Prepared by : Dr. walid elian

• No disease of the human body, belonging to the province of the surgeon, requires in its treatment a better combination of accurate, anatomical knowledge with surgical skill than hernia in all its varients.

• Sir, Astley Paston Cooper , 1804

*The inguinal region must be understood with regard to its three-dimensional configuration and relation .

*Inguinal canal *External oblique Aponeurosis .*Internal oblique Aponeurosis *Transversalis fascia . *Iliopubic Tract . * Cooper’s ligament .*Pre-peritoneal space.

A hernia is the abnormal protrusion of a peritoneal – lined sac through the musculo aponeurotic covering of the abdomen.

---> weakness of the abdominal wall, congenital or acquired in origin, result is the inability to contain the visceral contents of the abdominal cavity within their normal confines

A hernia is the abnormal protrusion of a peritoneal – lined sac through the musculo aponeurotic covering of the abdomen.

---> weakness of the abdominal wall, congenital or acquired in origin, result is the inability to contain the visceral contents of the abdominal cavity within their normal confines

• A patient with groin hernia usually present with the complaint of :

.Bulge in the inguinal region. .Minor pain or vague discomfort. . Ocassionally , parasthesias.• Masses other than hernias can occur in the inguinal region.

• The inguinal area is examined with the patient standing, the patient is then examined in supine position.

• Incarcerated hernia can be reduced manually in many instances.

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• Numerous classification systems for groin hernias exist. A simple and widely used classification system is the Nyhus classification.

• Approximately 700,000 inguinal herniorrhaphies are performed in USA each year.

• According to data from national center of health statistics, the five most common major surgical operation performed by general surgeons in 1991 were :

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• Numerous classification systems for groin hernias exist. A simple and widely used classification system is the Nyhus classification.

• Approximately 700,000 inguinal herniorrhaphies are performed in USA each year.

• According to data from national center of health statistics, the five most common major surgical operation performed by general surgeons in 1991 were :

•

• Groin hernia 680,000• Cholecystectomy 571,000• ------ of peritoneal adhesion 339,000 • Appendectomy 255,000• Partial excision of large intestine 220,000 *75% of all hernias occur in the inguinal region .*50% of hernias are indirect inguinal hernias.*24% of hernias are direct inguinal hernias.*10% incisional and ventral hernias.*3% of femoral *5%- 10% unusual hernias

• Traditionally divided into two categories: *Congenital origins. *Acquired defects.

• Congenital factors are responsible for the majority of groin hernias.

*Lack of obliteration of the processes vaginalis is the primary factor leading to the development of an indirect hernia.

*prematurity and low birth weight. *Congenital abnormalities in the pelvis. * Congenital deformities or collagen

deficiencies .

• Acquired defect : *Direct hernia attributed to the wear and

tear stresses of life,eg : straining to urinate or defecate, coughing,

heavy lifting. * Association between cigarette smoking

( groin hernias has been demonstrated). * the multifunction process of wound

healing provides many clues to the etiology of groin hernia.

*malnutrition and vit. deficiency *advance age .

• Occurs through a pace bounded: *Superiorly by iliopubic tract. *Inferiorly by cooper’s ligament. *Laterally by femoral vein. *Medially by insertion of iliopubic tract into cooper’s

ligament.

• On examination: *A mass below the inguinal ligament. *More common in females than males. *Repair -- standard cooper’s ligament (Mc Vay )

repair.

• Vast majority are congenital in origin.• The umbilical defect closes spontaneously by the

age of 2 years .• Hernias that persist after the age of 5 years are

frequently repaired surgically.• Umbilical hernias presenting during adulthood

are considered acquired hernias .• Increased intra-abdominal pressure can develop

umbilical hernias: -Pregnancy -Ascitis -Acute abdominal distention. Can be repaired by MAYO repair.

• Usually occur as a result of inadequate healing of previous incision or excessive strain at the site of abdominal wall scar.

• Many of the factors that lead to development of hernias persist at the time of 2nd repair

• -----> high recurrence : -Obesity -Advanced age. -Malnutrition -Ascites - Post operative wound infection - post operative pulmonary complication -certain medication ----- to poor wound

healing, e.g. steroid and chemotherapy

• Repair should occur when patient’s underlying medical condition have been stabilized.

-small hernias -----> simple inerrupted sutures .

-much more common ------> required prosthetic material .

• One in which a viscus forms aportion of the wall of hernial sac (inguinal )

• Most commonly the viscous involved is segment of bowel on urinary bladder .

• Primary danger is injury to the viscus during operation

• Essential to the repair is reduction of the viscera into the peritoneal cavity.

• Epigastric hernia : -hernias of linea alba occur more above the

umbilicus than below. -usually small, frequently multiple. -patient’s complain of painful, pulling

sensation at the mid line up on reclining . - Repaired with simple suture closure .

• The antimesentric border of the intestine must protrude into hernia sac but never to the point of involvement of the entire circumference of the intestine

• Strangulation can occur ----> painful mass , nausea , vomiting , abdominal distention.

• Can occur within any type of abdominal wall hernia, but most common is at the site of femoral hernia.

• Repair according to the location.• Critical to repair is an adequate evaluation of

intestine for viability

• The presence of Meckel diverticulum as a sole component of the hernia sac .

• Strangulation of Meckel -----> abscess formation

-------> fistulization .

• Through the fascia along the lateral edge of the rectus muscle at the space between the semilunal line and the lateral edge of the rectus.

• Usually successfully repaired at initial operation.

• Hernia though the obturator canal .• May present with compression of obturator

nerve -----> pain in the medial aspect of the thigh.

• Grynfeltt’s hernia -------> superior lumbar triangle

• Petitis’s hernia ---------> inferior lumbar triangle

• Diffuse lumbar ---------> incisional hernia of kidney incision

• Through greater sciatic ------------• Extremely unusual- difficult to diagnose.• Present either by - intestinal obstruction. - gluteal or infra-gluteal

mass .

• Through congenital or acquired defects• Very unconscious

• In adult patients, complication rates from open inguinal herniotomy vary from 1%-26%.

• Local and systemic complication have been well ducumented for many years .

• The rate, magnitude, and nature of complications are similar whether the laparoscopic or open approach

• Intra operative complications include: Injury or transection of spermatic cord structure . Vascular injury producing haermorhage . Severance or entrapment of nerves. Visceral injury (bowel or bladder) Systemic such as cardiac arrest and death post operation

– Post operative complications include : Wound complication :- infections, haematoma . Scrotum & testicle :- hematoma , atrophy, sterility. Genito urinary :-retention , UTI Pulmonary :- atelectasis , pneumonia . DVT Recurrence -----> 1%-7% for indirect 4%-10% for direct 5-35% for

recurrent