Hernia Shanghai Jiaotong University Medical School Renji Hospital Ni Xingzhi

HerniaHernia

Shanghai Jiaotong University Medical SchoolRenji Hospital

Ni Xingzhi

HerniaHernia

DefinitionDefinition A hernia is a swelling caused by the protrusion of A hernia is a swelling caused by the protrusion of

an organ or other tissue through an aperture in an organ or other tissue through an aperture in the wall surrounding the space in which it is the wall surrounding the space in which it is situated.situated.

Such an aperture may be present normal or Such an aperture may be present normal or abnormal, in which case it can be congenital or abnormal, in which case it can be congenital or acquiredacquired

HerniaHernia

CausesCauses Lowered abdominal strengthLowered abdominal strength

Abdominal wall where an orifice for an organ or soAbdominal wall where an orifice for an organ or some tissue go thorough such as inguinal and femoral canal,etme tissue go thorough such as inguinal and femoral canal,etcc

Or trauma, surgery, infection, obesity, senility etc. Or trauma, surgery, infection, obesity, senility etc.

Increased abdominal pressureIncreased abdominal pressureCough, constipation, dysuria, acites, pregnancy, Cough, constipation, dysuria, acites, pregnancy,

heavy-liftingheavy-lifting

HerniaHernia

Pathological anatomyPathological anatomy Hernia sacHernia sac

– Neck of sac Neck of sac corresponds where the orifice iscorresponds where the orifice is

– Mouth and bodyMouth and body Contents of sacContents of sac

– Intra-peritoneal structure: small intestine or omentumIntra-peritoneal structure: small intestine or omentum Covering of sacCovering of sac

– Layers of abdominal wallLayers of abdominal wall

HerniaHernia

ClassificationClassification Reducible herniaReducible hernia Irreducible herniaIrreducible hernia

– Can not return or completely Can not return or completely – With no severe symptomsWith no severe symptoms

Incarcerated herniaIncarcerated hernia Impaired blood supplyImpaired blood supply Strangulated hernia Strangulated hernia Impaired blood supply till nonImpaired blood supply till non

Special hernias:Special hernias:Richter’s, Littre”s (Meckel’s diverticulumRichter’s, Littre”s (Meckel’s diverticulum) )

HerniaHernia

Richter HerniaRichter Hernia

Hernia Hernia Inguinal herniaInguinal hernia

Anatomy Anatomy Inguinal herniaInguinal hernia 75% of hernia75% of hernia

– Inferior Inguinal ligamentInferior Inguinal ligament– Medial RectusMedial Rectus– superior Ant,sup.iliac spinesuperior Ant,sup.iliac spine

Indirect inguinal herniaIndirect inguinal hernia 60%60%

– Lateral to inferior epigastric vessel through inguinal canal to Lateral to inferior epigastric vessel through inguinal canal to scrotum or notscrotum or not

Direct inguinal herniaDirect inguinal hernia 25%25%

– Through Hesselbach triangle medial to inferior epigastric vessel Through Hesselbach triangle medial to inferior epigastric vessel


Inguinal Inguinal herniahernia– Inferior Inferior

Inguinal Inguinal ligamentligament

– Medial RectusMedial Rectus– superior superior

Ant,sup.iliac Ant,sup.iliac spinespine


Anatomy of Anatomy of the inguinal the inguinal region from region from the internal the internal aspect, as aspect, as seen with the seen with the laparoscopic laparoscopic approachapproach


AnatomyAnatomy Skin, fat and fascia(scarpa’s)Skin, fat and fascia(scarpa’s) External oblique muscleExternal oblique muscle

– External oblique muscle aponeurosisExternal oblique muscle aponeurosis– Inguinal ,lacunar and pectineal ligamentInguinal ,lacunar and pectineal ligament– External ring External ring Medial and superior to pubic tubercleMedial and superior to pubic tubercle

– Iliogastric and ilioinguinal nerveIliogastric and ilioinguinal nerve External oblique and transversus muscle External oblique and transversus muscle

– Conjoined tendonConjoined tendonfusion of the aponeuroses of the internal oblique and transversus musclefusion of the aponeuroses of the internal oblique and transversus muscles where they insert on the pubic tubercle and superior pubic ramus. s where they insert on the pubic tubercle and superior pubic ramus.


Skin, fat and fasciSkin, fat and fascia(scarpa’s)a(scarpa’s)

External oblique External oblique

musclemuscle– External obliqExternal obliq

ue muscle apoue muscle aponeurosisneurosis


• Inguinal ligaInguinal ligamentment

180-twist of the 180-twist of the external obliquexternal oblique muscle aponee muscle aponeurosis forms a urosis forms a shelving edge ishelving edge in the lower porn the lower portion of the ligation of the ligamentment


AnatomyAnatomy Transversalis fascia Transversalis fascia

– Internal ringInternal ring 1-2cm above mid-inguinal point1-2cm above mid-inguinal point Laterally to inferior epigastric arteryLaterally to inferior epigastric artery Spermatic cord (vas deferens, testicular vessels), round ligameSpermatic cord (vas deferens, testicular vessels), round ligame

ntnt

Extra-peritoneal fat Extra-peritoneal fat PeritoneumPeritoneum


Internal ringInternal ring– 1-2cm above mi1-2cm above mi

d-inguinal pointd-inguinal point– Laterally to inferiLaterally to inferi

or epigastric arteor epigastric arteryry

– Spermatic cord Spermatic cord (vas deferens, tes(vas deferens, testicular vessels), rticular vessels), round ligamentound ligament


inferior epinferior epigastric artigastric arteryery


Anatomy ofAnatomy of inguinal canalinguinal canal A canal for passage of spermatic cord in male and round liA canal for passage of spermatic cord in male and round li

gament in femalegament in female

Anterior----external oblique aponeurosis, Anterior----external oblique aponeurosis, internal oblique muscle(lateral 1/3)internal oblique muscle(lateral 1/3)

Posterior----transversalis fascia and peritoneumPosterior----transversalis fascia and peritoneum Superior---- internal oblique muscle and Superior---- internal oblique muscle and

conjoined tendonconjoined tendon Inferior----inguinal and lacunar ligamentInferior----inguinal and lacunar ligament


Anterior----externAnterior----external oblique aponeual oblique aponeurosis, internal oblirosis, internal oblique muscle(lateral que muscle(lateral 1/3)1/3)

Posterior----tranPosterior----transversalis fascia ansversalis fascia and peritoneum d peritoneum


Anterior----externAnterior----external oblique aponeual oblique aponeurosis, internal oblirosis, internal oblique muscle(lateral que muscle(lateral 1/3)1/3)

Posterior----tranPosterior----transversalis fascia ansversalis fascia and peritoneum d peritoneum


Superior---- internSuperior---- internal oblique muscle al oblique muscle and conjoined tand conjoined tendonendon

Inferior----inguinInferior----inguinal and lacunar ligal and lacunar ligamentament


Inguinal hernia


Anatomy ofAnatomy of Hesselbach’s Hesselbach’s triangletriangle

It is It is bounded superiorly bounded superiorly by lateral side of by lateral side of rectus abdominis, rectus abdominis, inferiorly by inferiorly by inguinal ligament inguinal ligament and laterally by and laterally by inferior epigastric inferior epigastric vessels.vessels.


Symptoms and Diagnosis of IIHSymptoms and Diagnosis of IIH Reducible hernia

– Inguinal protrusionInguinal protrusion– Dragging discomfort in the groinDragging discomfort in the groin– Particularly in lifting or strain Particularly in lifting or strain – Returns after lying down or with help of handsReturns after lying down or with help of hands

Irreducible hernia Irreducible hernia – Un-retractable inguinal protrusionUn-retractable inguinal protrusion– More discomfortMore discomfort


Symptoms and Diagnosis of IIHSymptoms and Diagnosis of IIH Incarcerated herniaIncarcerated hernia

– Sudden increased intra-abdominal pressureSudden increased intra-abdominal pressure– Sudden enlarged herniation with tendernessSudden enlarged herniation with tenderness– Bowel obstruction manifestations if content is small intBowel obstruction manifestations if content is small int

estineestine Strangulated herniaStrangulated hernia

– Relieved pain but herniation persistsRelieved pain but herniation persists– Infarction and perforation of strangulated bowelInfarction and perforation of strangulated bowel– Local and general infectionLocal and general infection

HerniaHernia

IncarcerationIncarceration


Symptoms and Symptoms and Diagnosis Diagnosis of DIHof DIH

Mostly seen in eldersMostly seen in elders Semi-spheres lateral to Semi-spheres lateral to

pubic tuberclepubic tubercle Seldom irreducible Seldom irreducible

and rarely and rarely strangulatesstrangulates

Never goes into Never goes into scrotumscrotum


DifferentiationDifferentiation IIH and DIHIIH and DIH see table 45-1(textbook)see table 45-1(textbook)

Other diseasesOther diseases– HydroceleHydrocele– Undescended testesUndescended testes– Acute bowel obstructionAcute bowel obstruction


AA NormalNormal

BB Proximal sacProximal sac

CC Hernia sac extended Hernia sac extended to the scrotumto the scrotum

DD Proximal and distal oProximal and distal obliteration with hydrbliteration with hydrocele of the cordocele of the cord

CC Hydrocele of the scroHydrocele of the scrotumtum

EE Patent processus witPatent processus with communicating hydh communicating hydrocelerocele


TreatmentTreatment Conservative Conservative

– Inguinal hernia trussInguinal hernia truss

SurgicalSurgical– Dissection of inguinal canalDissection of inguinal canal– Repair of myopectineal orificeRepair of myopectineal orifice– Closure of inguinal canalClosure of inguinal canal


TreatmentTreatment SurgicalSurgical

– HernioplastyHernioplasty FergusonFerguson BassiniBassini HalstedHalsted McVayMcVay ShouldiceShouldice

Hernia Hernia Inguinal hernia-Inguinal hernia-Bassini OperationBassini Operation

Incision of the External Oblique AponIncision of the External Oblique Apon

eurosiseurosis Isolating the spermatic cord Isolating the spermatic cord


Resection of the Cremaster MuscleResection of the Cremaster Muscle Management of an Indirect SacManagement of an Indirect Sac


Splitting the Transversalis FasciaSplitting the Transversalis Fascia


Suture of the Deep PlaneSuture of the Deep Plane


Suture of the Deep Plane Suture of the Deep Plane Reconstructing the Anterior Wall of theReconstructing the Anterior Wall of the Inguinal Canal and the Superficial PlanesInguinal Canal and the Superficial Planes

Hernia Hernia Inguinal hernia-Inguinal hernia-Shoudice RepairShoudice Repair



– Tension-free hernioplasty



– Tension-free

hernioplasty



– Laparascopic hernioplstyLaparascopic hernioplsty


Laparascopic hernioplstyLaparascopic hernioplsty– Placement of mesh internally in inguinal region Placement of mesh internally in inguinal region


TreatmentTreatment Irreducible and strangulated herniaIrreducible and strangulated hernia

– ManeuverManeuver Within3-4hrs, no tenderness and abdominal irritationWithin3-4hrs, no tenderness and abdominal irritation Patient not fit for surgery and without bowel infarctionPatient not fit for surgery and without bowel infarction

– SurgerySurgery No hernioplasty after bowel resectionNo hernioplasty after bowel resection

Hernia Hernia femoral herniafemoral hernia A femoral hernia projects through femoral canalA femoral hernia projects through femoral canal

– 3-5% of groin hernia3-5% of groin hernia– Mostly seen in women over 40 or pregnantMostly seen in women over 40 or pregnant

Stretching of pelvic ligament Stretching of pelvic ligament Widening of femoral ring during pregnancyWidening of femoral ring during pregnancy

Femoral canalFemoral canal– Medial to femoral veinMedial to femoral vein– Opens into abdomen through femoral ringOpens into abdomen through femoral ring

Femoral canalFemoral canal– In front by inguinal ligamentIn front by inguinal ligament– Laterally by femoral veinLaterally by femoral vein– Internally by lacunar ligmentInternally by lacunar ligment– Posteriorly by pectineal ligamentPosteriorly by pectineal ligament

Hernia Hernia femoral herniafemoral hernia

Femoral Femoral canalcanal

Hernia Hernia femoral herniafemoral hernia Femoral canaFemoral cana

ll– In front by inIn front by in

guinal ligamguinal ligamentent

– Laterally by Laterally by femoral veinfemoral vein

– Internally by Internally by lacunar ligmlacunar ligmentent

– Posteriorly bPosteriorly by pectineal liy pectineal ligamentgament

Hernia Hernia femoral herniafemoral hernia

Clinical featureClinical feature– A bulge in upper aspect of thigh, beneath inguinal ligamentA bulge in upper aspect of thigh, beneath inguinal ligament– Below and lateral the pubic tubercleBelow and lateral the pubic tubercle– Absence of a cough impulse over inguinal ringAbsence of a cough impulse over inguinal ring– Liable to strangulate and can not be readily reducedLiable to strangulate and can not be readily reduced

DifferentiationDifferentiation SurgerySurgery

– McVay’s procedure McVay’s procedure – Cut inguinal ligament to enlarge the ring to reduce heriationCut inguinal ligament to enlarge the ring to reduce heriation

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Hernia Shanghai Jiaotong University Medical School Renji Hospital Ni Xingzhi