external hernias

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Information about external hernias
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Published on March 8, 2011

Author: Dr.SamiAbdalhameid

Source: authorstream.com

Definition: Definition - A hernia is a protrusion of the whole or part of a viscus from its normal position through an opening in the wall of its containing cavity. - Eternal hernia is a protrusion of a viscus from the peritoneal cavity into an abnormal position the commonest site being inguinal canal. Classification: Classification -Inguinal – Femoral – Umblical & Para-Umblical – Epigastric – Incisional –Obturater Spigelian – Lumbar – Gluteal – Sciatic – Perineal – Hiatus. # Common hernias : Inguinal – Femoral – Umblical &Para-Umblical . Predisposing factors: Predisposing factors - All hernias occur at site of weakness or potential weakness of abdominal wall which acted on by continued or repeated increase in abdominal pressure. - Sites are : - Blood vessels & other structures enter or leave the abdomen or thoracic cavity . Congenital defects: Congenital defects - Persistence of processes vaginalis(= Indirect inguinal hernia) - Incomplete obliteration of umblicus(=Umblical hernia) - Patent canal of Nuck(=Indirect inguinal hernia in females) - Persistence communication between abdomen & thorax(Diaphragmatic hernia) Acquired defect: Acquired defect - Weakness of anterior abdominal wall result from surgical incision(=Incisional hernia) - Weakness as a result of : obesity, pregnancy, Wasting disease, aging process, polymyelitis & nerve division (Appendisectomy= ilioinguinal nerve injury=inguinal hernia) Precipitating factors: Precipitating factors - Chronic cough – Straining at defecation – Bladder neck obstruction – Pregnancy &Parturition – Vomiting –Severe muscular effort - Ascitis . Surgical pathology: Surgical pathology # The sac : usually peritoneal sac with a neck,body&fundus.Sac sometimes deficient posteriorly(sliding hernia) e.g., sigmoid,caec-um,bladder. (See Fig 1 below) # Contents : may be-omentum,bowel,portion of circumference of bowel,(Ritchers hernia),Mickels diverticulum (Littre's hernia),tow loop of bowel( Maydls hernia),bladder. # Contents may be : reducible,irreducible,obstructed,strangulated Fig 1 : Fig 1 Principles of treatment of hernia: Principles of treatment of hernia - No treatment in elderly with severe debility - Truss in infants up to 1 year of age(hoping normal obliteration process) - In healthy adults truss leads to atrophy of inguinal muscles=adhesions between sac & contents Principles of operative treatment: Principles of operative treatment - Precipitating factors should be controlled to reduce recurrence 1-Herniotomy=excision of sac(in infants & children this is all that is necessary) 2- Herniorrhaphy=closure of defect 3- Hernioplasty=by a mesh eg.Polypropylene mesh . Inguinal hernia: Inguinal hernia (Commonest type of hernia in both sex) # Surgical anatomy : - Inguinal canal is a an oblique passage about 4cm long, passing downwards &medially from internal ring to the external ring.Through the canal pass the spermatic cord in males &round ligament in females.The external ring is a V slit in the external oblique aponeurosis,1cm above &lateral to the pubic tubercle,transmits;vas diferens,testicular artery,artery of vas,cremastric artery,papiniform plexus of veins,ilioinguinal nerve,genital branch of genitofemoral nerve.processus vaginalis when present,cremastric muscle Surgical anatomy(cont.): Surgical anatomy(cont.) 1- Anterior wall of inguinal canal: made up of external oblique apponeurosis+internal oblique muscle laterally 2- Posterior wall : consists of transversalis fascia laterally & conjoint tendon medially 3- The roof : formed by internal oblique & transversalis muscles 4- The floor : formed by inguinal ligament laterally & lacunar ligament medially ( see Fig 2 below ) Fig 2: Fig 2 Types of inguinal hernia: Types of inguinal hernia 1- Direct inguinal hernia 2- Indirect inguinal hernia 3- Direct & indirect inguinal hernia( Dual, pantaloon or saddle bag) 4- Sliding Direct inguinal hernia: Direct inguinal hernia - Usually a diffuse bulge of medial portion of posterior wall, medial to inferior epig.vessels - May be : behind, above or below the cord - Direct inguinal hernias are acquired except in rare type where there is a defect in conjoint tendon ( Ogilvie's hernia ) . ( see Fig 3 below ) Fig 3: Fig 3 Indirect inguinal hernia: Indirect inguinal hernia - Enters the inguinal canal through the internal ring lateral to the inferior epig.vessels - Indirect inguinal hernias are usually congenital - Subdivided into: 1- Bubonocele (limited to inguinal canal) 2- Funicular(just above the epididymes) 3- Complete or scrotal(testis lie within lower part of hernia). ( see Fig 4 below ) Fig 4: Fig 4 Indirect & Direct hernia: Indirect & Direct hernia ( Dual , Pantaloon or Saddle bag hernia ) - Presents with dual sacs : - One medial & the other lateral to the inferior Epigastric vessels. ( see fig 5 below ) Fig 5: Fig 5 Sliding hernia: Sliding hernia - Almost exclusively in males, common on the left - Caused by laxity of the parietal peritoneum and viscus sliding underneath - Posterior wall not formed by peritoneum - Posterior wall formed by: sigmoid,caec-um,bladder. ( see Fig 6 below ) Fig 6: Fig 6 Clinical features: Clinical features # Symptoms : - A lump appears in the groin, sometimes after strenuous exercise, disappears on lying down - Discomfort or pain(stretching of neck sac) - Severe pain = obstruction or strangulation - Vomiting suggests obstruction or strangulation Clinical features(cont.): Clinical features(cont.) # General signs : - Precipitating factors=chronic lung diseases, urinary obstruction, colonic obstruction, previous Appendisectomy - Signs of obstruction or strangulation particularly dehydration, shock & peritonitis Clinical features(cont): Clinical features(cont) # Local signs : - Inspection = standing or coughing an indirect inguinal hernia passes downwards& medially towards the scrotum = Direct hernia protrudes directly forwards - Palpation= indirect hernia: when reducible returns in an upwards & lateral direction prevented by pressure on internal ring = Direct hernia: returns directly backwards can not be prevented by pressure on internal ring * Persisting pain, loss of cough impulse, edema& redness of skin strangulation may be suspected Differential diagnosis of a groin lump: Differential diagnosis of a groin lump - Femoral hernia - Inguinal lymph nodes - Saphena varix - Femoral aneurysm - Psoas abscess - Hydrocele of canal of Nuck - Encysted Hydrocele of the cord - Lipoma of the cord - incompletely descended testis Complicated inguinal hernia: Complicated inguinal hernia - Obstructed or strangulated require urgent operation - Short period of pre-operative resuscitation when dehydration is present - If bowel not viable=resection - Reduced spontaneously contents delivered and assessed - Couldn’t be delivered &there were signs of peritonitis pre-operatively =laparotomy Treatment: Treatment - Indirect inguinal hernia in children & adolescents = herniotomy alone - Indirect inguinal hernia in healthy adults: herniotomy, Herniorrhaphy, Hernioplasty, laparoscopic repair . Femoral hernia: Femoral hernia - Majority are acquired - Occurs more frequently in middle-aged & elderly females - Pregnancy probably an initiating factor - Prevalence of inguinal hernia in females is greater than femoral hernia Surgical anatomy: Surgical anatomy - Femoral sheath is a funnel-shape prolongation of fascia transversalis in front and fascia lata behind, it contains : femoral vessels, separated from medial side of femoral vein by a space=the femoral canal -Femoral canal is about 2cm long - Femoral ring is guarded arterially by: inguinal ligament,posterially by pectineal ligament, medially by lacunar ligament, laterally by femoral vein. ( see Fig 7 below ) Fig 7: Fig 7 Clinical features: Clinical features # Presented with a lump - usually small globular swelling below and lateral to the pubic tubercle, disappear on lying down # presented with obstruction or strangulation - lump becomes tense,tender&irreduicable - overlying skin becomes edematous when strangulation is present in addition to features of small bowel obstruction with pain & vomiting Treatment: Treatment - No place for conservative treatment, there is always risk of strangulation - Operation either : 1- Supra-inguinal 2- Inguinal 3- Sub inguinal Umblical hernia: Umblical hernia # Exomphalus is a rare neonatal condition - Midgut loop fails to retain into the abdominal cavity. ( see Fig 8 below ) -Presents at birth as two types : 1- Exomphalus minor 2- Exomphalus major Fig 8: Fig 8 Exomphalus minor: Exomphalus minor - The sac is small and the umbilical cord is attached at its summit - Treatment : - Twisting of the cord, so facilitating reduction of the sac, maintained by firm dressing for 2 weeks . Exomphalus major: Exomphalus major - Sac is large , contains small , large bowel & often part of liver - Umblical cord is at the inferior margin of the sac - Surgical repair is urgent synthetic material Umbilical hernia of infancy: Umbilical hernia of infancy - Occurs through a defect in the umbilical cicatrix during first few days of life - Sac protrude when the child cries or strain - Umbilical hernias are reducible and rarely strangulate Treatment of umbilical hernia: Treatment of umbilical hernia - Treatment is conservative since most disappear within 12-18 months, maintain retained by simple pad - Occasionally they persist after this period and operation is then recommended - The sac is excised through a transverse subumblical incision and small defect closed with few interrupted sutures . Para-umbilical hernia: Para-umbilical hernia - In majority of cases this occurs as an acquired condition in middle aged ,obese,multiparous women - There is often an initial small defect in linea alba just above the umblicus - Contents more often are: omentum,transverse colon, small bowel - Treatment is operative because of risk of complications.Repair,if defect is large mesh is used. ( see Fig 9 below ) Fig 9: Fig 9 Epigastric hernia: Epigastric hernia - This is a mid-line protrusion of extra peritoneal fat - Occasionally a small peritoneal sac through a defect in linea alba - Usually in fit muscular males under 40 - Many are symptomless, but pain, discomfort or digestive disturbances occur - It presents as small irreducible hernia midway between xiphisternum and the umblicus - Excision of fat, any sac and repair of defect. ( see Fig 10 below ) Fig 10: Fig 10 Incisional hernia: Incisional hernia - Most often in obese individual-persistent post-operative cough & post-operative abdominal distension - High incidence following operations for peritonitis (wound infection ). ( see Fig 11 below ) Fig 11: Fig 11 Clinical features: Clinical features - Great variations in degree of herniation - Skin may be thin & atrophic that normal peristalsis can be seen - Attacks of partial intestinal obstruction are common-strangulation is liable to occur - Most cases are asymptomatic Treatment: Treatment - Palliative=an abdominal belt is sometimes satisfactory specially hernias through upper abdominal incision - Operation : - Pre-operative weight reduction in obese - Mesh repair is the method of choice - Recurrence 30-50%(10%in specialist centers) Obturator hernia : Obturator hernia - An acquired hernia through the Obturator canal - Commoner in women & usually occurs after age of 50 years - Intestinal obstruction is the common mode of presentation - Diagnosis established at laparotomy - Occasionally a lump in upper and medial aspect of thigh - Pain may be referred to the knee - Treatment : sac & its contents reduced into the abdomen defect may be closed with mesh. ( see Fig 12 below ) Fig 12: Fig 12 Spigelian hernia: Spigelian hernia - Probably an acquired condition - Is a herniation through the outer border of rectus abdominis muscle half way between the pubis and the umblicus - May be confused with direct inguinal hernia but usually higher and medial - Treatment is operative as hernia is liable to strangulate . ( see Fig 13 below ) Fig 13: Fig 13 Lumbar hernia: Lumbar hernia - Either an incisional hernia (following loin incision ) or spontaneous through the lumbar triangle (iliac crest,post.edge of ext.oblique & the ant. edge of latismus dorsi) - Treatment : usually controlled by a belt although they are best treated surgically. ( see Fig 14 below ) Fig 14: Fig 14 Gluteal hernia: Gluteal hernia - Occurs through the greater sciatic notch - Either above or below pyriformis muscle - Most often diagnosed at laparotomy as for patients presenting with small bowel obstruction - Treatment is operative. ( see Fig 15 below ) Fig 15: Fig 15 Sciatic hernia: Sciatic hernia - Protrusion through the lesser sciatic notch - Usually discovered at operation for bowel obstruction - Rarely presented as a Gluteal swelling - May cause pain in the distribution of sciatic nerve . ( see Fig 16 below ) Fig 16: Fig 16 Perineal hernia: Perineal hernia - Most often occurs as incisional hernia following an abdominoperineal excision of the rectum - They are rare - Presenting in women as a swelling of the labia majora or as swelling in the ischiorectal fossa - Treatment is by combined abdominoperineal repair. ( see Fig 17 below ) Fig 17: Fig 17 Slide 61: THE DND

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