SURGERY Lecture 3 - Abdominal Hernia (Dr. Mendoza)
SURGERY Lecture 3 - Abdominal Hernia (Dr. Mendoza)
SURGERY Lecture 3 - Abdominal Hernia (Dr. Mendoza)
SURGERY BLOCK
2012
Abdominal Hernia
Dr. Mendoza
INTRODUCTION
Hernia
Historical Perspective
15th century:
castration with wound cauterization or henia sac
debridement
recommended a truss
Hernia
Latin for rupture
an abnormal protrusion of an organ or tissue through a defect
in its surrounding walls.
Occur at sites where aponeurosis and fascia are not covered by
striated muscle
Protrusion of abdominal viscera thru the abdominal wall
Important features or COMPONENTS of a hernia
HERNIAL ORIFICE or Defect
Defect or Fascial opening
HERNIAL SAC
peritoneal protrusion
found at ANTEROMEDIAL side of the sprematic cord
Contents
hollow viscera:
intestines
bladder
omentum
ALL Hernias should be repaired at time of discovery
Epidemiology
Types of Hernia
EXTERNAL ABDOMINAL HERNIAS
Inguinal hernia
75% of all hernias
2/3 INDIRECT: MC
1/3 DIRECT
High incidence of bilaterality in children
Incisional hernia: 15-20%
Umbilical and epigastric: 10%
Femoral: 5%
MC in Females
highest rate of complications 15-20%
Scrotal enlargement
In children d/t INDIRECT Hernia
In adults d/t PANTALOON Hernia
Prevalence of hernia increases with age
Most serious complication
strangulation
1-3% of groin hernias
All hernias should be repaired at time of discovery
Etiology of Hernias
Congenital
Hydrocele vs. indirect hernia
Hydrocele
(+) Transillumination
Patency rate of processus vaginalis
60% at 2mo
40% at 2yo
20% in adults
Connective tissue abnomalities
Malnutrition, Vitamin deficiency
Increased intra-abdominal pressure
COPD, dialysis, ascites, BPH
Chronic constipation
Strenuous labor
Terminology
REDUCIBLE HERNIA
can be replaced within surrounding musculature
Hernia that can be returned to the abdomen
IRREDUCIBLE or INCARCERATED HERNIA
Incarcerated Hernia that cannot be reduced into the
abdomen
STRANGULATED HERNIA
Incarcerated hernia w/ compromised blood supply to its
contents
occurs in hernia of small orifice and relatively voluminous
sacs
Clinical parameters for strangulation
Fever
Tachycardia
Exquisite tenderness
Erythema of overlying skin
Leukocytosis
Obstructive symptoms
COMPLETE OR EXTERNAL HERNIA
Sac & contents protrudes completely through the
abdominal wall
INCOMPETE HERNIA
Defect present without sac or contents protruding
completely through it
INTERPARIETAL HERNIA
sac contained within the abdominal wall
INTERNAL HERNIA
sac within the visceral cavity
INTERNAL ABDOMINAL HERNIAS can occur at
A: Paraduodenal
B: Foramen of Winslow
C: Intersigmoid
D: Pericecal
E: Transmesenteric
F: Retroanastomotic
HERNIA
PANTALOON HERNIA
direct and indirect components
indirect hernia component typically seen in elederly if
present
RICHTER'S HERNIA
contains antimesenteric portion of small bowel
the contents of the sac consist of only one side of the wall
of the intestine
SLIDING HERNIA
involves visceral retroperitonem of an organ (e.g.
bladder/ovary)
ANATOMY OF
Inguinal Region
Myopectinate Orifice of Fruchaud
Where majority of heniations occur
BOUNDARIES:
SUPERIOR: Transversus abdominis aponeurosis (TAA)
LATERAL: Iliopsoas muscle
INFERIOR: Pubic rami
MEDIAL: Rectus Abdominis muscle
VITAL STRUCTURES
Coopers Ligament
McVay approach
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2012
HERNIA
GROIN HERNIA
INGUINAL
Hernia
Groin Hernia
Incidence
INGUINAL HERNIA
75% of all hernias
rd
2/3 INDIRECT
rd
2/3 DIRECT
Male:Female= 7:1
Lifetime risk of developing a hernia
M= 5%, F= 1%
Right-sided in 84%; 25% bilateral
Most serious complication
Strangulation
1-3% of groin hernias
Most common surgical disease in males
60% indirect
36% direct
4% femoral
Most common groin hernia in BOTH sex
Indirect Inguinal Hernia
Femoral hernia
3x more in women
Highest rate of complication 15-20%
ALL hernias should be repaired at time of discovery
Classified as congenital vs acquired
Commonly thought that repeated in intra-abdominal
pressure contribute to hernia formation
Collagen formation and strucure deteriorates with age
hernia formation is more common in the older indiviual
REDUCIBILITY
Reducible
Incarcerated
Strangulated
CLINICAL Parameters for STRANGULATION
Fever & Tachycardia
Exquisite tenderness
Erythema of overlying skin
Leukocytosis
Obstructive symptoms
Diagnosis of Inguinal Hernia
HISTORY & PHYSICAL EXAM
GOLD Standard
best way to determine the presence or absence of an
inguinal hernia
74.5% sensitive and 96.3% specific
examine the patient in
standing
supine positions
CAN distinguish
direct vs indirect Inguinal Hernia
difficult to distinguish w/ exam alone
Inguinal vs Femoral hernia
PROCEDURE
examiner place the tip of the index finger at the most
dependent part of the scrotum and direct it into the
external inguinal ring.
patient is then asked to strain.
indirect hernia
will push against the fingertip
direct hernia
will push against the pulp of the finger
apply pressure over the mid-inguinal point
midway between the anterior superior iliac spine
and the pubic tubercle, and just above the
inguinal ligament
apply with the fingertip
INDIRECT HERNIA
will control hernia and prevent it from
protruding when the patient strains
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2012
DIRECT HERNIA
not be affected with this maneuver
RADIOLOGIC INVESTIGATION
Considered in when theres suspicion of OBSTRUCTION
PLAIN X-ray: Herniography
suspected hernia but clinical dx unclear
precedure done under FLOUROSCOPY following
injection of contrast medium
frontal and oblique radiographs are taken with and
without increased intra abdominal pressure
ULTRASONOGRAPHY
MRI
CT
Hernias are visualized as abnormal ballooning of the
anteroposterior diameter of the inguinal canal
simultaneous protrusion of fat or bowel within the inguinal
canal
LAPAROSCOPY
Differential Diagnosis of Inguinal Hernia
Femoral Hernia
Lymphadenopathy
Testicular masses
Hydrocele
(+) transillumination
MC Differential for inguinal hernia
Orchitis
Ectopic testicle
Lipoma of the cord
HERNIA
SURGERY BLOCK
2012
Hesselbachs Triangle
BOUNDARIES
MEDIAL:
Rectus Abdominis
LATERAL
Iferior Epigastric Artery
INFERIOR
Inguinal Ligament of Poupart
CLINICAL SIGNIFICANCE
Helps identify type of Inguinal Hernia
MEDIAL to Inferior Epigastric
Direct Hernia
LATERAL to Inferior Epigastric
Indirect Hernia
INGUINAL HERNIA
TYPE
Indirect
Inguinal
Hernia
Direct
Inguinal
Hernia
DESCRIPTION
RELATION
TO
Inferior
Epigastric
A.
Covered
by
Internal
Spermatic
Fascia
Usual
Onset
LATERAL
YES
Congenital
MEDIAL
NO
Adult
HERNIA
uterus, fallopian tube, ovary, ureter, and bladder can be
involved on either side
sliding component
usually found on the posterolateral side of the
internal ring.
it is not necessary to resect hernia sacs, and that simple
reduction into the preperitoneal space is sufficient.
eliminates the primary danger associated with sliding
hernias
injury to the viscus during high ligation and sac
excision
NYHUS CLASSIFICATION SYSTEM
TYPE
DESCRIPTION
Type I
Type II
TYPE III
IIIA
IIIB
IIIC
Type IV
IVA
IVB
IVC
IVD
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2012
Progressive Pneumoperitoneum
Done in successive sessions in preparation for
hernia surgery for patients with "loss of domain."
The viscera protrude outside the confines of
the abdominal cavity to the extent that
replacement followed by hernia repair
might cause respiratory embarrassment
and/or an abdominal compartment
syndrome.
OBJECTIVE
to stretch the abdominal wall preoperatively,
increasing the amount of room in the peritoneal
cavity.
decision to use pneumoperitoneum is most
commonly based on a CT scan, which allows
determination of the degree of domain loss
Anterior Inguinal Herniorrhapies
Bassini-Shouldice (1930)
Multilayer imbricated repair of the posterior wall
of the inguinal canal
OPEN Anterior PURE tissue repair
Done when MESH is not available
Use relaxing incisions
divides the anterior rectus sheath,
extending from the pubic tubercle
superiorly for a variable distance
Some surgeons "hockey stick" the incision
laterally at the superior extent.
rectus muscle itself is strong enough to
prevent future incisional herniation.
Allows various components of the
abdominal wall to displace laterally and
inferiorly
TYPES
MARCY
closure of internal ring, type I and II
TYPE I
abnormal inguinal floor w/
NORMAL inguinal ring
just ligate the sac
seen in children
HERNIA
TYPE II
MAIN INDICATION
Nyhus Type I Indirect Inguinal
Hernias
internal ring is normal.
appropriate for
children and young adults in
whom concern remains about the
long-term effects of prosthetic
material.
ESSENTIAL FEATURES
high ligation of the hernia sac
narrowing of the internal ring by
approximating the transversus
abdominis muscle medial to the
cord.
Displaces the cord structures
laterally allowing the placement
of sutures through the muscular
and fascial layers
BASSINI repair
MARCY repair
BASSINI
POPULAR
SIMPLEST REPAIR to perform
approx TAA w/ II, IPT; type II and III
COMPONENTS
Division of the external oblique
aponeurosis over the inguinal canal
through the external ring
Division of the cremaster muscle
lengthwise followed by resection,
while simultaneously exposing the
floor of the inguinal canal
to more accurately assess for a
direct inguinal hernia
Division of the floor or posterior wall
of the inguinal canal for its full length.
ensures adequate examination of
the femoral ring from above
surgeon is less likely to use the
transversalis fascia alone for
reconstruction, as it is the
WEAKEST LAYER of the posterior
wall.
High ligation of an indirect sac
Bassini's "Triple Layer"
Reconstruction of the posterior wall by
suturing the
transversalis fascia
transversus abdominis muscle,
internal oblique muscle
suture all 3 structures MEDIALLY to the
inguinal ligament laterally, and the
iliopubic tract.
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2012
MALONEY DARN
LONG NYLON SUTURE is repeatedly passed
between the tissues to create a weave that
similar to a mesh.
INITIAL LAYER
consists of a continuous nylon suture
to oppose the usual elements of the
abdominal wall medially (transversalis
fascia and the transversus abdominis,
rectus, and internal oblique muscles)
to the inguinal ligament.
first suture is continued into the
muscle about the cord, weaving in and
out to form reinforcement around the
cord
finally tied to the inguinal ligament on
the lateral side of the cord
SECOND LAYER
sutures made parallel or in a crisscross
fashion, plicating well into the inguinal
ligament below.
external oblique is closed over the cord
structures.
RATIONALE of the darn procedure
form a meshwork of nonabsorbable
suture that is well tolerated by the
tissues.
interstices fill with fibrous connective
tissue, producing a BUTTRESS across
the weakened area of the inguinal
canal
SHOULDICE
GOLD STANDARD for Anterior Tissue Repair
1.1% recurrence rate
similar w/ Bassini but using continuous
suturing (imbrication)
COMPONENTS
importance placed upon freeing the
cord from its surrounding adhesions,
resection of the cremaster muscle
high dissection of the hernia sac
division of the transversalis fascia.
CONTINUOUS
NONABSORBABLE
SUTURE is used to repair the floor.
Use monofilament steel wire.
HERNIA
SHOULDICE Repair:
CONTINUOUS Imbrication Sutures
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2012
LICHTENSTEIN Repair:
Running Locking Sutures
Prospective study
Danish hernia database of over 13000 hernia repairs
compared reoperations for recurrent hernia
Results After 5 years significantly lower (1/4 less
recurrence with mesh vs sutured repair)
Hence, Mesh has almost ZERO recurrence
Surgical Complications
Recurrence
MC complication
Infection
Hernia is classified as Class I: CLEAN WOUND
Other classes
Class II: Clean Contaminated
Neuralgia
HERNIA
Injury to genitofemoral nerve in triangle of PAIN
Bladder injury
Testicular injury
Vas Deferens injury
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McVAY Repair:
INTERRUPTED Sutures
FEMORAL
Hernia
Femoral Hernia
more common in females
wide pelvis in females diameter of femoral ring
40% present as emergencies with hernia incarceration or
stranglation
passes medial to the femoral vessels and nerve in the femoral
canal through the empty space
inguinal ligament forms the superior border
Palpation of the femoral canal just below inguinal ligament in
the upper thigh
FEMORAL TRIANGLE
Boundaries
SUPERIOR:
Inguinal Ligament
LATERAL
Sartorius Muscle
MEDIAL
Adductor Longus Muscle
Content: NAVEL
N: femoral nerve
A: femoral artery
V: femoral vein
Preperitoneal Spaces
TRIANGLE OF DOOM
BOUNDARIES
MEDIAL
vas deferens
LATERAL
spermatic vessels
Testicular Artery & Vein
INFERIOR
external iliac vessels
CONTENT
External Iliac Artery And Vein
deep circumflex iliac vein
genital branch of genitofemoral nerve
femoral nerve.
hidden by fascia
Staple should not be applied in this triangle otherwise;
chances of mortality are there if these great vessels are
injured
MOST important structure
Arteria corona mortis
Obturator vessels
External Iliac Vessels
TRIANGLE OF PAIN
BOUNDARIES
MEDIAL
Testicular Artery & Vein
BASE
iliopubic tract
HERNIA
SURGERY BLOCK
2012
INFERIOR
inferior edge of skin incision.
CONTENTS
Genitofemoral Nerve
lateral femoral cutaneous nerve
femoral nerve
staple in this area should be less because nerve
entrapment can cause Neuralgia.
SPACE OF RETZIUS
Space between the pubic bone & the urinary bladders
anterior & lateral walls
SPACE OF BOGROS
Extension of the space of Retzius laterally beyond the
urinary bladder wall
represents the retroinguinal preperitoneum
BOUNDARIES
ANTERIOR
transversalis fascia
MEDIAL
umbilico vesical fascia
transversalis fascia
peritoneum situated just behind the epigastrics
LATERALLY
pelvis wall
iliacus muscle
INFERIORLY
psoas muscle
external iliac vessels
femoral nerve
SUPERIORLY
Bogrosspace is in free continuity with the
lumbar retroperitoneum.
continuity explains the inferior expansion of
perirenal abcesses appearing in the groin.
CIRCLE OF DEATH:
AKA: Corona Mortis
refers to vascular ring form by the anastomosis of an
aberrant artery with the normal obturator artery arising
from a branch of the internal iliac artery.
At the time of laparoscopic hernia this vessel is torn both
end of vessel can bleed profusely, because both arise from
a major artery.
The surgeon should remember these anatomic landmarks
and the point of mesh fixation should be selected
superiorly, laterally and medially
OTHER HERNIAS
VENTRAL HERNIAS
Hernia
Epigastric Hernia
Protrusion of preperitoneal fat and peritoneum though the
decussating fibers of the rectus sheath in the midline (linea
alba) between the xiphoid process and the umbilicus
MIDLINE aponeurosis NOT intact
PARAUMBILICAL HERNIA
epigastric hernia that borders the umbilicus
Umbilical Hernia
Incidence reported -10%
Frequently in women.
femal to male ratio 3:1
Obesity and repeated pregnancies are common precursors
Strangulation of the colon and omentum is fairly common
In infant
Several times greater in black children
more common in premature children in all races
it closes spontaneously if
defect is < 1.5 cm
before 2 or 3 yo
repair is needed if
defect is > 2.0 cm
still present at > 2 years of age
MANAGEMENT
Non-Operative
most close spontaneously by acquired rather than
congenital in adults
Operative
Mayo Hernioplasty (vest-over pants)
use of prosthesis (mesh)
Polytetraflouroethylene (PTFE) mesh
Oburator Hernia
(+) Howship-Rhomberg Sign
Pressure on the obturator nerve causes pain on the region
of the hip & knee and inner aspect of thigh
rare form of hernia
protrusion of intra abdomnial contents through obturator
foramen
F:M ration 6:1
the foramen is formed by the ischeial and pubic rami
obturatorrvessels and nerve lie posterolateral to he hernia sac
in the canal
Small bowel is the most likely intraabdominal organ to be
found in the obturator hernia
Treatment: prosthesis
Spigelian Hernia
occurs along the semilunar line, which traverses a vertical space
along the lateral rectus border
occuring usually at sub-umbilical portion of Spiegels semilunar
and through Spieghels fascia
fused aponeurosis of the internal oblique and transverse
abdominis fascia
Below the arcuate line, the fascia of the two above
muscles are more parallel and does not crisscross)
> 90% of spigelian hernias are found
uncommon hernia of the anterior abdominal wall.
occur lateral to the rectus abdominis through a defect in the
linea semilunaris,
aponeuroses of the internal oblique and transversus
abdominis muscles.
typically present as bowel loops projecting laterally through the
abdominal wall.
difficult to palpate when they extend between the internal and
external oblique muscles.
HERNIA
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2012
LATERAL-DORSAL LOCATED
Hernia
Lumbar hernia
acquired lumbar hernias
back or flank trauma
poliomyelitis
back surgery
use of iliac crest as a donor site for bone grafts
kidney incision
2 lumbar spaces
Grynfeltt-Lesshaft Triangle
Superior triangle
Petit Triangles.
Inferior triangle
rare in occurrance
typically seen on the left side.
more common among men.
Clinically, they present as a soft-tissue flank bulge with
discomfort and/or muscle weakness.
HERNIA
Q&A
1.
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2012
HERNIA
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2012