Etymology of Hernia

Jibran Mohsin

Resident, Surgical Unit I

SIMS/Services Hospital, Lahore

Etymology

• Hernia means – ‘To bud’ or ‘to protrude’,

‘off shoot’ (Greek)

‘Rupture’ (Latin)

Parts of Hernia

• Sac– diverticulum of peritoneum with mouth, neck, body and fundus. – Neck is narrow in indirect sac but wide in direct sac

• Hernia without neck: Those hernias with larger mouth lack neck, e.g. direct hernia, incisional hernia

– Body of the sac is thin in infants, children and in indirect sac but is thick in direct and long standing hernia.

– Hernia without sac: • Epigastric hernia—it is protrusion of extra-peritoneal pad of fat

• Covering– layers of the abdominal wall through which the sac passes

Parts of Hernia

• Contents– Omentum—Omentocele (Epiplocele). Difficult to reduce the sac later, initially it can be

reduced easily.

– Intestine—Enterocele— commonly small bowel, but sometimes even large bowel. Difficult to reduce the sac initially.

– Richter’s hernia: A portion of circumference of bowel is the content.

– Urinary bladder may be the content or part of the posterial wall of the sac—cystocele.

– Ovary, often with fallopian tube.

– Meckel’s diverticulum—Littre’s hernia

– Fluid:• secreted from congested bowel or omentum or• infected fluid or • ascitic fluid or • blood from the strangulated sac.

Clinical Classification

• Reducible hernia– Reduced on its own or by patient or by surgeon– Expansile cough impulse positive

• Irreducible hernia– Contents can’t be returned to abdomen due to

• narrow neck, • adhesions(incarcerated), • overcrowding

– Predisposes to strangulation

Enterocele Reduces with gurgling difficult to reduce 1st portion

Omentocele doughy difficult to reduce last portion

Clinical Classification

• Obstructed hernia– Lumen of gut present in the hernial sac gets obstructed like any intestinal

obstruction– NOT seen in omentocele or richter’s hernia

• Inflamed hernia– Inflammation of contents of sac– e.g. appendicitis and salpingitis– Tender but NOT tense with red and edematous overlying skin

• Strangulated hernia– Compromised blood supply– Tense as well as tender with no cough impulse– Associated with obstruction in case of enterocele (exception: Richter’s hernia)

• Garrey’s Stricture

– Constriction due to ischemic narrowing of small bowel which has reduced from an obstructed hernia

Richter’s Hernia

• Portion of antimesenteric border of gut gets incarcerated and eventually strangulated without obstruction of lumen in the hernialorifice

• segment of the engaged bowel is nearly always the lower portion of the ileum

– but any part of the intestinal tract, from the stomach to the colon, including even the appendix

Richter’s Hernia

• Precondition for the formation of this particular hernia, as stated by Richter, is determined by the size and consistency of the hernial orifice

– big enough to ensnare the bowel wall, but small enough to prevent protrusion of an entire loop of the intestine

– margin of the hernial ring must be firm or, in Richter’s words, “possess strong spring-force.

Richter’s Hernia

• Tend to progress more rapidly to gangrene than ordinary strangulated ones– firm constricting ring that exerts direct pressure on the

bowel wall– free border of the intestine opposite the mesentery with

the predominance of terminal arterioles that is involved– late diagnosis or even misdiagnosis, thus allowing time for

bowel necrosis to develop.

• Also seen at site of laparoscopy port site– Thus incidence might increase with time – Especially if fascia not closed at 10 mm port site

Richter’s Hernia

• first description of a case of Richter’s hernia was made by Fabricius Hildanus (1560–1634) in 1606– illustrates a typical clinical presentation of a

perforated Richter’s hernia

• In his famous Treatise on the Ruptures in 1785, August Gottlob Richter (1742–1812) gave the first comprehensive description of hernias in which only part of the circumference of the bowel is strangulated, and termed them “the small ruptures.”

Richter’s Hernia

• The nomenclature of this hernia subsequently resulted in confusion

• Only 100 years later, in 1887, did the famous London surgeon Sir Frederick Treves distinguish these types of hernias from herniation of a Meckel diverticulum, which was classically described by Littre.

• Treves credited Richter with the distinction of having given the first scientific description of this particular lesion and suggested the term Richter’s hernia,– “(partly) because with Richter must rest the main credit of

establishing the individuality of this lesion.”

Sir Frederick Treves (1853–1923)

Richter’s Hernia

• 10% of strangulated hernias are Richter’s hernias (5–15%)

• 60 to 80 years old– but cases have been described even in infants

• In whites, the most common site is the femoral ring (36–88%), – followed by the inguinal canal (12–36%) and abdominal wall

incisional hernia (4–25%).– Rare sites, such as

umbilical, Obturator, supravesical, spigelian, triangle of Petit,sacral foramen, Morgagni, internal,or (traumatic) diaphragmatic hernias

Richter’s Hernia

• since the first description of a Richter’s-type herniation through a laparoscopy incision in 1977

– similar case reports have increasingly been published

Busoga Hernia

• variety of direct inguinal hernia common in the Busogaarea of Uganda and some other African countries, including South Sudan and Ghana where it particularly occurs in women.

• caused by a narrow defect in the conjoint tendon or transversalis fascia and consequently there is a risk of strangulation. – The neck of the sac is small, so that when strangulation

occurs, often only part of the circumference of the gut is involved causing what is known as a Richter's hernia

Littre’s Hernia(persistent omphalomesenteric duct hernia)

• Alexis de Littre (1700) reported ileal diverticula and attributed them to traction. – report three cases of incarcerated femoral hernia containing a

small bowel diverticulum

• August Gottlieb Richter (1785) defined them as preformed, and

• Johann Friedrich Meckel (1809) postulated their embryologic origin.

• Sir Frederic Treves (1897) distinguished between Littre and Richter hernia (partial enterocele)

Johann Friedrich Meckel (1781–1833), German anatomist

Litre’s Hernia

• also described the mucous urethral glands of the male urethra (littre’sgland)

• first to suggest the possibility of performing a lumbar colostomy for an obstruction of the colon

• Jean Louis Petit was one of his students. So was Jacques-BénigneWinslow in 1707

Alexis Littré(1654 – 1726)French physician andanatomist

• Meckel's diverticulum an out-pouching of the ileum, part of the small intestine, and found in approximately 2% of the population.(1809)

• Meckel's cartilage A cartilaginous bar from which the mandible is formed. Described in 1820.

• A syndrome – Meckel syndrome – is also named after him. This condition was described in 1822.

• A protein – mecklin – the gene for which is found on chromosome 8 (8q21.3-q22.1) is named after him.

Amyand Hernia

• rare form of inguinal hernia in which thevermiform appendix is located within the hernial sac.

• Seen in < 1% of inguinal hernia

• Claudius Amyand (1681-1740), French born English surgeon– performed the first successful appendectomy in 1735, on

an 11-year-old boy who presented with an inflamed, perforated appendix in his inguinal hernia sac

De Garengeot Hernia

• appendix-containing incarcerated

femoral hernia

• Akopian and Alexander, named this hernia after the 18th century Parisian surgeon Rene Jacques Croissant de Garengeot(1688-1759).

– He is quoted in the surgical literature as the first to describe this situation in 1731.

Maydl's hernia (Hernia-in-W)

• hernial sac contains two loops of bowel with another loop of bowel being intra-abdominal– loop of bowel in the form of 'W lies in the hernial sac and

the centre portion of the 'W loop may become strangulated, either alone or in combination with the bowel in the hernial sac

– more often seen in men, and predominantly on the right side

• Postural or manual reduction of the hernia is contra-indicated as it may result in non-viable bowel being missed

Karel Maydl (1853 –1903) Austrian surgeon

Gibbon’s Hernia

Hernia with Hydrocele

Edward Gibbon(1737–1794)

English historian and Member of ParliamentSuffered from hydrocele;

Due to in fashion close fit clothing his conditions lead to chronic and disfiguring inflammation followed by numerous surgeries, last 3 of which lead to peritonitis and eventually death

Berger’s Hernia

Hernia in pouch of Douglas

(Cul-de-sac)

______________________________________________________________________________Berger(’s) Disease/syndrome ( IgA Nephropathy/nephritis)

-associated with Henoch Schonlein Purpura(HSP)

Buerger(’s) Disease (Thromboangiitis Obliterans/Presenile Gangrene)(Winiwarter–Buerger syndrome)

History of Berger Disease

• In 1801, William Heberden, English Physician (1710-1801) first described the disease – in a 5-year-old child with abdominal pain, hematuria, hematochezia

and legs purpura

• In 1837, Johann Lukas Schönlein*, German naturalist and professor of medicine (1793-1864) described – purpura rheumatica (Schönlein's disease) an allergic non-

thrombopenic purpura rash(now HSP)

.___________________________________________________________________*also discovered the parasitic cause of ringworm or favus (Trichophyton schönleinii)*also attributed with naming the disease, Tuberculosis, in 1839

(Prior to Schönlein's designation, Tuberculosis had been called "consumption“)

History of Berger Disease

• In 1868, Eduard Heinrich Henoch, German physician (1820 –1910)– a student of Schönlein's,

– further associated colic bloody diarrhea, painful joints and renal involvement

• Jean Berger (1930–2011)– Pioneering French Nephrologist and Pathologist

– in 1968, were the first to describe IgA deposition in this form of glomerulonephritis

William Heberden Johann Lukas Schönlein

Eduard Heinrich Henoch Jean Berger

History of Buerger Disease

• In 1876, Carl Friedländer*, German pathologist and microbiologist (1847–1887)– referred to it as "arteritis obliterans".

• In 1879, Felix von Winiwarter, Austrian Physician (1852 -1931) – 57-year old male patient who had an unusual obliteration of

the arteries and veins of the leg– attributed this disorder to new growth of tissue from the intima, and – proposed the name "endarteritis obliterans" for the disease

• In 1908, Leo Buerger, Austrian American Pathologist, Surgeon & Urologist (1879–1943)– called it "presenile spontaneous gangrene" after studying amputations in 11

patients.– in 1924 published a monograph based on analyses taken from 500 patients

*died a premature death, aged 39 or 40, after a brief stint with a respiratory disease, believed to be caused by his discovered infectious organism, the Friedlander's Bacillus (Klebsiella pneumoniae )

Felix von Winiwarter

Pouch of Douglas*

• Also called

– Rectouterine pouch/excavation

– Rectovaginal/Ehrhardt-Cole Recess

– Douglas pouch/cavity/space/cul-de-sac (cavumDouglasi)

* Scottish anatomist Dr. James Douglas (1675–1742)Three other nearby anatomical structures are also named for him –

the Douglas fold, the Douglas line and the Douglas septum

• Douglas fold– A fold of peritoneum forming the lateral boundary of

Douglas' pouch.

• Douglas line– The arcuate line of the sheath of the rectus

abdominis muscle.

• Douglas septum– The septum formed by the union of Rathke's folds,

forming the rectum of the fetus

Pantaloon Hernia(Double/Dual Hernia, Saddle Hernia & Romberg Hernia)

Ipsilateral, concurrent direct and indirect inguinal hernias

Pantaloon Hernia(Double/Dual Hernia, Saddle Hernia & Romberg

Hernia)Italian Pantalone

(Pan:all Leone: Lion)(Greek: Παντελεήμων [Panteleímon], "all-compassionate")

• After San Pantalone (Saint Pantaleon; died 303 AD)– Roman(venetian) Physician & Martyr

• Character in Commedia Dellarte(16th century)– Skinny old dotard ( foolish merchant- venetian) who wears

spectacles, slippers & tight fitting combination of trousers & stockings (Baggy trousers)

13th Century Icon of Saint Panteleimon, including scenes from his life, from the Monastery of St. Katherine on Mount Sinai.

Pantaloon Hernia(Double/Dual Hernia, Saddle Hernia & Romberg Hernia)

• Buffoon in pantomimes

– Foolish vicious absurd old man

– Stock character

– Accomplice/butt of clown’s jokes/tricks

• Wide breeches worn especially in England during reign of Charles II

– Extending from waist to ankle

Pantaloon Hernia(Double/Dual Hernia, Saddle Hernia & Romberg Hernia)

• Close fitting trousers usually having straps passing under instep & worn especially in 19th

century

• Loose fitting usually shorter than ankle length trousers

• Garment’s brand name

Etymology

saddle (n.)Old English sadol "seat for a rider," from Proto-Germanic *sathulaz (cognates: Old Norse söðull, Old Frisian sadel, Dutch zadel, zaal, German Sattel "saddle"), from PIE *sed- (1) "to sit" (cognates: Latin sedere "to sit," Old Church Slavonic sedlo "saddle;" see sedentary)

. Figurative phrase in the saddle "in an active position of management" is attested from 1650s. Saddle stitch (n.) was originally in bookbinding (1887).

saddle (v.)Old English sadolian "to put a riding saddle on;". The meaning "to load with a burden" is first recorded 1690s. Related: Saddled; saddling.

Moritz Heinrich Romberg

(1795 – 1873)

German Physician

Obturator Hernia

• Hernia through the obturator foramen/canal

Obturator comes from the Latin obturare, to close up/obstruct. The obturator foramen of the os coxa, completely covered by a membrane, was named by the great French surgeon AmbroiseParé in 1550,

Ambroise Paré(1510 – 1590)

French barber surgeon

Howship–Romberg sign( Romberg sign)

• Obturator nerve neuropathy due to compression of it by an obturator hernia

– pain and paresthesia along the inner aspect of the thigh, down to the knee(referred pain through geniculate branch of obturator nerve)

– inner thigh pain on internal rotation of the hip

John Howship Moritz Heinrich Romberg(1781 –1841) (1795-1873)English surgeon German Physician(died of leg abscess)

Lumbar Hernia

• New Latin lumbaris, from Latin lumbus loin

• In tetrapod anatomy,

– lumbar is an adjective

– that means of or pertaining to the abdominal segment of the torso, between the diaphragm and the sacrum (pelvis)

Lumbar Triangle for Lumbar Hernia

Border

Inferior Iliac Crest

Anterior External oblique

Posterior Latissimus Dorsi

Floor Internal Oblique

Inferior lumbar (Petit) triangle

Superior lumbar (Grynfeltt-Lesshaft) triangle

Border

Superior 12th rib

Medial Quadratus Lumborum

Lateral Internal Oblique

Floor Transversalis Fascia

Roof External Oblique

Jean-Louis Petit

(1674 – 1750)

French surgeon

Grynfeltt described a hernia through the superior lumbar triangle in 1866

Lesshaft independently reported a similar case in 1870

Femoral Hernia

• Hernia through the femoral canal

Retrovascular hernia (Narath’s hernia) The hernial sac emerges from the abdomen within the femoral sheath but lies posteriorly to the femoral vein and artery, visible only if the hip is congenitally dislocated

Velpeau hernia The hernia sac lies in front of the femoral blood vessels in the groin

External femoral hernia of Hasselbach and Cloquet

The neck of the sac lies lateral to the femoral vessels.

Transpectineal femoral hernia of Laugier The hernia sac transverses the lacunar ligament or the pectineal ligament of Cooper

Callisen’s or Cloquets hernia The hernial sac descends deep to the femoral vessels through the pectinealfascia

Béclard's hernia The h ernia sac emerges through the saphenous opening carrying the cribriform fascia with it

De Garengeot's hernia This is a vermiform appendix trapped within the hernial sac.

Retrovascular Hernia

• Narath’s Hernia

– Behind femoral artery in congenital dislocation of hip

• Serofini’s Hernia

– Behind femoral vessels

Albert Narath(1864 –1924)

Austrian surgeon & anatomist

Velpeau (Prevascular/Teale’s) Hernia

• Hernia in front of femoral vessels

Alfred-Armand-Louis-Marie Velpeau(1795 – 1867)

French anatomist and surgeon

Velpeau

• Provides 1st accurate description of leukemia in 1827

• Velpeau Bandage– A wrapping used to immobilize the arm to the chest wall

• Velpeau's disease– Hidradenitis suppurativa

• Velpeau's canal– Inguinal canal

• Velpeau's fossa– Ischiorectal fossa

External femoral hernia of Hasselbach and Cloquet(Hesselbach Hernia)

neck of the sac lies lateral to the femoral vessels

Franz Kaspar Hesselbach(1759 – 1816)

German surgeon & anatomist

Hesselbach

• Cribriform fascia

– Hesselbach's fascia

• Interfoveolar ligament

– Hesselbach's ligament

• Inguinal triangle

– Hesselbach's triangle

Cloquet’s (Callisen’s) Hernia

femoral hernia perforating the aponeurosis of the pectineus (Pectineal fascia) and insinuating itself between this aponeurosis and the muscle,

lying therefore behind the femoral vessels

Jules Germain Cloquet(1790 –1883)French physician and surgeon

Cloquet’s

– Cloquet canal(Hyaloid Canal)• minute canal running through the vitreous from the discus

nervi optici to the lens.

– Cloquet's septum(Femoral Septum)• Fibrous membrane bounding the annulus femoralis at the

base of the femoral canal

– Cloquet's gland/node• 1 of the deep inguinal lymph nodes located in or adjacent to

the femoral canal

• Also called Rosenmuller node/gland

Béclard's hernia

Hernia sac emerges through the saphenous opening carrying the cribriform fascia with it

Pierre Augustin Béclard(1785 – 1825)

French anatomist and surgeon

Beclard’s

• Béclard's nucleus– core of ossification in the cartilage of the

distal epiphysis of the femur during the latter part of fetal life

– Use in forensic medicine to determine the age of a fetus or newborn infant

• Beclard's anastomosis(arcus raninus)– Anastomosis between the right and the left end-

branch of the deep lingual artery

Beclard’s

• Béclard's triangle

– Area whose boundaries are the posterior border of the hyoglossus, the posterior belly of the digastric muscle and the greater horn of the hyoid bone

Transpectineal femoral hernia of Laugier(Laugier’s Hernia)

Hernia sac transverses the lacunar ligament or the pectineal ligament of Cooper

Stanislas Laugier(1799 - 1872)

French surgeon

Laugier sign

In fracture of the lower portion of the radius, the styloid processes of the radius and of the ulna are on the same level

Phantom Hernia

• a muscular bulge as a result of local muscular paralysis due to interference with nerve supply of the affected muscles, like poliomyelitis.

– common in lumbar region

– often seen in lower abdomen

Phantom:Something apparently seen, heard, or sensed, but having no physical reality

Phantom

• Phantom limb

– feeling of pain in amputated toe or limb

• Phantom tumour

– tumour like lesion in lung like interlobar pleural effusion

Gluteal & Sciatic Hernia

• protrusion of the peritoneal sac through the greater or lesser sciatic foramen

• Classified based on their relationship to the pyriformismuscle and ischial spine.– 1. Suprapyriformis. Through greater sciatic foramen– 2. Infrapyriformis. (Gluteal Hernia)– 3. Subpyriformis. Sciatic Hernia

• Sac lies deep to gluteus maximus. – Large hernias protrude below the buttock crease.

Interparietal (Interstitial) Hernia

• Herniation through parietal peritoneum into various layers of the abdominal wall

• Common in Down’s syndrome, Prune Belly syndrome

• Often it can attain large size

• May mimic abdominal wall lipoma; haematoma

• As neck of the sac is often narrow, can present with irreducibility or obstruction

• Commonly it is deep to external oblique aponeurosis

• Types – Preperitoneal - between peritoneum and transversus

abdominis muscle – 20%

– Interparietal / intermuscular-between external oblique and internal oblique; commonest – 60%.• It is commonly associated with inguinal hernia

– Extraparietal (inguino superficial) – herniates through external oblique aponeurosis into subcutaneous plane – 20%

Spigelian Hernia(Lateral Ventral Hernia)

• type of interparietal hernia occurring at the level of arcuate line through spigelian point

• Hernial sac lies either deep to the internal oblique or between external and internal oblique muscles

• common between arcuate line to umbilicus

Spigelian Hernia

• a hernia through the spigelian fascia, which is the aponeurotic layer between the rectus abdominis muscle medially, and the semilunar line laterally

• occur through spigelian’s line or spigelian’sfascia which runs along the outside edge of each of the rectus abdominis (6 pack) muscles

Anatomy of abdominal wall.

1: Linea semilunaris (spigelian; semilunar line/zone)

9th Costal cartilagepubic tubercle

2: rectus abdominis muscle;

3: transversus abdominal muscle;

4: spigelian aponeurosis/fascia

5: linea semicircularis(arcuateline; Douglas Line)

Spigelian Hernia

• Although named after Adriaan van der Spieghel (1578 – 1625; Belgian anatomist)– he only described the semilunar line (linea

Spigeli) in 1645 (publised 20 years after his death)

• It was Josef Klinkosch (name long forgotten!) in 1764 who first defined the spigelian hernia as a defect, hole or hernia in the semilunar line.

• common misconception that they protrude below the arcuate line owing to deficiency of the posterior rectus sheath at that level, but in fact the defect is almost always above the arcuate line

• Spigelian Fascia/aponeurosis– refers either to the combined aponeuroses of the external

abdominal oblique muscle, the internal abdominal oblique muscle and transversus abdominis muscle, or just the aponeurosis of the transversus abdominis

• caudate lobe of the liver is also known as Spiegel's lobe

Raveenthiran Syndrome

• Raveenthiran described a new syndrome in which spigelian hernia and cryptorchidism (undescended testis) occur together

Spigelian Hernia Belt

• majority of Spigelian hernias are found in a transverse band lying 0-6 cm cranial to a line running between both anterior superior iliac spines referred to as the Spigelian hernia belt.

Epigastric Hernia (Fatty Hernia of Linea Alba)

• 10% common.

• 20% of epigastric hernias are multiple—Swisscheese like.

• It occurs usually through a defect in the decussation of the fibres of linea alba, any where between xiphoid process and umbilicus.

• Extraperitoneal fat protrudes through the defect as fatty hernia of the linea alba presenting like a swelling in the upper midline with an impulse on coughing.

• It is sacless hernia. – Later protrusion enlarges and drags a pouch of peritoneum,

presenting as a true epigastric hernia.

Epigastric Hernia

• often associated with peptic ulcer and so pain may be due to peptic ulcer.

– gastroscopy is done to rule out acid peptic disease.

Parameter Epigastric Hernia Para Umbilical Hernia

Site Midline raphe(linea alba) anywhere between xiphoid process and umbilicus(usually midway)

Through thinned and atttenuatedlinea alba

Pathology Initially transverse split in linea alba-elliptical defect

Rounded defect with well defined fibrous margin

Etiology Small BVs pierce linea albaAbnormal decussation of aponeurtoicfibres related to heavy physcial activity

Stretching and thinning of lineaalba

Gender Common in muscular men( fit healthy males 25-40 years)

M:F (1:5) overweighted men or multipara female

Risk Factors manual labourers • Obesity• Multiple pregnancies• Flabby abdominal wall• Liver Cirrhosis

Number 20 % multiple(swiss cheese like)

It is sacless hernia. Later protrusion enlarges and drags a pouch of peritoneum, presenting as a true epigastric hernia

Overlying dermatitis

Crescent shaped umbilicus

Para Umbilical Hernia Epigastric hernia

Incision Transverse Vertical midline

Very small(< 1 cm) Figure-of-eight sutureDarn repair

1-2 cm Mayo’s Repair

>2 cm Mesh Repair

Ventral* Hernia

• Hernias of anterior abdominal wall

• EXCEPTIONs to above definition

– Inguinal and femoral hernias not included even though they are ventral

– Lumbar Hernia included despite being dorsolateral

*Latin "venter" meaning belly

Indirect Inguinal Hernia

• Bubonocele• from Greek boubōn groin + kēlē tumour/swelling

• Funicular– funicular, also known as an inclined plane or cliff railway, is

a cable railway in which a cable attached to a pair of tram-like vehicles on rails moves them up and down a steep slope

– the ascending and descending vehicles counterbalance each other.

OR– having the form of or associated with a cord usually under

tension

Funicular in Hastings, England

Funicular in Lyon, (France)

Duquesne Incline, Pittsburgh, Pennsylvania, U.S., with full-length parallel tracks

Sliding inguinal Hernia( NOT sliding hiatal Hernia)

• posterior wall of the sac is not only formed by the parietal peritoneum, but also by sigmoid colon on left side; caecum on right side and often with portion of the bladder (Both sides)

• Rarely small bowel sliding hernia or sacless sliding hernia can occur.

• Sliding hernia occurs exclusively in males. Mainly on the left side

Mery’s Hernia

(Perineal Hernia)

Postoperative Perineal Hernia Through perineal scar (excicion of rectum)

Median sliding Perineal Hernia Complete rectal prolapse

Anterolateral Perineal Hernia Swelling of labium majus

Posterolateral Perineal Hernia Pass through levator ani to enter ischiorectal fossa

Holthouse’s hernia

Inguinal hernia that has turned outwards into the groin.

Inguinal hernia with extension of the loop ofintestine along the Poupart ligament.

Carsten Holthouse,English surgeon

1810-1901

Barth’s Hernia

Hernia between abdominal wall and persistent vitello-intestinal duct.

Jean Baptiste Philippe Barth

French physician (1806-1877)

Diaphargmatic Hernia

• Congenital diaphragmatic hernia– Morgagni's hernia– Bochdalek hernia– Diaphragmatic eventration

• Hiatal hernia

• Iatrogenic diaphragmatic hernia

• Traumatic diaphragmatic hernia

Morgagni (Retrosternal/parasternal)Hernia

• rare anterior defect of the diaphragm

• 2% of all CDH cases

• characterized by herniation through the foramina of Morgagni which are located immediately adjacent and posterior to the xiphoid process of the sternum

Foramina of Morgagni

• Also called – sternocostal hiatus/triangle– Larrey's triangle

• Small zones lying between costal and sternal attachments of thoracic diaphragm

• Contents– superior epigastric arteries as terminations of the

internal thoracic arteries, with accompanying veins and lymphatics.

Giovanni Battista Morgagni(1682 – 1771) Italian anatomistFather of modern anatomical pathology

Eponymous structures

• Aortic sinus ("sinus of Morgagni")

• Columns of Morgagni

• Foramina of Morgagni

• Hydatid of Morgagni

• Morgagni's hernia

Bochdalek hernia

• also known as a postero-lateral diaphragmatic hernia

• >95 % of CDH

• 80-85 % left sided

Vincent Alexander Bochdalek(1801 – 1883)

Bohemian anatomist

Associated Eponyms

• Bochdalek's cyst– congenital cyst at the root of the tongue

• Bochdalek's flower basket– part of the choroid plexus of the 4th ventricle protruding through the

lateral bursa (recessus lateralis) of the 4th ventricle (Luschka'sforamen).

• Bochdalek's foramen– congenital defective opening through the diaphragm, connecting

pleural and peritoneal cavities

• Bochdalek's ganglion– ganglion of dental nerve in the jaw (maxilla) above the root of the

canine teeth.

Associated Eponyms

• Bochdalek's hernia– Congenital diaphragmatic hernia which allows protrusion of abdominal viscera

into the chest.

• Bochdalek's triangle– Lumbocostal triangle, a triangle-shaped slit in the muscle plate between

lumbar or sternal part in the diaphragm and the 12th rib.

• Bochdalek's valve– fold of membrane in the lacrimal duct near the punctum lacrimale.– Also called Foltz' valvule;French ophthalmologist Jean Charles Eugène Foltz

(1822–1876) )

• Vater's duct– a duct that in the embryo connects the thyroid diverticulum and the posterior

part of the tongue.

Hiatus/Hiatal Hernia

• Type I (sliding) hernia– characterized by an upward herniation of the cardia and GE junction in

the posterior mediastinum. The most common one. (C)

• Type II (rolling or paraesophageal) hernia (PEH)– characterized by an upward herniation of the gastric fundus alongside

a normally positioned cardia. The GE junction is in its normal place (D).

• Type III (combined sliding-rolling or mixed) hernia– characterized by an upward herniation of both the cardia and the

gastric fundus.

• Type IV hiatal hernia– is declared in some taxonomies, when an additional organ, usually the

colon, herniates as well.

Parameters Gastroschisis (Belly Cleft) EXOMPHALOS (Omphalocele)

Etiology defect of the anterior abdominal wall just lateral to the umbilicus

failure of all or a part of the gut to return tothe coelomic cavity during early foetal life

Sac coverings NilUmbilicus is normal. The defect is almost always to right of an intact umbilical cord.

Thin, consists of threelayers—outer amniotic membrane, middle Wharton’sjelly and inner peritoneal layer

Non-rotation and intestinal atresia are common associations.Cardiac anomaly is not common as in omphalocele.

often associated with congenital anomaliesof cardiac and genitourinary system - 70%.

Etymology

• -Schisis

– Ancient Greek σχίσις (schisis)

– breaking up of attachments or adhesions

– Fissure

– denoting a cleft or cleavage

– <gastroschisis> <cranioschisis> <palatoschisis>

Etymology

• Gastric(gas-trik)

– Greek gastr-, gastēr, (stomach)

– alteration of *grastēr, from gran to gnaw, eat

• Epi-

– a prefix occurring in loanwords from Greek,

– where it meant “upon,” “on,” “over,” “near,” “at,” “before,” “after”

• Omphalos– a religious stone artifact, or baetylus– Greek, means "navel“

• In Greek lore, Zeus (God of sky & thunder) sent two eagles across the world to meet at its center, the "navel" of the world.– Omphalos stones marking the centre were erected in several places

about the Mediterranean Sea; the most famous of those was at Delphi

• Omphalos is also the name of the stone given to Cronus

• In the ancient world of the Mediterranean, it was a powerful religious symbol

• Omento-– Latin for Apron

• Epiploic-– Related/associated with omentum

• Entero-– refers to the intestine (from Greek ἔντερον, enteron)

–

• It is protrusion of abdominal wall muscles during leg rising test as weak, soft, supple, swelling,

– signifies poor abdominal muscle tone.

– also concludes that particular hernia requires mesh repair (hernioplasty)

– Common in old age, obese patient.

Malgaigne bulging

Joseph-François Malgaigne(1806 – 1865)

French surgeon and medical historian

Associated eponyms

• Malgaigne's ( Subastragalar) amputation – Amputation of the foot in which the astragalus is conserved

• Malgaigne's fracture– Vertical pelvic fracture with bilateral sacroiliac dislocation and fracture of the

pubic rami

• Malgaigne's hernia– Infantile inguinal hernia prior to the descent of the testis

• Malgaigne's luxation (Nursemaid’s Elbow)– Partial dislocation of the head of the radius within the elbow joint

• Malgaigne's triangle/Fossa– Also known as the superior carotid triangle

Rectus abdominis diastasis(diastasis recti, abdominal separation)

(Divarication of rectus abdominus Muscles-DRAM)

• a separation of the two rectus abdominis muscle pillars

• results in the characteristic bulging of the abdominal wall in the epigastrium

• sometimes mistaken for a ventral hernia – despite the fact that the midline aponeurosis is intact

and no hernia defect is present

Rectus abdominis diastasis(diastasis recti, abdominal separation)

(Divarication of rectus abdominus Muscles-DRAM)

• Congenital– as a result of a more lateral insertion of the rectus

muscles to the ribs and costochondral junctions

• Acquired– advancing age– obesity, or – Post-partum

• advanced maternal age• after multiple or twin pregnancies• high-birth-weight infants Diastasis: Greek Separation

Internal Hernia

• Occur when the intestine (the ‘viscus’) passes beneath a constricting band or through a peritoneal window (the ‘defect’) within the abdominal cavity or in the diaphragm.

• They present as– Acute intestinal obstruction, with or without intestinal ischaemia, perforation and peritonitis,

or– Chronic recurrent abdominal pain and vomiting due to incomplete and intermittent intestinal

obstruction.

• Sites of internal herniation include – (i) the paraduodenal and paracaecal fossae, – (ii) the lesser sac through the epiploic foramen (foramen of Winslow) or a defect in the

transverse mesocolon, – (iii) beneath congenital bands or adhesions, – (iv) through defects in the small bowel mesentery, – (v) between the lateral abdominal walls and intestinal stomas, and – (vi) through defects in the diaphragm (hernias of Bochdalek and Morgagni).

Miscellanoeus

• Traumatic Hernia

• Sportman’s Hernia

• Parastomal Hernia

• Incisional Hernia

Available at surgicalpresentations