HERNIA
Begashaw M (MD)
Introduction

Common surgical problem
 Adequate knowledge is important
 Prevent serious complications
Definition
– Is a protrusion of a viscus through an
opening in the wall of the cavity
Component

Sac -Out pouch of the peritoneum-Four parts-Mouth,Neck,Body&Fundus
 Content-viscus/organ inside a sac
- Small bowel and omentum – the
commonest
- Large bowel appendix
- Bladder
CLASSIFICATION

Reducible - viscus can be returned back
 Irreducible - contents can’t be returned back
 Obstructed - intestineis occluded but no
impairment of vascular supply
 Strangulated - vascularity of viscus is impaired
 Richter’s - only one side of wall is herniated
 Sliding - extra peritoneal structure form part of
wall of the sac
HERNIAS
Risk factors

Increased intra
abdominal pressure
- Chronic cough
- Straining at urination or
defecation
- Heavy wt lifting
- Abdominal distension

Weakened abdominal
wall
- Advanced age
- Malnutrition
- Congenital defect – ppv
- Trauma/surgery
Clinical features
 History
- Lump
- Pain, local aching, discomfort
- Factors predisposing to increased intra
abdominal pressure
- Symptoms of int. obstruction/strangulation
Physical examination
- Examine  Standing & Lying
- Lump – reducible, cough impulse with bowel
sound
- Reduced on lying & increases in size
_coughing/ straining
- Obstruction – tense, tender, irreducible with
absent cough impulse
- Strangulation – more tenderness, with warm
indurated, and inflamed overlying skin
Examination
Investigation

a clinical diagnosis
 investigation is rarely needed
Complications
1. Irreducibility
2. Obstruction
3. Strangulation is a surgical emergency
 Risk of obstruction and strangulation is very
high in femoral hernia, paraumblical hernia
and indirect inguinal hernia with narrow
neck
Principles of management
1. Herniotomy - removal of the sac and
closure of the neck
- in infants and children
2. Herniorrhaphy - Herniotomy and repair of
the wall to prevent recurrence
Obstruction

Non operative
-Gentle reduction
- Put patient in head down position
- Sedative is given
- Gentle manipulation to reduce the hernia
 Urgent Surgery
- Failed reduction
- All strangulated hernia
Strangulation
Anatomy-inguinal canal

Boundary
Anteriorly: External oblique apponeurosis
Posteriorly: Fascia transversalis
Inferiorly: Inguinal ligament
Superiorly: Conjoined tendon and internal oblique
M
 Runs in antero inferior (InternalExternal ring)
_Internal ring -2cm above & 2cm medial to mid
inguinal ligament
_External ring -just above pubic crest & tubercle
Anatomy
Anatomical site of groin hernia
Contents of inguinal canal





Male
Spermatic vessels
Vas deference
Ileo inguinal nerve
Genito femoral nerve

Female
 Round ligament
Anatomy of Femoral canal
 Is
a narrow rigid space
 Boundary
- Inguinal ligamentsuperiorly
- Pectineal posteriorly
- Lacunar mediallyF
- Femoral veinlaterally
 prone to obstruction & strangulation
Inguinal hernia
- accounts for 80%
- commonest is all ages & sexes
- 20 x more common is males than women
- more common on right side
Classification
1-Indirect_passes through internal inguinal
ring along the inguinal canal
-May extend down to the scrotum
2 -Direct_Bulges through post wall of
inguinal canal
Classification
Hernia
Indirect inguinal hernia
60% on right
- 40% Lt side
- 20% bilateral
- Due congenital defect
patent processes vaginalis
- 20 times more common in men
-
Direct inguinal hernia
-
-
due to wear and tear associated
advanced age
increased intra abdominal pressure
Femoral Hernia
- acquired downward protrusion of intestinal
contents into the femoral canal
- 4 times more common in females
- rare in children
Clinical features
History
- Elderly or middle aged
woman
- lump on anterior and upper
thigh
- may present with complaints
associated with int.
obstruction or strangulation
Physical examination
- Small lump on lower groin,
lateral and below pubic
tubercle
- Reducible/irreducibility
- Bowel sound/cough impulse
– usually absent
Femoral hernia
Management
- surgical repair without delay
Umbilical Hernia



Umbilicus is one of the weak sites of the abdomen
A hernia can occur at this potential site
Risk factors
Female sex
Multiparity
Obesity
Ascites
 Complications
Obstruction
Strangulation
Rupture
Umblical hernia
Treatment

Expectant - Spontaneous closure is expected
in 80% cases of umbilical hernia in under
five children
 SurgeryBeyond five years
Incisional Hernia

Risk Factors
-Wound infection
-Poor surgical technique (
-Chronic cough
-Straining
-Obesity
Clinical features

Risk of obstruction and strangulation is very
rare
 Local discomfort
 Cosmetic problems
 Difficulties with micturation and bowel
movement when very large
 Treatment
Hernioplasty
Incisional hernia