Transcript H E R N I A S
H E R N I A S AND INCISIONAL HERNIAS
Definition:
Hernia develops whenever the lining or contents of one finite anatomic space protrudes abnormally either into a surrounding tissue plane or into some adjacent body cavity
The defective hiatus in supporting structures is generally referred to as a ring or neck, while an outpocketing from the parent cavity is called the sac
Allthough a sac need not be present, all hernias by definition are associated with a weekness, defect, or dilated hiatus in the confining wall of a primary compartment
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Classification
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Anatomical Inguinal hernia (75% of hernias) Femoral hernia (6%) Epigastric and ombilical hernia (5%) Rarer abdominal wall hernias ( obturator, spigelian, lombar, sciatic, perineal)
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Clinical Reduicible - coercible
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- uncoercible Irreduicible – incarcerated (no vasculary injury) - strangulated (with vasculary injury)
Anatomy of the inguinal region
Some definitions regarding hernia contents Reducible – the contents can return to the abdominal cavity Ireducible – incarcerated (viable contents) - strangulated (ischemic or necrotic contents) Sliding – part of the wall of the sac may be colon on the left, caecum on the right, or bladder on either side Richter’s hernia – a hernia that has strangulated a part of the intestinal wall, without compromising the lumen (stangulation not excluded)
Maydl’s hernia – hernia containing two adjacent loops of small intestin, with strangulation of the segment between the loops Littre’s hernia – a hernia containing a Meckel diverticulum
Inguinal hernia
Definition: a protrusion of part of the contents of the abdomen through the inguinal region of the abdominal wall
75 % of all hernias
More common in male than in female
Anatomy of the inguinal canal
This canal has the following boundaries 1.
Anterior – aponeurosis of the external oblique 2.
Posterior – conjoint tendon combined tendon of internal oblique and transversus abdominis. 3.
Roof - arching fibres of internal oblique and transversus abdominis 4.
Floor – inguinal ligament 5.
Medially is the pubic symphysis. 6.
Laterally is the anterior superior iliac spine.
Contens of the inguinal canal - spermatic cord in men - round ligament in women
The inguinal region (posterior view)
Anatomical classification of inguinal hernia A. Indirect hernia – passes through the intern ring Direct hernia – passes through the Hasselbach triangle, a weak point of the posterior wall of the inguinal canal - little significance for treatment B. Inguinal hernia Inguino-scrotal hernia
Types of inguinal hernia
Precipitating factors
Increased intraabdominal pressure: - physical activity (ocupational history) - straining defecation or urination ( rectal or colon cancer, prostatic enlargement, constipation) - obesity - pregnancy - ascites - valsavagenic (coughing
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Presence of an abnormal congenital anatomic route (patent processus vaginalis)
Clinical features - symptomes
Local symptoms - Pain or discomfort (there are painless hernias too) - A lump in the inguinal region.
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Pain + irreducibility of a previously reducible hernia = strangulation => emergency operation is indicated.
Clinical features - symptomes
Systemic symptoms – are signs of complicated hernias
- Colicky abdominal pain - vomiting - abdominal distension - absolute constipation
A small defect is more dangerous because a tight defect is more likely to strangulate
Clinical features - signs
Inspection - a lump in the inguinal region having expansile cough impulse
Palpation - examination of the patient in standing and lying - palpation of the inguinal supperficial ring through the scrotum - reducible / unreducible - direct / indirect hernia
Percussion and auscultation - a hernia that contains gut may be resonant, and bowel sounds may be audible over it
Differential diagnosis
1. Femoral hernia - below and lateral to pubic tubercle 2. Lymph node - no cough impulsion - usually below inguinal ligament 3. Varicocele – dilated veins in spermatic cord visible with patient standing 4. Cyst of canal Nuck – able to get above lump (females only) 5. Hydrocele – not reducible (males only) 6. Undescebded testis- absence of the testis in scrotum - may be associated with patent processus vaginalis
Evolutive complications
Incarceration
Strangulation => infarction and necrosis of the contents => perforation of the bowel
Rare complications - local pressure effects on structures in proximity of the sac - rupture of the hernia
Treatmet of inguinal hernia
Hernia reduction (taxis)
- should be tried in acute incarcerated hernia - should be done with gentle efforts - may need analgesia and sedation - if unsuccesfully after a few minutes of continous pressure => emmergency operation (otherwise risk of injury of the sac contents)
Using of a truss
– if surgery is considered inappropriate
Hernia repair
Basic principles
1. Eliminate or control factors that have favored the evolution of the hernia 2. Totally remove the sac or at least interrupt the communication between abdomen and hernia pouch 3. Correct any associated fascial defect by - narrowing a normally situated hiatus - transferring supporting structures to overcome any fascial weakness - implanting autogenous fascia or synthetic substitute
Hernia repair technique
There have been described several techniques Most used: Halsted, Bassini, Shouldice, McVay, Ferguson Approach – transperitoneal (seldom used) - inguinal Classification of techniques: - anatomical - prefunicular - retrofunicular Repair of the abdominal wall
Steps of the repair of the inguinal hernia 1.
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Inguinal incision Incision of the aponeurosis of the externus muscle => open the inguinal canal Dissection of the spermatic cord and isolation of the hernia sac Opening the sac, verifying and repositioning its contents Ligation and excision of the sac Reconstruction of the abdominal wall
McVay procedure (retrofunicular)
Shouldice procedure (anatomical)
Laparoscopic repair of inguinal hernia
Is considered appropriate only in indirect hernias with no muscular defect in the abdominal wall Laparoscopic herniorrhaphy by insertion of synthetic mesh to eliminate the muscular defect associated with an inguinal hernia is now the procedure most widely used
Femoral hernia
Definition: a protrusion of peritoneum through the femoral canal It may contain - abdominal contents - extraperitoneal fat Are twice as common on the right side as on the left Are four times more common in women than in men Incidence increases with advancing age
Anatomy of the femoral canal
Borders: - anteriorly - the inguinal ligament - posteriorly - the pectineal (Cooper's) ligament medially - the unyielding lacunar ligament, and - laterally by the iliopsoas muscle Contents (from lateral to medial): - the femoral and the genitofemoral nerve - the femoral artery - the femoral vein The sac progresses usually towards the foramen ovale
Anatomy of the femoral canal
Development of femoral hernia
Clinical features
If reducible it may present as an asymptomatic lump or as localized intermittent discomfort If it becomes irreducible, the lump and localized discomfort become constant features Mild pyrexia + localized discomfort => strangulated omentum within the hernial sac Obstruction => strangulated small bowel is likely
Richter's hernias are common in femoral hernias => strangulation of the antemesenteric intestinal wall without obstruction Occasionally present with visible distension of the long saphenous vein => the hernia has extended through the fossa ovalis and is compressing the sapheno-femoral junction Because of the tight femoral ring strangulation is more frequent than in inguinal hernias
Femoral hernias - treatment
Femoral hernias should not be treated conservatively (impossible to control the hernial neck with a truss and the incidence of strangulation is high) Principles of femoral hernia repair: - excision or reduction of the hernial sac - and narrowing of the stretched femoral opening
Approaches to femoral hernia repair
The low approach - is suitable only for the uncomplicated small elective hernia in a thin patient - the incision is placed directly over the hernia, parallel to the inguinal ligament - the stretched femoral opening is narrowed by placing one or two non-absorbable sutures medial to the femoral ring, apposing the inguinal and pectineal ligaments
Low approach – sac dissection
Low approach – apposition of the inguinal and pectineal ligament
Approaches to femoral hernia repair
The inguinal approach - is useful when a concomitant inguinal hernia needs to be repaired and obligatory when a femoral hernia is misdiagnosed as an inguinal hernia - The same incision as for an inguinal hernia - The femoral canal is approached through transversalis fascia on the back wall of the inguinal canal - Closure of the tissue layers is then completed as for an inguinal hernia.
Inguinal approach
Inguinal approach
EPIGASTRIC HERNIA
Is a protrusion of preperitoneal fat through a gap in the decussating fibres of the supraumbilical portion of the linea alba. The defect usually occurs where the linea alba is pierced by a blood vessel A peritoneal sac may accompany fat through the defect and may contain omentum but only rarely bowel The majority – asymptomatic Rarely - Vague upper abdominal pain and nausea associated with epigastric tenderness (more severe when the patient is lying)
Umbilical hernia
Classification:
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Congenital (omphalocel, exomphalos)
- At birth the umbilicus is absent and a broad defect in the abdominal wall is present through which viscera protrude into the umbilical cord. Peritoneum, but not skin, covers the protruding viscera 2.
Infantile
-after birth because of the failure of fusion of the ombilical cord stump to the umbilical ring - always covered by skin
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Adult paraumbilical hernia
- is an acquired hernia which occurs following disruption of the linea alba above, or much less commonly below, the umbilical cicatrix - Precipitating factors: obesity multiple pregnancy ascites - Gastrointestinal symptoms due to traction between the hernial contents and the stomach and colon - Has a small neck => Incarceration and strangulation are common => Early operation is advisable
Massive paraumbilical hernia
Umbilical hernia – steps of the repair
Incision Dissection of the sack Opening of the sac and contents reduction Ligation and resection of the sac Closure of the defect in one or two layers (Mayo procedure) - in case of massive defect synthetic mesh can be used
Incisional hernia
Wounds may fail in one of two ways: 1.
Wound dehiscence
= partial or complete disruption of an abdominal wound closure with protrusion or evisceration of the abdominal contents - occurs prior to cutaneous healing 2.
Incisional hernia
= abnormal protrusion of a viscus through the musculoaponeurotic layers of a surgical scar - lie under a well healed skin incision
Incisional hernia - Ethiology
Preoperative factors: obesity - age - uraemia - anaemia - male sex - previous irradiation - diabetes - malnutrition - malignant disease - vitamin C depletion - administration of steroids or cytotoxic drugs.
Incisional hernia - Ethiology
Operative factors
- the type of incision (medial, pararectal, Kocher) - the choice of suture material - the method of wound closure Are less important in the development of incisional hernia
Incisional hernia - Ethiology
Postoperative factors
- wound sepsis - increased intra-abdominal pressure due to: - inadequate postoperative analgesia - vomiting - development of a postoperative chest infection resulting in coughing - gross distension from paralytic ileus
Incisional hernia – Clinical features
The majority are asymptomatic Small defects in the scar may result in large hernias => incarceration and strangulation Large hernias are unsightly and may give rise to abdominal discomfort Pressure necrosis and ulceration may occur in the skin overlying a large hernia.
Incisional hernia following laparatomy for peritonitis
Management of incisional hernia
Conservative
- weight loss, elastic corset
Surgical repair
– types: 1.In the same way as a laparotomy wound is repaired, with a mass closure of No. 1 nylon.
2.The rectus sheath may be overlapped as in the ‘Mayo’ double-breasted ‘vest over pants’ repair 3.The defect may be repaired by the use of a darn of nylon or fascia lata.
4.Lower midline incisions may be amenable to closure by swinging muscle over to close the defect.
5.Large defects may be repaired by implanting a non absorbable mesh of tantalum, Marlex, Mersilene, or polytetrafluoroethylene (PTFE)