hernias. historical perspective 15 th century - castration with wound cauterization or hernia sac...
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HERNIASHERNIAS
Historical PerspectiveHistorical Perspective
1515thth century - century - Castration with Castration with wound wound cauterization or cauterization or hernia sac hernia sac debridementdebridement
recommended a recommended a trusstruss
Father of Modern Inguinal Father of Modern Inguinal Hernia RepairHernia Repair
EDUARDO BASSINI
HerniaHernia
Latin for Latin for rupturerupture
an abnormal protrusion of an organ an abnormal protrusion of an organ or tissue through a defect in its or tissue through a defect in its surrounding wallssurrounding walls
Occur at sites where aponeurosis and Occur at sites where aponeurosis and fascia are not covered by striated fascia are not covered by striated muscle muscle
Which of the following statements Which of the following statements is/are true regarding incidence of the is/are true regarding incidence of the abdominal wall hernia?abdominal wall hernia?
A.A. Two-thrirds of all inguinal hernias Two-thrirds of all inguinal hernias are classified as indirect.are classified as indirect.
B.B. Femoral hernias are more common Femoral hernias are more common in females than in males.in females than in males.
C.C. Direct hernias are common in Direct hernias are common in females.females.
D.D. Hernias generally occur with equal Hernias generally occur with equal frequency in males and femalesfrequency in males and females
E.E. Premature babies have a 10% Premature babies have a 10% incidence of having inguinal hernia.incidence of having inguinal hernia.
EpidemiologyEpidemiology
700,000 hernia repairs year700,000 hernia repairs year Inguinal hernias -75% of all herniasInguinal hernias -75% of all hernias
2/3 Indirect, remainder are direct2/3 Indirect, remainder are direct Incisional hernias – 15 to 20%Incisional hernias – 15 to 20% Umbilical and epigastric – 10%Umbilical and epigastric – 10% Femoral – 5%Femoral – 5%
EpidemiologyEpidemiology
Prevelance of hernias increases with Prevelance of hernias increases with ageage
Most serious complication – Most serious complication – strangulationstrangulation 1 to 3% of groin hernias 1 to 3% of groin hernias
Femoral – Femoral – highest rate ofhighest rate of complicationscomplications 15% to 20% 15% to 20% recommended all be repaired at time of recommended all be repaired at time of
discoverydiscovery
Abdominal Wall Abdominal Wall AnatomyAnatomy
AnatomyAnatomy Inguinal ligamentInguinal ligament
(Poupart’s) – inferior (Poupart’s) – inferior edge of edge of external external obliqueoblique
Lacunar ligamentLacunar ligament – – triangular extension of triangular extension of the the inguinal ligamentinguinal ligament before its insertion before its insertion upon the pubic upon the pubic tubercle tubercle
conjoined tendonconjoined tendon (5- (5-10%)- Internal oblique 10%)- Internal oblique fuses with transversus fuses with transversus abdominis aponeurosisabdominis aponeurosis
Cooper’s LigamentCooper’s Ligament - - formed by the formed by the periosteum and fascia periosteum and fascia along the superior along the superior ramus of the pubis. ramus of the pubis.
Inguinal CanalInguinal Canal Between deep and Between deep and
superficial inguinal superficial inguinal ringsrings
BoundariesBoundaries Superifical – Superifical – external external
oblique aponeurosisoblique aponeurosis Superior – Superior – internal and internal and
transversustransversus Inferior – shelving edge Inferior – shelving edge
of of inguinal ligamentinguinal ligament and lacunar ligamentand lacunar ligament
Posterior (floor) – Posterior (floor) – transversalis fasciatransversalis fascia and aponeurosis of and aponeurosis of transversus abdominis transversus abdominis musclemuscle
Inguinal CanalInguinal Canal Contains the Contains the
spermatic cord and spermatic cord and round ligament of the round ligament of the uterusuterus
Spermatic cordSpermatic cord Cremasteric muscle Cremasteric muscle
fibersfibers Testicular vesselsTesticular vessels Genital branch of Genital branch of
genitofemoral nervegenitofemoral nerve Vas deferens Vas deferens Cremasteric vesselsCremasteric vessels
Components of Hesselbach’s triangle Components of Hesselbach’s triangle include which of the following anatomic include which of the following anatomic landmarks?landmarks?
A.A. Pectineal ligamentPectineal ligament
B.B. Lateral border of the rectus sheathLateral border of the rectus sheath
C.C. Cooper’s ligamentCooper’s ligament
D.D. Inguinal ligamentInguinal ligament
E.E. Inferior epigastric vesselsInferior epigastric vessels
TerminologyTerminology
ReducibleReducible – can be replaced – can be replaced within surrounding musculaturewithin surrounding musculature
IncarceratedIncarcerated – cannot be reduced – cannot be reduced
StrangulatedStrangulated – compromised blood – compromised blood supply to its contentssupply to its contents
Sends sensory branches to the inner Sends sensory branches to the inner thigh and medial aspect of the thigh and medial aspect of the scrotumscrotum
A.A. Ileoinguinal nerve Ileoinguinal nerve
B.B. Genitofemoral nerveGenitofemoral nerve
C.C. BothBoth
D.D. NeitherNeither
A sliding inguinal hernia on the left A sliding inguinal hernia on the left side is likely to involve which of the side is likely to involve which of the following?following?
A.A. Jejunum composing the posterior Jejunum composing the posterior wall of the sacwall of the sac
B.B. Ovary and fallopian tube in a Ovary and fallopian tube in a female infantfemale infant
C.C. OmentumOmentumD.D. Sigmoid colon composing the Sigmoid colon composing the
posterior wall of the sacposterior wall of the sacE.E. Cecum composing the Cecum composing the
anteromedial wall of the sacanteromedial wall of the sac
TerminologyTerminology
Pantaloon – Pantaloon – direct and indirectdirect and indirect components components Richter’s – contains Richter’s – contains antimesenteric portionantimesenteric portion
of small bowelof small bowel Sliding – involves Sliding – involves visceral peritoneumvisceral peritoneum of an of an
organ , i.e. bladder, ovaryorgan , i.e. bladder, ovary Littre’s – hernia contains Littre’s – hernia contains Meckel’s Meckel’s
diverticulumdiverticulum Petit – hernia at Petit – hernia at inferiorinferior lumbar triangle lumbar triangle Grynfelt – hernia at Grynfelt – hernia at superiorsuperior lumbar lumbar
triangletriangle
Groin HerniasGroin Hernias
IndirectIndirect DirectDirect FemoralFemoral
Inguinal HerniaInguinal Hernia
Classified as congenital vs. acquiredClassified as congenital vs. acquired
commonly thought that repeated commonly thought that repeated increases in intra-abdominal pressure increases in intra-abdominal pressure contribute to hernia formationcontribute to hernia formation
collagen formation and structure collagen formation and structure deteriorates with age, and thus hernia deteriorates with age, and thus hernia formation is more common in the older formation is more common in the older individual. individual.
Clinical PresentationClinical Presentation
Groin bulgeGroin bulge Often asymptomaticOften asymptomatic Dull feeling of discomfort or Dull feeling of discomfort or
heaviness in the groinheaviness in the groin Focal pain – raise suspicion for Focal pain – raise suspicion for
incarceration or strangulationincarceration or strangulation Symptoms of bowel obstructionSymptoms of bowel obstruction
Inguinal herniaInguinal hernia
Male inguinal hernia Female inguinal hernia
DiagnosisDiagnosis
Physical Exam Physical Exam 74.5% sensitive and 74.5% sensitive and
96.3% specific96.3% specific examine the patient examine the patient
in the standing and in the standing and supine positionssupine positions
difficult to difficult to distinguish direct distinguish direct and indirect on and indirect on exam on aloneexam on alone
DiagnosisDiagnosis
Radiologic InvestigationsRadiologic Investigations Herniography Herniography
Suspected hernia, but clinical dx unclearSuspected hernia, but clinical dx unclear Procedure done under flouroscopy following Procedure done under flouroscopy following
injection of contrast mediuminjection of contrast medium Frontal and oblique radiographs are taken Frontal and oblique radiographs are taken
with and without increased intra-abdominal with and without increased intra-abdominal pressure pressure
Ultrasonography Ultrasonography MRI MRI CTCT
HerniographyHerniography
Right direct inguinal hernia
Left indirect inguinal hernia
Direct Inguinal HerniaDirect Inguinal Hernia
Direct Inguinal HerniaDirect Inguinal Hernia
MedialMedial to the to the inferior epigastric inferior epigastric artery and veinartery and vein, , and within and within Hesselbach's Hesselbach's triangle triangle
acquired weakness acquired weakness in the inguinal in the inguinal floor floor
Indirect Inguinal herniaIndirect Inguinal hernia
Abdominal contents protrude through Abdominal contents protrude through internal inguinal ringinternal inguinal ring
Indirect Inguinal HerniaIndirect Inguinal Hernia Accepted hypothesisAccepted hypothesis: :
incomplete or incomplete or defective obliteration defective obliteration of the of the processus processus vaginalisvaginalis during the during the fetal period fetal period
remnant layer of remnant layer of peritoneum forms a peritoneum forms a sac at the internal sac at the internal ring ring
more frequently on more frequently on the right the right
FemoralFemoral More common in More common in
females females Up to 40% present as Up to 40% present as
emergencies with hernia emergencies with hernia incarceration or incarceration or strangulation strangulation
Passes medial to the Passes medial to the femoral vessels and femoral vessels and nerve in the femoral nerve in the femoral canal through the empty canal through the empty space space
Inguinal ligament forms Inguinal ligament forms the superior borderthe superior border
FemoralFemoral
palpation of the femoral canal just palpation of the femoral canal just below the inguinal ligament in the below the inguinal ligament in the upper thigh upper thigh
NAVELSNAVELS
Which of the following statements Which of the following statements is/are true regarding direct inguinal is/are true regarding direct inguinal hernias?hernias?
A.A. The most likely cause is destruction of The most likely cause is destruction of connective tissue resulting form physical connective tissue resulting form physical stress.stress.
B.B. Direct hernias should be repaired Direct hernias should be repaired promptly because of the risk of promptly because of the risk of incarceration.incarceration.
C.C. A direct hernia may be a sliding hernia A direct hernia may be a sliding hernia involving a portion of the bladder wall.involving a portion of the bladder wall.
D.D. A direct hernia may pass through the A direct hernia may pass through the external inguinal ring.external inguinal ring.
E.E. Colon carcinoma is a known cause of Colon carcinoma is a known cause of direct inguinal hernias.direct inguinal hernias.
TreatmentTreatment
Non-OperativeNon-Operative ObservationObservation Trusses can provide symptomatic relief Trusses can provide symptomatic relief
Hernia control in ~30% of patientsHernia control in ~30% of patients
OperativeOperative
BassiniBassini ShouldiceShouldice McVayMcVay LichtensteinLichtenstein PreperitonealPreperitoneal LaparoscopicLaparoscopic
Bassini (early 20Bassini (early 20thth Century) Century) Transversus abdominis to ThompsonTransversus abdominis to Thompson’’s ligament and s ligament and
internal oblique musculoaponeurotic arches or internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligamentconjoined tendon to the inguinal ligament
Shouldice (1930s)Shouldice (1930s) Multilayer imbricated repair of the posterior wall of the Multilayer imbricated repair of the posterior wall of the
inguinal canalinguinal canal McVay (1948)McVay (1948)
Edge of the transversus abdominis aponeurosis to Edge of the transversus abdominis aponeurosis to CooperCooper’’s ligament; incorporate Coopers ligament; incorporate Cooper’’s ligament s ligament and the iliopubic tract (transition suture) and the iliopubic tract (transition suture)
BASSINI
SHOULDICE
MCVAY
Lichtenstein Lichtenstein First pure prosthestic, tension-free First pure prosthestic, tension-free
repair to achieve low recurrence repair to achieve low recurrence ratesrates
Prosthetic RepairProsthetic Repair Polypropylene mesh most common and Polypropylene mesh most common and
preferred preferred allows for a fibrotic reaction to occur allows for a fibrotic reaction to occur
between the inguinal floor and the posterior between the inguinal floor and the posterior surface of the mesh, thereby forming scar surface of the mesh, thereby forming scar and strengthening the closure of the hernia and strengthening the closure of the hernia defect defect
Polytetrafluoroethylene (PTFE) meshPolytetrafluoroethylene (PTFE) mesh often used for repair of often used for repair of ventral or incision ventral or incision
herniashernias in which the fibrotic reaction with in which the fibrotic reaction with the underlying serosal surface of the bowel the underlying serosal surface of the bowel is best avoided is best avoided
Prospective studyProspective study Danish Hernia Danish Hernia
database of over database of over 13,000 hernia repairs13,000 hernia repairs
Compared re-Compared re-operations for operations for recurrent hernia recurrent hernia
Results: After 5 years Results: After 5 years significantly lower significantly lower (1/4 less) recurrence (1/4 less) recurrence with mesh vs. with mesh vs. sutured repair sutured repair
LaparoscopicLaparoscopic
The cause of neuropathic The cause of neuropathic postherniorrhaphy inguinodynia postherniorrhaphy inguinodynia includes which of the following?includes which of the following?
A.A. Formation of scar tissueFormation of scar tissue
B.B. Transection of the ilioinguinal, Transection of the ilioinguinal, iliohypogastric, or the iliohypogastric, or the genitofemoral nervesgenitofemoral nerves
C.C. Suture entrapment of nervesSuture entrapment of nerves
D.D. Staple entrapment of nervesStaple entrapment of nerves
E.E. Periosteal reactionPeriosteal reaction
Surgical ComplicationsSurgical Complications
RecurrenceRecurrence Infection Infection NeuralgiaNeuralgia Bladder injuryBladder injury Testicular injuryTesticular injury Vas Deferens injuryVas Deferens injury
Other HerniasOther Hernias
Which of the following is/are true Which of the following is/are true statements regarding umbilical statements regarding umbilical hernias?hernias?
A.A. They are embryonic equivalent of a They are embryonic equivalent of a small omphalocelesmall omphalocele
B.B. Repair in infants is usually deferred until Repair in infants is usually deferred until approximately 4 years of ageapproximately 4 years of age
C.C. Repair in adults is usually indicatedRepair in adults is usually indicated
D.D. The “vest-over-pants” type of repair is The “vest-over-pants” type of repair is stronger than simple approximation of stronger than simple approximation of fascial marginsfascial margins
E.E. They are most common in Caucasian They are most common in Caucasian infantsinfants
UmbilicalUmbilical
IncidenceIncidence Reported ~10%Reported ~10% several times greater in Black childrenseveral times greater in Black children more common in premature children all more common in premature children all
racesraces Most close spontaneously by age 2 or 3Most close spontaneously by age 2 or 3 Acquired rather than congenital in Acquired rather than congenital in
adultsadults Female to male ratio 3:1 Female to male ratio 3:1
EpigastricEpigastric midline junction of the midline junction of the
aponeuroses (linea aponeuroses (linea alba) alba) betweenbetween the the xiphoid processxiphoid process and and umbilicusumbilicus
Paraumbilical hernia - Paraumbilical hernia - epigastric hernia that epigastric hernia that borders the umbilicusborders the umbilicus
Estimated frequency Estimated frequency 3-5%3-5%
More common in More common in Males 3:1Males 3:1
20% may be multiple20% may be multiple
EpigastricEpigastric ClinicalClinical
Often asymptomatic, incidental findingOften asymptomatic, incidental finding If symptomatic, vague abdominal pain above the If symptomatic, vague abdominal pain above the
umbilicus exacerbated by standing or coughing; umbilicus exacerbated by standing or coughing; relieved in supine positionrelieved in supine position
Severe pain secondary to incarceration/strangulation of Severe pain secondary to incarceration/strangulation of preperitoneal fat (often no peritoneal sac) or omentumpreperitoneal fat (often no peritoneal sac) or omentum
Exam: palpate small, soft, reducible mass superior to Exam: palpate small, soft, reducible mass superior to the umbilicusthe umbilicus
RARERARE to have strangulated bowel to have strangulated bowel TxTx
Excise fat and sac, close primarilyExcise fat and sac, close primarily
An 82-year-old previously healthy woman has a 12-hour An 82-year-old previously healthy woman has a 12-hour history of severe epigastric pain associated with nausea and history of severe epigastric pain associated with nausea and vomiting. She has had no previous abdominal operations. Her vomiting. She has had no previous abdominal operations. Her WBC count is 21,000/cu mm. The plain films and abdominal WBC count is 21,000/cu mm. The plain films and abdominal CT shown are obtained.CT shown are obtained.
Which of the following best Which of the following best describes this patient’s describes this patient’s diagnosis?diagnosis?A.A. Pain in the medial thigh and knee is Pain in the medial thigh and knee is
uncommonly associated with this uncommonly associated with this conditioncondition
B.B. It is unusual in womenIt is unusual in women
C.C. It is unusual in elderly patientsIt is unusual in elderly patients
D.D. It is seldom associated with It is seldom associated with intestinal necrosisintestinal necrosis
E.E. It is usually unilateralIt is usually unilateral
ObturatorObturator Rare form of herniaRare form of hernia Protrusion of intra-Protrusion of intra-
abdominal contents abdominal contents through through obturator obturator foramenforamen
F:M ratio 6:1F:M ratio 6:1 The obturator foramen is The obturator foramen is
formed by the ischial and formed by the ischial and pubic rami pubic rami
obturator vessels and obturator vessels and nerve lie posterolateral to nerve lie posterolateral to the hernia sac in the canal the hernia sac in the canal
Small bowel is the most Small bowel is the most likely intraabdominal likely intraabdominal organ to be found in an organ to be found in an obturator herniaobturator hernia
ObturatorObturator
4 cardinal signs : 4 cardinal signs : intestinal obstructionintestinal obstruction (80%) (80%) Howship-Romberg signHowship-Romberg sign (50%) –History of (50%) –History of
repeated episodes of bowel obstructionrepeated episodes of bowel obstruction that resolve quickly and without that resolve quickly and without intervention intervention
Palpable massPalpable mass (20%) (20%)
Tx: Sugical RepairTx: Sugical Repair
Spigelian HerniaSpigelian Hernia occurs along the occurs along the
semilunar line, which semilunar line, which traverses a vertical traverses a vertical space along the space along the lateral rectus border lateral rectus border
where more than 90% where more than 90% of spigelian hernias of spigelian hernias are foundare found
Spigelian HerniaSpigelian Hernia
ClinicalClinical Swelling in middle to Swelling in middle to
lower abdomen lower abdomen lateral to rectus lateral to rectus musclemuscle
Usually reducibleUsually reducible Up to 20% present Up to 20% present
with incarcerationwith incarceration Tx: surgicalTx: surgical
Mesh not requiredMesh not required Recurrence is Recurrence is
uncommonuncommon
LumbarLumbar
Acquired lumbar hernias Acquired lumbar hernias – – back or flank trauma, back or flank trauma,
poliomyelitis, back surgery, poliomyelitis, back surgery, and the use of the iliac and the use of the iliac crest as a donor site for crest as a donor site for bone grafts bone grafts
Contains to anatomic Contains to anatomic triangles, inferior and triangles, inferior and superior lumbar superior lumbar trianglestriangles Grynfelt’sGrynfelt’s Petit’s Petit’s
Strangulation is rareStrangulation is rare Soft swelling in lower Soft swelling in lower
posterior abdomenposterior abdomen
SciaticSciatic Via greater or lesser Via greater or lesser
sciatic notch sciatic notch greater sciatic notch is greater sciatic notch is
traversed by the traversed by the piriformis muscle, and piriformis muscle, and hernia sacs can protrude hernia sacs can protrude either superior or inferior either superior or inferior to this muscle to this muscle
suprapiriform defect 60%suprapiriform defect 60% Infrapiriform 30% Infrapiriform 30% subspinous (through the subspinous (through the
lesser sciatic foramen) lesser sciatic foramen) 10% 10%
Which of the following hernias is most Which of the following hernias is most likely to recur after primary repair?likely to recur after primary repair?
A.A. Epigastric herniaEpigastric hernia
B.B. Spigelian herniaSpigelian hernia
C.C. Indirect herniaIndirect hernia
D.D. Femoral herniaFemoral hernia
E.E. Incisional herniaIncisional hernia
Ventral wall (Incisional)Ventral wall (Incisional) Highest incidence in Highest incidence in
midline and transverse midline and transverse incisions incisions
Up to20% after laparotomyUp to20% after laparotomy 1/3 present in 5-10 years 1/3 present in 5-10 years
postoperativelypostoperatively Risk factors Risk factors
obesity, DM, ascites, obesity, DM, ascites, steroids, smoking steroids, smoking malnutrition, wound malnutrition, wound infectioninfection
Technical aspects of wound Technical aspects of wound closureclosure Type of incision Type of incision Excessive tension (prone to Excessive tension (prone to
fascial disruption)fascial disruption)
Which of the following hernias Which of the following hernias represent an incarceration of a limited represent an incarceration of a limited portion of small bowel?portion of small bowel?
A.A. Spigelian herniaSpigelian hernia
B.B. Grynfelt’s herniaGrynfelt’s hernia
C.C. Petit’s herniaPetit’s hernia
D.D. Richter’s herniaRichter’s hernia
E.E. Littre’s herniaLittre’s hernia