HERNIAHERNIA

Learning ObjectivesLearning Objectives

What is a Hernia?What is a Hernia? Types of HerniaTypes of Hernia Common PresentationsCommon Presentations Anatomy of the Abdominal Wall Anatomy of the Abdominal Wall Anatomy of the Inguinal RegionAnatomy of the Inguinal Region

What is a Hernia?What is a Hernia?

What is a Hernia?What is a Hernia?

A protrusion of an organ A protrusion of an organ or tissue outside itsor tissue outside its normal compartmentnormal compartment

consists of: consists of: zz A sac A sac zz Its coverings Its coverings zz Its contentsIts contents

What is a Hernia?What is a Hernia? The wall can be the The wall can be the

zz abdominal wall abdominal wall zz muscle fascia muscle fascia zz diaphragmdiaphragm

Hernias can be congenital or acquired Hernias can be congenital or acquired Abdominal wall hernias are very common Abdominal wall hernias are very common Account for approximately 10% of general surgical Account for approximately 10% of general surgical

workload workload

Common External HerniasCommon External Hernias

ABDOMINAL WALL & ABDOMINAL WALL & GROINGROINzz MidlineMidline

zz UmbilicalUmbilicalzz ParaPara-- umbilicalumbilicalzz EpigastricEpigastric

zz InguinalInguinalzz Direct/ Indirect/ CombinedDirect/ Indirect/ Combined

zz FemoralFemoralzz IncisionalIncisional

Common PresentationsCommon Presentations

A lumpA lumpzz Comes and goesComes and goeszz Appears on straining /coughingAppears on straining /coughing

A painA painzz Dragging pain/ Pain on exertionDragging pain/ Pain on exertion

Incidental finding on examination/ imagingIncidental finding on examination/ imaging Presenting as a complicationPresenting as a complication

zz Incarceration/ Intestinal obstructionIncarceration/ Intestinal obstruction

ComplicationsComplications

If intestinal strangulation occurs, symptoms can If intestinal strangulation occurs, symptoms can include: include: zz Constipation Constipation zz Blood in Stools Blood in Stools zz Fever Fever zz Vomiting Vomiting zz Shock Shock zz These symptoms indicate the need for These symptoms indicate the need for emergency emergency

medical attention.medical attention.

AetiologyAetiology

The two main The two main aetiologicalaetiological factors for factors for acquired hernias are acquired hernias are zz Increased intraIncreased intra--abdominal pressure abdominal pressure

e.g. straining or liftinge.g. straining or lifting

zz Abdominal weakness Abdominal weakness e.g. advancing age or malnutrition e.g. advancing age or malnutrition

Anatomy of the Anatomy of the Abdominal WallAbdominal Wall

Muscles of the Abdominal WallMuscles of the Abdominal Wall The abdominal wall is composed of four paired muscles The abdominal wall is composed of four paired muscles

zz internal and external internal and external obliquesobliques, , zz transversustransversus abdominisabdominis, and rectus , and rectus abdominisabdominis

These muscles run at right and oblique angles to one These muscles run at right and oblique angles to one another, giving the abdominal wall added strengthanother, giving the abdominal wall added strength

FasciaeFasciae AponeurosesAponeuroses TransversalisTransversalis FasciaFascia

AponeurosesAponeuroses Membranes separating Membranes separating

muscles from each other.muscles from each other. Flat Tendon Flat Tendon attaching attaching

muscles to a fixed point muscles to a fixed point Shiny, whitishShiny, whitish--silvery colorsilvery color HistologicallyHistologically similar to similar to

tendons, tendons, At Umbilicus At Umbilicus all 3 all 3

aponeurosesaponeuroses pass pass anteriorallyanteriorally

Rectus Rectus AbdominusAbdominus Paired Paired musclemuscle running running

vertically on each side of the vertically on each side of the anterior wall of the abdomenanterior wall of the abdomen

There are two parallel There are two parallel muscles, separated by a band muscles, separated by a band of connective tissue called the of connective tissue called the linea alba linea alba (white line). (white line).

It extends from the It extends from the pubic pubic symphysissymphysis inferiorly to the inferiorly to the xiphoidxiphoid and lower costal and lower costal cartilages superiorly.cartilages superiorly.

Six PackSix Pack

Linea AlbaLinea Alba A fibrous structure that runs down the A fibrous structure that runs down the

midline of the midline of the abdomenabdomen in humans and in humans and other vertebrates. other vertebrates.

The name means The name means white linewhite line Composed mostly of shiny white Composed mostly of shiny white

collagen connective tissue.collagen connective tissue. It is formed by the fusion of the It is formed by the fusion of the

aponeuroses of the abdominal aponeuroses of the abdominal musclesmuscles

Separates the left and right rectus Separates the left and right rectus abdominisabdominis muscles. muscles.

In muscular individuals its presence In muscular individuals its presence can be seen on the skin, forming the can be seen on the skin, forming the depression between the left and right depression between the left and right halves of a "six pack."halves of a "six pack."

Only Only connective tissueconnective tissue, and no , and no important important nerves or blood vessels, nerves or blood vessels,

Therefore a Therefore a median incisionmedian incision through through the linea alba is a common surgical the linea alba is a common surgical approach.approach.

Diagram Diagram Xs through Abdominal Xs through Abdominal

RegionRegion

ArcuateArcuate LineLine Horizontal line that demarcates the lower limit of the rectus shHorizontal line that demarcates the lower limit of the rectus sheath.eath. Superior to the Superior to the arcuatearcuate line, the internal oblique line, the internal oblique aponeurosisaponeurosis splits splits

to envelope the to envelope the rectus rectus abdominisabdominis muscle. muscle. Inferior to the Inferior to the arcuatearcuate line, the inferior oblique and line, the inferior oblique and transversustransversus

abdominisabdominis aponeuroses merge and pass superficial to the rectus aponeuroses merge and pass superficial to the rectus muscle.muscle.

Therefore, Therefore, Inferior to the Inferior to the arcuatearcuate line, the rectus line, the rectus abdominisabdominis rests directly on the rests directly on the

transversalis fasciatransversalis fascia.. If one dissects the If one dissects the anterolateralanterolateral abdominal wall, the abdominal wall, the arcuatearcuate line may line may

be seen, since all the aponeuroses are translucent.be seen, since all the aponeuroses are translucent.

Rectus Sheath: Cross Section Above Arcuate Line

Aponeurosis of transversusabdominis muscle

Aponeurosis of internaloblique muscle

Aponeurosis of externaloblique muscle

Superior epigastric vessels

Anterior layerof rectus sheath

Rectusabdominismuscle

Linea alba

Skin

External obliquemuscle

Internal obliquemuscle

Peritoneum

Transversalis fascia

Posterior layer of rectus sheath

Falciform ligament

Subcutaneous fat (superficial fascia)(Campers fascia)

Transversus abdominis muscleExtraperitoneal (fatty) tissue

Aponeurosis of transversusabdominis muscle

Aponeurosis of internaloblique muscle

Aponeurosis of externaloblique muscle Anterior layerof rectus sheath

Rectusabdominismuscle

Skin

Branches ofinferiorepigastric vessels

Linea alba

Internal obliquemuscle

External obliquemuscle

PeritoneumExtraperitoneal (fatty) tissue

Transversalis fascia Subcutaneous fat (superficial fascia)(Campers fascia)

Umbilicalprevesical

fascia

Medialumbilicalligamentand fold

Urachusin medianumbilical

fold

Transversus abdominismuscle

Rectus Sheath: Cross Section Below Arcuate Line

External ObliqueExternal Oblique

External ObliqueExternal Oblique Lateral and anterior parts of the Lateral and anterior parts of the abdomenabdomen Muscular portion occupies the side, Muscular portion occupies the side, AAponeurosisponeurosis of EO forms the anterior wall of the of EO forms the anterior wall of the

abdomen.abdomen. Only Abdominal Muscle that extends above costal Only Abdominal Muscle that extends above costal

marginmargin Attached to Iliac Crest Attached to Iliac Crest inferiorallyinferiorally The The aponeurosisaponeurosis of the external oblique muscle forms of the external oblique muscle forms

the the inguinal ligamentinguinal ligament. . The muscle also contributes to the The muscle also contributes to the inguinal canal.inguinal canal. Just deep to the external oblique is the Just deep to the external oblique is the internal oblique internal oblique

muscle.muscle.

11stst LayerLayer External External ObliquesObliques

Internal ObliqueInternal Oblique

Internal ObliqueInternal Oblique Fibers run perpendicular to the Fibers run perpendicular to the external oblique external oblique

muscle,muscle, The internal oblique performs two major functions. The internal oblique performs two major functions.

1.1. antagonist (opponent) to the diaphragm, antagonist (opponent) to the diaphragm, 2.2. Its contraction rotates and sideIts contraction rotates and side--bends the trunk by pulling the rib bends the trunk by pulling the rib

cage and midline towards the hip and lower back, of the same cage and midline towards the hip and lower back, of the same side. side.

zz It acts with the It acts with the external oblique muscleexternal oblique muscle of the opposite sideof the opposite side

zz For example, the right internal oblique and the left For example, the right internal oblique and the left external external oblique oblique contract as the torso flexes and rotates to bring the left contract as the torso flexes and rotates to bring the left shoulder towards the right hip. shoulder towards the right hip.

zz For this reason, the internal For this reason, the internal obliquesobliques are referred to as "same are referred to as "same side rotators."side rotators."

TransversusTransversus AbdominusAbdominus So called from the direction of So called from the direction of

its fibers, is its fibers, is Most internal of the flat Most internal of the flat

muscles of the abdomenmuscles of the abdomen Immediately beneath the Immediately beneath the

internal oblique muscleinternal oblique muscle.. From Inguinal Canal to From Inguinal Canal to

DiaphragmDiaphragm

22ndnd and 3and 3rdrd LayersLayers Internal Internal ObliquesObliques

&& Transverse Transverse AbdominusAbdominus

Transversalis fasciaTransversalis fascia A thin A thin aponeuroticaponeurotic membrane which membrane which

lies between the inner surface of the lies between the inner surface of the TransversusTransversus abdominusabdominus and the and the extraperitonealextraperitoneal fat.fat.

Below, it has the following Below, it has the following attachments: attachments: zz posteriorlyposteriorly, to the whole length of the , to the whole length of the

iliac crestiliac crestzz between the between the anterior superior iliac anterior superior iliac

spine spine and the and the femoral vessels femoral vessels it is it is connected to the posterior margin of connected to the posterior margin of the the inguinal ligamentinguinal ligament

It descends in front of the femoral It descends in front of the femoral vessels to form the anterior wall of the vessels to form the anterior wall of the femoral sheath.femoral sheath.

The The spermatic cord spermatic cord in the male and in the male and the the round ligament of the uterus round ligament of the uterus in the in the female pass through the transversalis female pass through the transversalis fascia at a spot called the fascia at a spot called the inguinal inguinal ringring..

This opening is not visible externallyThis opening is not visible externally

44thth LayerLayer TransversalisTransversalis FasciaFascia

Summary of Abdominal Summary of Abdominal Wall MusclesWall Muscles

Muscles of the Abdominal WallMuscles of the Abdominal Wall

In addition to forming the abdominal wall, these In addition to forming the abdominal wall, these muscles:muscles:zz Are involved with lateral flexion and rotation of the Are involved with lateral flexion and rotation of the

trunktrunkzz Help promote urination, defecation, vomiting, Help promote urination, defecation, vomiting,

coughing, childbirth and screamingcoughing, childbirth and screaming

Muscles of the Abdominal WallMuscles of the Abdominal Wall

Muscles of the Abdominal WallMuscles of the Abdominal Wall

Inguinal AnatomyInguinal Anatomy

Inguinal LigamentInguinal Ligament Inguinal CanalInguinal Canal Spermatic CordSpermatic Cord Pubic TuberclePubic Tubercle

Inguinal AnatomyInguinal Anatomy Vessels that provide blood to Vessels that provide blood to

the testicle exit the abdomen the testicle exit the abdomen through a hole in the through a hole in the abdominal wall (inguinal ring).abdominal wall (inguinal ring).

In women, this ring is also In women, this ring is also present, despite the absence present, despite the absence of testicular vessels. of testicular vessels.

In normal cases, the inguinal In normal cases, the inguinal ring is small enough to prevent ring is small enough to prevent the passage of abdominal the passage of abdominal contents outside of the contents outside of the abdominal cavity. abdominal cavity.

1.1. Inguinal ligament Inguinal ligament 2.2. Transversus Transversus abdominisabdominis

Muscle Muscle 3.3. Transversus Transversus abdominisabdominis

aponeurosisaponeurosis4.4. Internal oblique MuscleInternal oblique Muscle5.5. Internal oblique Internal oblique

aponeurosisaponeurosis6.6. Transversalis fascia Transversalis fascia 7.7. CremastericCremasteric fascia fascia

forming middle coating forming middle coating of spermatic cord of spermatic cord

8.8. Pubic tubercle Pubic tubercle

Normal Inguinal AnatomyNormal Inguinal Anatomy

Inguinal AnatomyInguinal Anatomy

The inguinal canal represents the oblique The inguinal canal represents the oblique passage through the anterior abdominal passage through the anterior abdominal wall of the vas deferens (or round wall of the vas deferens (or round ligament)ligament)

It is 5cm long and lies directly above the It is 5cm long and lies directly above the medial half of the inguinal ligamentmedial half of the inguinal ligament

Testis cord structuresTestis cord structures

Hernia AnatomyHernia Anatomy Inguinal ring enlarges Inguinal ring enlarges Bowel/tissue can Bowel/tissue can

pass through it. pass through it. Pain and often lump Pain and often lump

in the groin. in the groin. In most cases, the In most cases, the

bowel is able to rebowel is able to re--enter the abdomen on enter the abdomen on its own. (reducible)its own. (reducible)

Types of HerniaTypes of Hernia

Hernia DefinitionHernia Definition

SeveritySeverity Reducible Reducible Irreducible Irreducible Obstructed or Obstructed or

incarcerated incarcerated StrangulatedStrangulated

PositionPosition MidlineMidline

zz UmbilicalUmbilicalzz ParaPara-- umbilicalumbilicalzz EpigastricEpigastric

InguinalInguinalzz Direct/ Indirect/ Direct/ Indirect/

CombinedCombined FemoralFemoral IncisionalIncisional

Types of Hernia?Types of Hernia?

Types of HerniaTypes of Hernia Reducible HerniaReducible Hernia Irreducible HerniasIrreducible Hernias

zz a narrow neck a narrow neck

zz or the contents adhere to the sac wallor the contents adhere to the sac wall

Types of HerniaTypes of Hernia Obstructed orObstructed or Incarcerated HerniaIncarcerated Hernia

zz Less frequently, the Less frequently, the intestine becomes trapped intestine becomes trapped outside of the abdomen.outside of the abdomen.

zz Viable intestineViable intestine

All inguinal hernias All inguinal hernias must be repaired ormust be repaired or

Strangulated HerniaStrangulated Hernia. . zz Intestine passing through Intestine passing through

the inguinal ring becomes the inguinal ring becomes trapped trapped

zz Deprived of blood flowDeprived of blood flowzz Venous Drainage Venous Drainage

compromisedcompromised

Positions of HerniasPositions of Hernias

Inguinal herniaInguinal hernia

The most common hernia The most common hernia Up to 75% of all abdominal herniasUp to 75% of all abdominal hernias For a thorough understanding of inguinal hernias, much insight iFor a thorough understanding of inguinal hernias, much insight is needed in s needed in

the anatomy of the the anatomy of the inguinal canalinguinal canal.. Inguinal hernias are further divided into Inguinal hernias are further divided into

zz IndirectIndirect the more common the more common (2/3) (2/3) the inguinal canal is entered via a congenital weakness at its ethe inguinal canal is entered via a congenital weakness at its entrance (the internal ntrance (the internal

inguinal ring, and inguinal ring, and zz Direct" type Direct" type

(1/3)(1/3) where the hernia contents push through a weak spot in the back wwhere the hernia contents push through a weak spot in the back wall of the inguinal all of the inguinal

canal. canal. Inguinal hernias are more common in men than women Inguinal hernias are more common in men than women While femoral hernias are more common in women.While femoral hernias are more common in women.

Diagram of an Diagram of an indirectindirect, , scrotalscrotalinguinal hernia inguinal hernia ((medianmedian view from the view from the left).left).

Direct Vs IndirectDirect Vs Indirect

DirectDirect Posterior wallPosterior wall Less commonLess common OlderOlder SmallerSmaller HesselbachsHesselbachs MedialMedial Lower riskLower risk

IndirectIndirect Deep ringDeep ring 70%70% CongenitalCongenital ScrotalScrotal Deep ringDeep ring LateralLateral StrangulateStrangulate

Femoral herniaFemoral hernia

Femoral hernias occur just below Femoral hernias occur just below the the inguinal ligamentinguinal ligament

Abdominal contents pass into the Abdominal contents pass into the weak area at the posterior wall of weak area at the posterior wall of the the femoral canalfemoral canal. .

Hard to distinguish from the Hard to distinguish from the inguinal type (especially when inguinal type (especially when ascending ascending cephaladcephalad): however): howeverzz generally appear more rounded, generally appear more rounded, zz strong female preponderance in strong female preponderance in

femoral hernias. femoral hernias. zz The incidence of strangulation in The incidence of strangulation in

femoral hernias is high. femoral hernias is high. Repair techniques are similar for Repair techniques are similar for

femoral and femoral and inguinal hernia.inguinal hernia.

Umbilical HerniaUmbilical Hernia

Especially common in Especially common in infants of infants of AfricanAfrican descent descent

Occur more in boys Occur more in boys Protrusion of intraProtrusion of intra--

abdominal contents abdominal contents through a weakness at through a weakness at the site of passage of the the site of passage of the umbilical cord umbilical cord through the through the abdominal wall abdominal wall

Often resolve Often resolve spontaneously spontaneously

In adults, more frequent In adults, more frequent in in obeseobese or or pregnantpregnantwomen. women.

IncisionalIncisional HerniaHernia

An An incisionalincisional hernia occurs hernia occurs when the defect is the result of when the defect is the result of an incompletely healed an incompletely healed surgical wound. surgical wound.

In median In median laparotomylaparotomy incisions incisions in the in the linea albalinea alba, they are , they are termed termed ventral herniasventral hernias. .

These can be the most These can be the most frustrating and difficult to treat, frustrating and difficult to treat, as the repair as the repair utilisesutilises already already attenuated tissue.attenuated tissue.

HERNIALearning ObjectivesWhat is a Hernia?What is a Hernia?Diapositiva numero 5Diapositiva numero 6What is a Hernia?Common External HerniasCommon PresentationsComplicationsAetiologyAnatomy of the Abdominal WallMuscles of the Abdominal WallAponeurosesRectus AbdominusLinea AlbaDiagram Xs through Abdominal RegionArcuate LineDiapositiva numero 19Diapositiva numero 20External ObliqueExternal Oblique1st LayerExternal ObliquesInternal ObliqueInternal ObliqueTransversus Abdominus2nd and 3rd LayersInternal Obliques&Transverse AbdominusTransversalis fascia4th LayerTransversalis FasciaSummary of Abdominal Wall MusclesMuscles of the Abdominal WallDiapositiva numero 32Muscles of the Abdominal WallMuscles of the Abdominal WallDiapositiva numero 35Diapositiva numero 36Inguinal AnatomyDiapositiva numero 38Inguinal AnatomyDiapositiva numero 40Diapositiva numero 41Diapositiva numero 42Diapositiva numero 43Normal Inguinal AnatomyDiapositiva numero 45Diapositiva numero 46Inguinal AnatomyTestis cord structuresHernia AnatomyTypes of HerniaHernia DefinitionTypes of Hernia?Types of HerniaTypes of HerniaDiapositiva numero 55Positions of HerniasDiapositiva numero 57Diapositiva numero 58Inguinal herniaDiapositiva numero 60Direct Vs IndirectDiapositiva numero 62Femoral herniaUmbilical HerniaIncisional Hernia