الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجراحة المرحلة الرابعة. الدكتور عاصم قبطان MD – FRCS . HERNIA. A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity. - PowerPoint PPT Presentation
MD FRCS 1M.A.KM.A.Kubtan1HERNIAA hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity2M.A.K2M.A.KubtanAnatomical location of HerniasExternal Hernia .Internal Hernia .3M.A.KExternal HerniaThe most frequent varieties accounting for 75% of cases being the : Inguinal . Femoral . Umbilical . Paraumbilical hernia 4M.A.K5
M.A.KGeneral features common to all herniasAetiologyAny condition that raises intra-abdominal pressureHernias are more common in smokers, which may be the result of an acquired collagen deficiencythe appearance of a hernia in an adult can be a sign of intra-abdominal malignancyStretching of the abdominal musculature because of an increase in contents, as in obesity6M.A.KIntra-abdominal pressure raised inpowerful muscular effort.Whooping cough is a predisposing cause in childhood .Chronic cough .Straining on micturition .Straining on defaecation .
7M.A.KComposition of a herniaThe sac .The covering .The content.8M.A.KThe sacThe sac is a diverticulum of peritoneum, consisting of mouth, neck, body and fundus .The diameter of the neck is important .The body of the sac varies greatly in size .In cases occurring in infancy and childhood, the sac is gossamer thin.
9M.A.KThe coveringCoverings are derived from the layers of the abdominal wall .In longstanding cases they become atrophied from stretching and so amalgamated that they are indistinguishable from each other.10M.A.KContentsomentum Intestine : commonly small bowel but may be large intestine or appendix. A portion of the circumference of the intestine = Richters hernia. A portion of the bladder (or a diverticulum) may constitute part of or be the sole content of a direct inguinal, a sliding inguinal or a femoral hernia Ovary with or without the corresponding fallopian tube. A Meckels diverticulum = a Littres hernia; Fluid, as part of ascites.11M.A.KClassificationA hernia can be classified into five different types
Reducible contents can be returned to abdomenIrreducible contents cannot be returned but there are no other complications .Obstructed bowel in the hernia has good blood supply but bowel is obstructed .Strangulated blood supply of bowel is obstructed .Inflamed contents of sac have become inflamed
12M.A.KReducible & Irreducible herniasReducible Hernia
The hernia either reduces itself when the patient lies down .Can be reduced by the patient or the surgeon.The intestine usually gurgles on reduction .Omentum, in contrast, is described as doughy .A reducible hernia imparts an expansile impulse on coughing.The contents cannot be returned to the abdomen It is usually due to adhesions between the sac and its contents .Note that any degree of irreducibility predisposes to strangulation .
13M.A.KAn expansile impulse on coughingM.A.K14
Obstructed & Incarcerated Hernia Obstructed Hernia Incarcerated HerniaThis is an irreducible hernia containing intestine that is obstructed from without or within .The symptoms (colicky abdominal pain and tenderness over the hernia site) .Usually there is no clear distinction clinically between obstruction and strangulation .The safe course is to assume that strangulation is imminent and treat accordingly.This term is correctly employed only when it is considered that portion of the colon occupying a hernial sac is blocked with faeces.The contents of the bowel should be capable of being indented with the finger, like putty.15M.A.KStrangulated herniaA hernia becomes strangulated when the blood supply of its contents is seriously impaired .Gangrene may occur as early as 56 hours after the onset of the first symptoms.Inguinal hernia may be 10 times more common than femoral hernia .Femoral hernia is more likely to strangulate because of the narrowness of the neck and its rigid surrounding .M.A.K16Pathology of Strangulated HerniaInitially, only the venous return is impeded .The wall of the intestine becomes congested and bright red with the transudation of serous fluid into the sac.The intestinal pressure increases, distending the intestinal loop and impairing venous return further .As venous stasis increases, the arterial supply becomes more and more impaired.
M.A.K17ContinueBlood is extravasated under the serosa and is effused into the lumen .At this stage the walls of the intestine have lost their tone and become friable.Bacterial transudation occurs secondary and the sac fluid becomes infected.Gangrene appears at the rings of constriction .The colour varying from black to green depending on the decomposition of blood in the subserosa.The mesentery involved by the strangulation also becomes gangrenous.Perforation of the wall of the intestine occurs, either at the convexity of the loop or at the seat of constriction.Peritonitis spreads from the sac to the peritoneal cavity.
M.A.K18Symptoms of strangulated hernia Sudden pain, situated over the hernia .Generalised abdominal pain, colicky in character and often located mainly at the umbilicus.Nausea and subsequently vomiting ensue.The patient may complain of an increase in hernia size.M.A.K19Signs of Strangulated HerniaOn examination the hernia is tense, On examination the hernia is tense .Extremely tender and irreducible .There is no expansile cough impulse.The spasms of pain continue until peristaltic contractions cease with the onset of ischaemia.Paralytic ileus , peritonitis , and septicaemia develop.Spontaneous cessation of pain may be a sign of perforation .
Richters herniaIs a hernia in which the sac contains only a portion of the circumference of the intestine (usually small intestine).It usually complicates femoral hernia .Rarely, obturator hernias.M.A.K21
Types of Strangulated HerniaStrangulated Richters hernia .Strangulated omentocele .Inflamed hernia .M.A.K22Inflamed HerniaM.A.K23
Suffering from colicky abdo pain due to strangulated hernia M.A.K24
Inguinal herniaSurgical anatomyThe superficial inguinal ring .The deep inguinal ring .The inguinal canal about 3.75 cm .
The relationships of an indirect inguinal and a femoral hernia to the pubic tubercle; the inguinal hernia emerges above and medial to the tubercle whereas the femoral hernia lies below and lateral to it.M.A.K26
Natural history of inguinal herniasInguinal hernias in babies are the result of a persistent processus vaginalis . Indirect inguinal hernia is the most common hernia of all, especially in the young. Direct inguinal hernia becomes more common in the elderly .M.A.K27Inguinal herniaIndirect hernias are most common in the young .Inguinal hernia is more common on the right side in the male.In adult males, 65% of inguinal hernias are indirect .In adult males, 55% are right-sided.The hernia is bilateral in 12% of cases.Males are 20 times more commonly affected than females.M.A.K28M.A.Kubtan28Types of indirect inguinal herniaBubonocele. The hernia is limited to the inguinal canal Funicular. The processus vaginalis is closed just above the epididymis. The contents of the sac can be felt separately from the testis, which lies below the hernia. Complete (synonym: scrotal). rarely present at birth but is commonly encountered in infancy. It also occurs in adolescence or in adulthood. The testis appears to lie within the lower part of the hernia.M.A.K29Differential diagnosis in the maleVaginal hydrocele .Encysted hydrocele of the cord.Spermatocele;Femoral hernia;An incompletely descended testis in the inguinal canal . lipoma of the cord this is often a difficult but unimportant diagnosis and it is usually not settled until the parts are displayed by operation.M.A.K30Sliding Hernias M.A.K31Herniating bladder wall
Types of Indirect (oblique ) inguinal herniaM.A.K33
FunicularCompleteComplete ( Scrotal Hernia )M.A.K34
Indirect Inguinal Hernia in elderly womanM.A.K35
Direct inguinal herniaIn adult males, 35% of inguinal hernias are direct.12% of patients will have a contralateral hernia in addition .A direct inguinal hernia is always acquired.The sac passes through a weakness or defect of the transversalis fascia .Women usually never develop a direct inguinal hernia .M.A.K36Predisposing factors to direct inguinal hernia and features Smoking .Occupations that involve straining and heavy lifting.Damage to the ilioinguinal nerve (previous appendicectomy) .M.A.K37Features of direct inguinal herniasAll are acquiredThey are most common in older menThey rarely strangulateM.A.K38Preoperative treatment of strangulated inguinalherniasResuscitate with adequate fluidsEmpty stomach with nasogastric tubeGive antibiotics to contain infectionCatheterise to monitor haemodynamic stateM.A.K39Non-operative treatment of herniasOnly indicated in children .Forcible reduction must never be attempted .M.A.K40M.A.K41
The essentials of the differential diagnosis between afemoral and an inguinal herniaFemoral herniaFemoral hernia is the third most common type of primary hernia.It accounts for about 20% of hernias in women and 5% in men.Of all hernias it is the most liable to become strangulated .Strangulation is the initial presentation of 40% of femoral hernias .
M.A.K42Surgical anatomy of Femoral HerniaThe femoral canal occupies the most medial compartment of the femoral sheath and extends from the femoral ring above to the saphenous opening below.The femoral canal contains fat, lymphatic vessels and the lymph node of Cloquet .
M.A.K43 Clinical featuresFemoral hernia is rare before puberty .Between 20 and 40 years of age the prevalence rises and this continues to old age .The right side (Fig. 57.14) is affected twice as often as the left and in 20% of cases the condition is bilateral.Adherence of the greater omentum sometimes causes a dragging pain.Rarely, a large sac