HERNIAS

HERNIAS
Prof. Dr. M. Süphan ERTÜRK
Definition
A hernia is an abnormal protrusion of the
contents of an anatomical cavity through a
congenital defect or weakened region in its
wall.
Frequency
•
Groin
– Indirect inguinal
– Direct inguinal
– Femoral
•
•
Incisional
Ventral
75%
60-65 %
15 %
5%
10 %
10 %
– Epigastric
– Umbilical
– Spigelian
•
Others
–
–
–
–
–
–
Hiatal
Lumbar
Obturator
Perineal
Sciatic
Peristomal
5%
Etiology
• Congenital defects
• Enlarged foramen
• Loss of tissue strength and elasticity
• Trauma
• Increased intra-abdominal pressure
Structures of a hernia
• Hernial orifice
• Hernial sac
• Hernial content
• Hernial coverings
Descriptive terms
- Reducible: The hernia contents can
be pushed back (return) into the
abdomen spontaneously or manual
pressure.
- Irreducible: The hernia
cannot be pushed back.
- Incarcerated
- Strangulated
contents
Descriptive terms
- Complete
- Incomplete
- SlidingRichter’s hernia
- Maydl’s hernia
- Littre’s hernia
Surgical Anatomy, Skandalakis
Indirect inguinal hernia
• Indirect
inguinal
hernia
passes
through the internal
ring and traverses
the inguinal canal.
• It may extend into
the
scrotum
(complete hernia).
Current Surg Diagn & Treatm, Lange
Indirect inguinal hernia
- Most common type of hernia in both men
and women (5 to 10 times more common in
men than in women).
- Approximately 5% of men develop an
inguinal hernia during their life.
- A pediatric inguinal hernia is almost always
indirect and is more common on the right
(60% right, 30% left, 10% bilateral).
- Bilateral indirect inguinal hernia occurs in
up to 10% of patients.
- Potential indirect hernias
- Undescended testis,
- Testis in the inguinal canal
- Testicular or spermatic cord hydrocele.
Direct inguinal hernia
•It occurs in the floor of
the inguinal canal
because of an acquired
weakness in fascia
transversalis.
•The abdominal
structures protrude
through the
Hesselbach’s triangle
into the posterior wall
of the inguinal canal.
•The hernia rarely
descends into the
scrotum.
•Direct hernias are seen
Current Surg Diagn & Treatm, Lange
Femoral hernia
• A
femoral
hernia
develops through an
enlarged femoral ring.
• Femoral ring
– femoral vein
– inguinal ligament
– lacunar ligament
– pectineal
ligament
(Cooper)
Surgical Anatomy, Skandalakis
Femoral hernia
• Because the neck of a femoral hernia is
narrow, incarceration and strangulation
are frequent (30-40%).
• Femoral hernia is more common in women
(1/3 of all groin hernias) than in men (2%
of all groin hernias). However, inguinal
hernia is more frequent both in men and in
women than femoral hernia.
• Femoral hernias are related to physical
exertion and to pregnancy
Diagnosis
History
- Most hernias produce no symptoms until the patient
notice a lump or swelling in the groin.
- Some patients may describe a sudden pain and
bulge while lifting, coughing or straining (physical
activity).
- The mass may be intermittantly present and may be
painful.
- In general, direct hernias produce fewer symptoms
than indirect inguinal hernias and are less likely to
become incarcerated or strangulated.
Diagnosis .
Physical examination
- A mass may be visible, and its size may depend on
its position.
- The mass may be tender, may be reducible with
gentle pressure, and bowel sounds may be audible.
- The mass may be small or nonpalpabl but may
become palpabl with coughing and straining.
- Differentiation between direct and indirect hernia on
examination is difficult, and is of little importance
since most groin hernias should be treated
surgically.
Diagnosis ..
Radiology
– Plain films
– Upper GI series
– Contrast medium enema,
– Herniography (to demonstrate
peritoneal outpouchings)
– US and CT may be helpful.
Umbilical hernia
• Umbilical hernias occur at the umbilicus.
• It occurs 10 times more often in women
than in men.
• The defect is common in children, but is
usually (95%) obliterated spontaneously.
• In adults, umbilical hernias are often
associated with increased intra-abdominal
pressure (ascite, pregnancy, obesity, large
intra-abdominal tumor).
Epigastric hernia
• It
develops
through a defect in
the
linea
alba
above
the
umbilicus.
• About
20%
of
epigastric hernias
are multiple
Current Surg Diagn & Treatm, Lange
Incisional hernia
• Incisional hernia is the most common type
of ventral hernia.
• It results from poor wound healing in a
previous surgical incision.
• Common etiologic factors: poor surgical
technique, wound infection, wound
hematoma,
advanced
age,
obesity,
malnutrition,
increased
postoperative
abdominal
pressure
(ileus,
ascites,
pulmonary complication).
Spigelian hernia
They are most commonly seen where
the
linea
semicircularis
(linea
linea
arcuate)
crosses
the
semilunaris (line of Spiegel).
Obturator hernia
It is a herniation through an
obturator foramen. With abduction,
extension or internal rotation of the
knee, it may cause a pain along the
obturator nerve which is referred to
as Howship-Romberg sign. It is more
frequent in elderly women and is
difficult to diagnose.
Lumbar hernia
• Superior lumber
triangle
(Grynfeltt)
• Inferior
lumber
triangle (Petit)
Current Surg Diagn & Treatm, Lange
Perineal hernia
Perineal hernias occur in the pelvic
floor usually following surgical
procedures such as:
• abdomino-perineal resection
• perineal prostatectomy
• pelvic exenteration
Sciatic hernia
Sciatic hernia is
very rare and
consists
of
of
herniation
intra-abdominal
contents through
the
greater
sciatic foramen
Peristomal hernia
It develops around
the site of an
intestinal ostomy
Diaphragmatic hernias
• Esophageal hiatus
• Posterolateral
(Bochdalek)
• Anterior
(Morgagni, Larrey)
İnsan Anat Atl, Sobotta