Hernias of the antero-Hernias of the antero-lateral wall of the lateral wall of the

abdomenabdomen-particular forms--particular forms-

Inguinal herniasInguinal hernias

Anatomy briefing

Definition: hernias produced through a defect situated on the posterior wall of the inguinal canal

Inguinal canal: a space designed for the passage of – Testis – peritoneal diverticula present at birth – Round ligament – peritoneal diverticula present at

birth (Nuck) Major opening in the mucsculo-fascial structure

of the abdominal wall

Inguinal canal

Inguinal canal - structure

Anatomic structures are dynamic – description represents a schematic view– 4 walls (anterior, posterior, superior and

inferior)– 2 orifices: internal and external

Anterior wall Fascia of the

external oblique muscle

Fascia ends in 2 pillars– Spina pubis– Anterior part of

pubic bone and rectus sheat

Inferior wall

Inguinal ligament Concavity opened above Internally – it reflects fibers towards the

pectineal ridge = the triangular ligament of Gimbernat and prolonges on the pubic branch of the iliac bone forming one body with the ligament of Cooper – solid strutcture

Inferior wall

Superior wall

Inferior border of internal oblique and transversus : the conjoined ligament

Fusion of the structures is NOT the rule The resultant structure is not fibrotic and

sometimes very friable – not suitable for suturing

Posterior wall

Fascia transversalis in it’s way towards the vascular sheat

Ligament of Thompson (inferiorly)

2 fibrotic structures ligaments of Henle and Hasselbach

Posterior wall

Weak anatomic region predisposed to hernia formation

Muscular structures are supposed to close the defect during effort

Inferior eipgastric vessels separate 3 parts– Profound inguinal orifice (external oblique hernia)– Middle part (medial to the epigastric vessels)– direct

inguinal hernia – Internal part (medial to the umbilical artery) inetrnal

oblique hernia

Orifices

Profund (lateral or internal)– Situated in fascia transversalis – the external part – A weak point of the abdominal wall

Superficial (medial or external) – Between the pillars of the fascia of the external

oblique muscle– The place where a hernia engages towards the scrotum– Place to introduce finger for palpation

Content of the inguinal canal

Women: round ligament + vessels Men: spermatic cord

– cremaster– vas deferens– spermatic artery– deferntial artery – 2 venous plexuses – Nervous branches (ilio-hipogastric, ilioininguinal,

genital)

Shall we all develop hernia?

There is a content passing from the abdomen to scrotum

BUT– The trajectory is oblique through muscles and

during effort the structures are compressed together

– Oblique muscles work as a curtain and close the defect

– Internal orrifice is strangulate during effort

External oblique inguinal hernia Congenital: persistentce of the peritoneal

diverticula through which the testis migrated in scrotum. Frequently associated with abnormal migration of the testis. – Complete form with totaland free

comunication from the peritoneum till scrotum– Incomplete forms – vaginala testicularis is

separeted +/- hydrocele or cystic remnants in the spermatic cord.

External oblique inguinal hernia

Acuired : migration of the peritoneal sac– Herniation point– Interstitial hernia– Inguino-pubic hernia– Inguino-scrotal henria

Clinical signs

Common signs for all hernia Digital exploration through the superficial

orifice – Evaluation of the defect– Relations with the epigastric vessels = variety

of hernia

Differential diagnosis Uncomplicated interstitial hernia

– Ectopic testis – Cysts of the spermatic cord– Solid tumors

Uncomplicated inguino-pubic hernia– Crural hernia (line of Malgagine)– Lypoma of labia major – Cyst of the Nuck canal

Inguino-scrotal hernia– Hydrocel– Varicocel– Testicular tumors

Direct inguinal hernia

A weak point hernia The area of weakness is the middle

inguinal area (between the epigastric artery and remnant of the umbilical artery)

Sac is completely separated from the spermatic cord which is pushed away

Particularities

Frequently in older people, associated with other hernias

Frequently bilateral Generally small and do not descend in the

scrotum, trajectory being perpendicular on the inguinal ligament.

Defect is large – unlikely to produce comlications

Differential diagnostic Mostly with the external oblique hernia

Oblique Direct

Age Any Old

Location Uni/bilateral Bilateral 50%

Form Pear shape Hemispheric

Trajectory Oblique Perpendicular

Scrotum Yes No

Muscular tonus Normal Weak

Epigastric arte. Internal External

Complications Frequent Rare

Treatment of Inguinal Hernia

Objectives:– Resection of the hernia sac– Treatment of the defect – a solid wall to

prevent hernia recurrence

LARGE VARIETY OF TECHNIQUES

Operative principles Incision of superficial

structures and isolation of spermatic cord.

Isolate the hernia sac and the structure migrated with the peritoneal layer (lipomas)

Open the hernia sac

Control de content Resction of the sac

and suture the peritoneal defect

Posterior wall repair

GOAL – prevent recurrences “Anatomical” procedures

– Behind the spermatic cord (Bassini, Shouldice, McVay)

– In front of the spermatic cord (Kimbarowski, Forgue)

Procedures that use a synthetic structure (mesh repair) – respect the principle of tension-free repair.

Behind the cord repair procedures

Mesh repair

Laparoscopic mesh repair

Orthopedic treatment

ONLY when the patient refuses operations or major contraindication for surgical repair

Femoral hernia Femoral hernia

Anatomy

Through the femoral ring in the triangle of Scarpa

Femoral ring:– Inguinal ligament (ant)– pectineal fascia and ligament of Coopper (post)– lig Gimbernat (internal)– ileo-pectineal ligament (ext)

Variants

– Herniation point – incomplete (under the cribriform fascia) – complete

Prevascular, retrovascular, external Laugier (through the fibers of the ligament of

Gimbernat) Femuro-pectineal (under the pectineal fascia) Multi-divericular In combination with inguinal hernia – distension

of the groin

Higher incidence in women

4x more frequent in women Diameter of the pelvic girdle is larger Accentuated lordosis in lumbar area Pregnancies: weakens the abdominal wall

+ sustained increase in intraabdominal pressure

Pathological particularities Small sac, pear-like, well delimitated

neck which is fibrotic DIFFERENCES from other hernia:

multiple layers like the onion skins (skin, subcutaneous tissue, cribriform fascia, properitoneal tissue, fascia transversalis)

Content: any organ, including caecum, apendix, colon, urinary baldder)

Major risk for complications, especially the strangulation – lateral pinch

Clinical signs - particularities Few or no functional signs: little pain or

heaviness in the groin or during extension of the hip.

+/- digestive symptoms (colicky pain, urinary symptoms) more often believed to have another source

TYPICALLY the signs indicate and abdominal suffering and the physician does not explore the groin

Clinical examination

Small pseudo-tumor in the Scarpa triangle , most typical medial to the femoral vessels. INCONSTANT

Round or oval shape Prolonged under the inguinal ligament – if

the tumor can be felt Frequently obese patients with lare

subcutaneous fat layer

Clinical examination

Consistency is elastic or granular – atypical for a hernia

IREDUCIBLE but not associated with a loud symptomatology in the groin

IMPULSION AND EXPANSION are either absent or faint

High percentage are complicated at presentation

Differential diagnosis

REDUCIBLE:– Inguinal hernia (line

of Malgaigne)– Varicose vein– Aneurism of the

superficial femoral artery

– Tuberculous (cold) abscess migrated in the Scarpa triangle

Differential diagnosis

IREDUCIBLE:– Strangulated inguinal

hernia– Cyst of the canal of

Nuck– Ectopic testis– Lypoma– Lymphnode

enlargement – Venous thrombosis – Hematoma

Treatment Principles same with all hernia Access:

– femoral – inguino-femoral– inguinal

Parietal reconstruction: – Closing the femroal ring by

suturing the inguinal ligament to Cooper ligament and pectineal fascia

– Suturing the conjoined tendon to Cooper ligament

– Mesh prosthesis

Umbilical herniaUmbilical hernia

A. Congenital

Failure in the development of the abdominal wall– Embryonic form (defect appears before the 3rd

month and organs are not covered by peritoneum – not real hernia

– Fetal form – covered by peritoneum

Pathology

Translucent covering (displastic wall) without vessels and muscles

You can see abdominal viscera through the wall. Content can be as much as the whole abdominal content

Clinical aspects

Large ventral tumor, present at birth and surrounded by a skin ring

Transparent wall: abdominal visceraEVOLUTION: spontaneous rupture + death TRATAMENT: surgical- small defects: as in hernia- large defects: skin flaps +/- serial operations

B. Umbilical hernias of the child

Causes:– Weak umbilical scar

(infection, distension)– High intraabdominal

pressure (crying, coughing, fimosis, etc

Pathology:– Small sac with a large

neck, little chances of strangulation

Treatment

Conservative: if– Less then 2 years– Less then 2 cm diameter

• Has to be maintained reduced via a skin fold until spontaneous closure

Surgical: – Resection of the sac– Parietal repair

C. Umbilical hernias of the adult

Weak point Obese women,

multiple pregnancies, chronic peritoneal dyalisis, ascites.

Particularities Direct herniation most typically (indirect

machanism is possible if the ring is asymmetrically positioned)

Sac initially small may become multidiverticular + changes generated by the degenration of the sac by expnasion

Rigid neck – strangulation factor Content: most frequent properitoneal fat,

but viscus can migrate as well

Clinical signs

Pain on effort +/- digestive symptoms Typical signs of hernia with a major

tendency to become irreducible If palpation of the ring is possible – large,

round, rigid defect

Complications

Strangulation (rigid ring, with rapid progression to necrosis)

Progressive enlargement – irreducible and loosing the right to stay in the abdominal cavity

Treatment

Surgical: – Omfalectomy and treatment of hernia – Techniques that conserve the umbilical scar

(subcutaneous dissection) – Plastic surgery

Epigastric herniasEpigastric hernias

Particularities Supraumbilical median line Frequent multiple hernias At the crossing of fibers in the linea alba Small, irreducible and containing mostly

properitoneal fat One particular form – diastases of the

rectus sheat Symptomatic hernia require treatment

Ventro-lateral herniaVentro-lateral herniaSpiegelSpiegel

Particularities

Anatomic: defect in the ventro-lateral abdominal wall where vessels pass subctaneous. (lateral to the rectus sheat)

Hernia pushes the fascia of the external oblique muscle (interstitial form) or overpasses is (complete form)

Particularities

Clinical: pain + abdominal deformity Dg: in interstitial forms sometimes no

signs. Positive dg by US scan Rsik of becoming irreducible or

strangulated Surgical treatment like any hernia

UNUSUAL HERNIAUNUSUAL HERNIA

Lumbar hernia Pposterior wall (triangle of J.L. Petit – G.

oblique, G. dorsal, iliac bone) or Grynfeld qudrate space (C12 with small dentate muscle, paravertebral muscles, small oblique and lumbar quadrat) – extraperitoneal– paraperitoneal– peritoneal

Other forms

Obturator Perineal Hiatus Internal Ischiatic

Postoperative herniaPostoperative hernia

Generalities

HERNIAS = peritoneal diverticulum under the skin + defect developed postraumatic

EVISCERATIONS = posttraumatic wall defect without a peritoneal covering

Ethiology

Posttraumatic or postoperative Causes that favor postoperative hernia

– Old age – scaring abnormalities– Co-morbidities (liver cirrhosis, cancer diabetes)– Obesity– Type of incision– Postoperative infection– Increased intraabdominal pressure developed

postoperative – Not adequate suture material

Pathology

Abdominal wall defect – variable in diameter, frequently multiple, situated under the skin scar

Hernia sac: thickened peritoneum, multidiverticular, frequently under the skin in contact with it

Visceral content

Clinical examination

Pseudo-tumor with all characters of hernia Related with the scar Diemension and number of parietal defects Reducible or irreducible Skin overlaying the hernia

Treatment

Evisceration: urgent, viscus should be placed back in the abdomen and skin should be closed

Postoperative hernia: complex treatment preferably elective