hernias - semmelweis.husemmelweis.hu/sebeszet1/files/eloadasok/eng/herniassza.pdf · if he has a...

Hernias

Ákos SZŰCS M.D.

Semmelweis University, Faculty of Medicine, 1st Department of Surgery


Pathomorphology

Each abdominal hernia consists of

• hernia gate

• hernia sac

• hernia contents

Hernia sac forms by outpouching of parietal

peritoneum and can contain small intestine and

omentum. Sometimes it containes other organs:

large intestine, urinary bladder, ovary, and

appendix.

• The main parts of the hernia pouch are neck, body

and fundus.


Common Presentations

A lump

• Comes and goes

• Appears on straining /coughing

A pain

• Dragging pain/ Pain on exertion

Incidental finding on examination/ imaging

Presenting as a complication

• Incarceration/ Intestinal obstruction

.


Common Presentations

Dg:

•Anamnesis and physical examination

–Inspection may reveal an obvious swelling in the inguinal

area. If he has a small hernia, the affected area may simply

appear full.

–As part of your inspection, have the patient lie down. If the

hernia disappears, it's reducible

–Auscultation should reveal bowel sounds. The absence of

bowel sounds may indicate incarceration or strangulation.

–Palpation helps to determine the size of an obvious hernia. It

also can disclose the presence of a hernia in a male patient.

•Sonography of the hernia pouch.

•Plain X-ray for suspected bowel obstruction

•Common blood analysis.

•Common urine analysis.


Inguinal hernia

Anatomy:

•„Corona Mortis”

–is an anatomical variant, an

anastomosis between the obturator

and the external iliac or inferior

epigastric arteries or veins

–It is located behind the superior

pubic ramus at a variable distance

from the symphysis pubis

–The name "corona mortis" or

crown of death testifies to the

importance of this feature, as

significant hemorrhage may occur if

accidentally cut and it is difficult to

achieve subsequent hemostasis

Anatomy:

• Hernias are divided into two main

groups: congenital and acquired.

The main reason of congenital hernias

is malformation. Thus, inguinal hernia

arose in case of no closure of the

process of peritoneum, which passes

by inguinal channel during descending

the testis. On such hernias testis is

located in the hernia pouch. Acquired

inguinal hernia has hernia pouch and

testis located outside it.


Inguinal hernia

Th:

•Bassini repair

•Shouldice repair (tension free technique)

•Lichtenstein repair (using a mesh)

•Laparoscopic hernia repair

–(TEP – totally extraperitoneal)

–(TAPP - transabdominal preperitoneal)

–(IPOM - intraperitoneal onlay mesh)


Femoral hernia

Etiology:•Accounts for 4% of Groin Hernias

•More common in elderly women

•Gender predisposition: Female by 3 to 1 ratio

Pathophysiology:•Associated with increased intraabdominal pressure

•Hernia sac bulges into femoral canal–Femoral canal lies immediately medial to femoral vein

–The femoral canal is the way that the femoral artery, vein, and nerve leave the

abdominal cavity to enter the thigh.

–Although normally a tight space, sometimes it becomes large enough to allow

abdominal contents (usually intestine) into the canal.

•This hernia causes a bulge below the inguinal crease in roughly the

middle of the thigh.

•Rare and usually occurring in women, these hernias are particularly at risk

of becoming irreducible and strangulated.


Umbilical hernia

Etiology:

•These common hernias (10-30%) are often noted at birth as a

protrusion at the bellybutton (the umbilicus).

•This is caused when an opening in the abdominal wall, which

normally closes before birth, doesn’t close completely.

•Even if the area is closed at birth, these hernias can appear

later in life because this spot remains a weaker place in the

abdominal wall.

•They most often appear later in elderly people and middle-

aged women who have had children


Incisional hernia

Etiology:•Abdominal surgery causes a flaw in the abdominal wall that must

heal on its own.

•This flaw can create an area of weakness where a hernia may

develop.

•This occurs after 2-10% of all abdominal surgeries, although some

people are more at risk

•Risks for postoperative hernia development–Vertical scar more commonly affected than horizontal

–Wound infection

–Wound dehiscence

–Malnutrition

–Obesity

–Tobacco abuse

•After surgical repair, these hernias have a high rate of returning

(20-45%).


Umbilical and incisional hernia

Th:

•Mayo repair:

–After the Mayo method defect of anterior abdominal wall

in the umbilical ring is sutured by U-shaped stitches in

transversal direction

•Repair using a mesh:

–After the Mayo method defect of anterior abdominal wall

in the umbilical ring is sutured by U-shaped stitches in

transversal direction and placed a mesh


Rare hernias

Spigelian hernia

Obturator hernia

Richter hernia


Complications of hernia

Incarceration - strangulation

•Signs and sympthoms

–Clinical Features

–Physical Findings

•Dg:

–CBC (complete blood count) and electrolytes

–Abdominal x-ray series

–CT scan

•Th - Surgery:

–Resection is not needed (no irreversible damage)

–Resection is needed (irreversible damage)


Complications of hernia repair

•Nerve injury (n. ilioinguinalis, n. genitofemoralis)

•Vessel injuy (a.,v. femoralis, epigastrica inferior,

spermatica)

•Injury of the ductus deferens

•Injury of the bladder

•Bowel injury

•Infections

–Wound infection

–Infection of the implanted mesh

hernias - semmelweis.husemmelweis.hu/sebeszet1/files/eloadasok/eng/herniassza.pdf · if he has a...

Documents