and strangulated hernia are the two stages of a
pathologic course
Richter’s hernia (intestinal wall hernia )
a hernia that has strangulated or incarcerated a part of the intestinal
wall without compromising the lumen.
Littre hernia: a hernia that has incarcerated the intestinal diverticulum
(usually Meckel diverticulum).
Reductive incarcerated hernia: reduction of the hernial contents
( intestine ) into abdominal cavity.
Sliding hernia
viscera forms a portion of the wall of the
hernia sac
Richter——intestinal wall
Littre ——intestinal diverticulum
incarcerated hernia: is one whose contents cannot be returned
to the abdomen, with severe symptoms
incarcerated hernia
Reductive incarcerated hernia
strangulated hernia:
denotes compromise to the blood supply of the contents of the sac
Indirect Hernia Route
Note:
The hernia sac
passes outside the
boundaries of
Hesselbach's
triangle and follows
the course of the
spermatic cord.
Direct Hernia Route
Note:
The hernia sac
passes directly
through
Hesselbach's
triangle and may
disrupt the floor
of the inguinal
canal.
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
elliptic, pear-shaped
semispheric, wide base
compress the internal
ring after reduced
Un-controlled
controlled
Relationship of
spermatic cord with sac
Posterior to the sac
Anterior and lateral to
the sac
Relationship of sac neck Sac neck is lateral to it
with inferior epigastric
artery
Sac neck is medial to it
Incarcerated incidence
low
high
Treatment
1. nonoperative therapy
Indications:
<1 year old
elderly patients or with severe systemic
disease--truss
2, Specific Surgical Procedures
• Lichenstein (Tension Free) Repair
• Bassini Repair
• McVay (Cooper’s Ligament) Repair
• Shouldice (Canadian) Repair
• Laproscopic Hernia Repair
Bassini Repair
– Is frequently used for
indirect inguinal
hernias and small
direct hernias
– The conjoined tendon
of the transversus
abdominis and the
internal oblique
muscles is sutured to
the inguinal ligament
McVay Repair
• AKA: Cooper’s
ligament Repair
– Is for the repair of
large inguinal hernias,
direct inguinal
hernias, recurrent
hernias and femoral
hernias
– The conjoined
tendon is sutured to
Cooper’s ligament
from the pubic
cubicle laterally
McVay Repair
Note:
This repair
reconstructs the
inguinal canal
without using a
mesh prosthesis.
Ferguson
 Repair the anterior wall of
the inguinal canal

Inguinal Lig
Conjoint tendon
Spermatic cord
Ferguson repair
Shouldice Repair
• AKA: Canadian Repair
– A primary repair of the hernia defect with 4
overlapping layers of tissue.
– Two continuous back-and-forth sutures of
permanent suture material are employed.
The closure can be under tension, leading to
swelling and patient discomfort.
Lichtenstein Repair
AKA: Tension-Free Repair
One of the most commonly
performed procedures, using
prosthetic materials
A mesh patch is sutured over the
defect with a slit to allow
passage of the spermatic cord
Lichtenstein Repair
Note:
Open mesh repair.
Mesh is used to
reconstruct the
inguinal canal.
Minimal tension is
used to bring
tissue together.
Laparoscopic Hernia Repair
– Early attempts resulted in exceptionally high
reoccurrence rates
– Current techniques include
• Transabdominal preperitoneal repair (TAPP)
• Totally extraperitoneal approach (TEP)
Types of Laparoscopic Inguinal Hernia
Repair
• IPOM (IntraPeritoneal On-lay Mesh) repair. A mesh is placed intra-
abdominally covering the hernia defect and then secured to the
abdominal wall. Very popular at the beginning of laparoscopic experience,
it has since been abandoned.
• TAPP (Trans Abdominal Pre-Peritoneal) repair. With this technique, the
pre-peritoneal space is accessed from the abdominal cavity and a mesh is
then placed and secured. This is procedure of choice for recurrent inguinal
hernias or in case of incarcerated bowel – visualized.
• TEP (Totally ExtraPeritoneal) repair. The mesh is again placed in the
retroperitoneal space, but in this case, the space is accesed without
violating the abdominal cavity. This is probably the most physiological
repair although technically more demanding. The procedure of choice for
bilateral inguinal hernia repairs
Trochar placement for both
TEP & TAPP
Laparoscopic Mesh Repair
Note:
Viewed from inside the
pelvis toward the direct
and indirect sites. A broad
portion of mesh is stapled
to span both hernia
defects. Staples are not
used in proximity to
neurovascular structures.
Femoral ring
Inguinal lig.
Femoral hernia
Coope
r Lig.
Femoral V.
OPERATION
McVay REPAIR
Direct suture
Incisional Hernia
The incision most common for
hernia: trans-rectus incision
The major reason for incisional
hernia :
incisional infection 50%
Poor nutritional status
Incision hernia
Incision hernia
Intraperitoneal abscess
Gross:
I.
Supra-mesocolic
spaces: falciform
lig.
a)
b)
Right sub-phrenic
space:
suprahepatic
space /
infrahepatic space
Left subphrenic
space: - space bet.
left lobe of liver &
stomach
- lesser sac
II.
Gross:
1.
Infra-mesocolic spaces:
a)
b)
Right lateral paracolic / right medial paracolic gutter
Left medial paracolic / left lateral paracolic gutter
ANATOMY:
I.
Microscopic:
–
Mesothelium – 1.8 m2
1.
2.
3.
II.
Mesothelial cells (cuboidal
cells/flattened cells)
» Stomata
Basement membrane
Connective tissue (collagen,
elastic fiber, fibroblast,
adipose, endothelial cells,
mass cells, machrophage).
Gross:
–
–
Intra-abdominal area:
(intraperitoneal /
retroperitoneal)
Intra-peritoneal Space –
defined by mesothelial
membrane
a. visceral peritoneum
b. parietal peritoneum
Thanks
Welcome questions!