Sheng Yan MD, PhDThe First Affiliated Hospital Zhejiang University

Hernias, and Intraperitoneal abscess

General consideration DefinitionHernia means a sprout, and protrusion. External abdominal wall hernia is an abnormal protrusion of

intra-abdominal tissue or the whole or part of a viscera through an opening or fascial defect in the abdominal wall.

most occur in the groin

Historical Hernias

Hernias have been documented throughout history with varying success at either reduction or repair.

Trusses & Techniques

Camper’sScarpa’s Fascia

Inguinal canal Contents: spermatic cord, round ligament, ilioinguinal nerve anterior: skin, superficial fascia, and external ablique aponeurosis posterior: transversalis fascia superior: conjoined tenden inferior: inguinal ligamentHesselbach’s triangle Bounded by the inguinal ligament, the inferior epigastric vessels,

and the lateral edge of rectus muscle.

scrotum

Anatomy

Pathological anatomy The hernia composed of:• covering tissue: skin, subcutanous tissue• hernial sac: protrusion of peritonum, neck of the sac: is narrow where the sac emerges from the abdomen body of the sac • hernial contents: small intestine, major omentum

Etiology 1. intensity of abdominal wall decreased common factors: 1) site that some tissues pass through the abdominal wall, eg. Spermatic cord, round ligament of uterus 2) bad development of abdominal white line 3) incision, trauma, infection et al. defect in collagen synthesis or turnover 2. any condition which increases intra-abdominal pressure chronic cough, chronic constipation, dysuria, ascites, pregnancy, cry

Causes of indirect inguinal hernia

1. congenital abnormality of anatomy

due to failure of fusion of the processus vaginalis peritonei after the

testis has descended into the scrotum.

2. acquired weakness or defect of abdominal wall

Clinical manifestation and diagnosis Symptoms: pain, discomfort, dragging sensation Sign: reducible or irreducible lump, expansive cough impulse Reducing the hernia fully, compress the internal ring: be controlled – indirect not controlled -- direct

Hernia Exam

Differential diagnosis• 1 hydrocele of testis translucent test (+)• 2 communicated hydrocele• 3 hydrocele of cord: not reducible• 4 undescended testis• 5 acute intestinal obstruction

Clinical types 1. reducible hernia is one in which the contents of the sac return to the

abdomen spontaneously or with manual pressure when the patient is recumbent.

2. irreducible hernia is one whose contents or part of contents cannot be returned to the abdomen, without serious symptoms.

hernias are trapped by the narrow neck Sliding hernia is one in which the wall of a viscus forms a portion of the

wall of the hernia sac. It is may be colon ( on the left), cecum (on the right) or bladder (on either side).

Belongs to irreducible hernia

3. incarcerated hernia: is one whose contents cannot be returned to the abdomen, with severe symptoms.

4. strangulated hernia: denotes compromise to the blood supply of the contents of the sac.

incarcerated hernia and strangulated hernia are the two stages of a pathologic course

Richter’s hernia (intestinal wall hernia ) a hernia that has strangulated or incarcerated a part of the intestinal

wall without compromising the lumen. Littre hernia: a hernia that has incarcerated the intestinal diverticulum

(usually Meckel diverticulum). Reductive incarcerated hernia: reduction of the hernial contents

( intestine ) into abdominal cavity.

Sliding hernia

viscera forms a portion of the wall of the hernia sac

Richter——intestinal wallLittre ——intestinal diverticulum

incarcerated hernia: is one whose contents cannot be returned to the abdomen, with severe symptoms

incarcerated hernia Reductive incarcerated hernia

strangulated hernia: denotes compromise to the blood supply of the contents of the sac

Indirect Hernia Route

Note: The hernia sac

passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.

Direct Hernia Route

Note: The hernia sac

passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.

Differences between indirect and direct hernia

feature indirect direct

age children, young people aged people

pathway of protrusion coming down the inguinal canal, may enter the scrotum

pass through Hesselbach’s triangle, rarely enter the scrotum

contours of sac elliptic, pear-shaped semispheric, wide base

compress the internal ring after reduced

Un-controlled controlled

Relationship of spermatic cord with sac

Posterior to the sac Anterior and lateral to the sac

Relationship of sac neck with inferior epigastric artery

Sac neck is lateral to it Sac neck is medial to it

Incarcerated incidence high low

Treatment 1. nonoperative therapy Indications: <1 year old elderly patients or with severe systemic

disease--truss

2, Specific Surgical Procedures• Lichenstein (Tension Free) Repair

• Bassini Repair

• McVay (Cooper’s Ligament) Repair

• Shouldice (Canadian) Repair

• Laproscopic Hernia Repair

Bassini Repair

– Is frequently used for indirect inguinal hernias and small direct hernias

– The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

• AKA: Cooper’s ligament Repair– Is for the repair of

large inguinal hernias, direct inguinal hernias, recurrent hernias and femoral hernias

– The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally

McVay Repair

McVay Repair

Note: This repair

reconstructs the inguinal canal without using a mesh prosthesis.

FergusonFerguson repairrepairFergusonFerguson repairrepair

Conjoint tendonConjoint tendonInguinal LigInguinal Lig

Spermatic cordSpermatic cord

Ferguson Repair the anterior wall of

the inguinal canal

Shouldice Repair• AKA: Canadian Repair

– A primary repair of the hernia defect with 4 overlapping layers of tissue.

– Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be under tension, leading to swelling and patient discomfort.

Lichtenstein RepairAKA: Tension-Free RepairOne of the most commonly

performed procedures, using prosthetic materials

A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord

Lichtenstein Repair

Note: Open mesh repair.

Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.

Laparoscopic Hernia Repair

– Early attempts resulted in exceptionally high reoccurrence rates

– Current techniques include• Transabdominal preperitoneal repair (TAPP)• Totally extraperitoneal approach (TEP)

Types of Laparoscopic Inguinal Hernia Repair

• IPOM (IntraPeritoneal On-lay Mesh) repair. A mesh is placed intra-abdominally covering the hernia defect and then secured to the abdominal wall. Very popular at the beginning of laparoscopic experience, it has since been abandoned.

• TAPP (Trans Abdominal Pre-Peritoneal) repair. With this technique, the pre-peritoneal space is accessed from the abdominal cavity and a mesh is then placed and secured. This is procedure of choice for recurrent inguinal hernias or in case of incarcerated bowel – visualized.

• TEP (Totally ExtraPeritoneal) repair. The mesh is again placed in the retroperitoneal space, but in this case, the space is accesed without violating the abdominal cavity. This is probably the most physiological repair although technically more demanding. The procedure of choice for bilateral inguinal hernia repairs

Trochar placement for both TEP & TAPP

Laparoscopic Mesh Repair

Note: Viewed from inside the

pelvis toward the direct and indirect sites. A broad portion of mesh is stapled to span both hernia defects. Staples are not used in proximity to neurovascular structures.

Femoral herniaFemoral herniaFemoral herniaFemoral hernia

Inguinal lig.Inguinal lig.Inguinal lig.Inguinal lig.

CoopCooper er Lig.Lig.

CoopCooper er Lig.Lig. Femoral Femoral

V.V.Femoral Femoral V.V.

Femoral ringFemoral ring

McVay REPAIRDirect suture

McVay REPAIRDirect suture

OPERATIONOPERATIONOPERATIONOPERATION

The incision most common for hernia: trans-rectus incision

The major reason for incisional

hernia : incisional infection 50%

Incisional Hernia

Poor nutritional status

Incision hernia

Incision hernia

Intraperitoneal abscess

Gross:I. Supra-mesocolic

spaces: falciform lig.

a) Right sub-phrenic space: suprahepatic space / infrahepatic space

b) Left subphrenic space: - space bet. left lobe of liver & stomach

- lesser sac

II. Gross:1. Infra-mesocolic spaces:

a) Right lateral paracolic / right medial paracolic gutter

b) Left medial paracolic / left lateral paracolic gutter

ANATOMY:I. Microscopic:

– Mesothelium – 1.8 m21. Mesothelial cells (cuboidal

cells/flattened cells)» Stomata

2. Basement membrane3. Connective tissue (collagen,

elastic fiber, fibroblast, adipose, endothelial cells, mass cells, machrophage).

II. Gross:– Intra-abdominal area:

(intraperitoneal / retroperitoneal)

– Intra-peritoneal Space – defined by mesothelial membranea. visceral peritoneum

b. parietal peritoneum

ThanksWelcome questions!