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Unformatted text preview: HERNIAS
Mount Sinai School of Medicine
Basic Science Lecture Historical Perspective
Historical Perspective 15th century Castration with wound cauterization or hernia sac debridement recommended a truss Father of Modern Inguinal Hernia Father of Modern Inguinal Hernia Repair EDUARDO BASSINI Hernia
Hernia Latin for rupture an abnormal protrusion of an organ or tissue through a defect in its surrounding walls Occur at sites where aponeurosis and fascia are not covered by striated muscle Which of the following statements is/are true Which of the following statements is/are true regarding incidence of the abdominal wall hernia?
E. Twothrirds of all inguinal hernias are classified as indirect.
Femoral hernias are more common in females than in males.
Direct hernias are common in females.
Hernias generally occur with equal frequency in males and females
Premature babies have a 10% incidence of having inguinal hernia. Epidemiology
Epidemiology 700,000 hernia repairs year
Inguinal hernias 75% of all hernias 2/3 Indirect, remainder are direct Incisional hernias – 15 to 20%
Umbilical and epigastric – 10%
Femoral – 5% Epidemiology
Epidemiology Prevelance of hernias increases with age
Most serious complication – strangulation 1 to 3% of groin hernias Femoral – highest rate of complications 15% to 20% recommended all be repaired at time of discovery Abdominal Wall Abdominal Wall Anatomy Anatomy
Anatomy Inguinal ligament (Poupart’s) – inferior edge of external oblique
Lacunar ligament – triangular extension of the inguinal ligament before its insertion upon the pubic tubercle conjoined tendon (510%) Internal oblique fuses with transversus abdominis aponeurosis
Cooper’s Ligament formed by the periosteum and fascia along the superior ramus of the pubis. Inguinal Canal
Inguinal Canal Between deep and superficial inguinal rings Boundaries Superifical – external oblique aponeurosis
Superior – internal and transversus
Inferior – shelving edge of inguinal ligament and lacunar ligament
Posterior (floor) – transversalis fascia and aponeurosis of transversus abdominis muscle Inguinal Canal
Inguinal Canal Contains the spermatic cord and round ligament of the uterus
Spermatic cord Cremasteric muscle fibers
Genital branch of genitofemoral nerve
Vas deferens Cremasteric vessels Components of Hesselbach’s triangle include which Components of Hesselbach’s triangle include which of the following anatomic landmarks?
E. Pectineal ligament
Lateral border of the rectus sheath
Inferior epigastric vessels Terminology
Terminology Reducible – can be replaced within surrounding musculature Incarcerated – cannot be reduced
Strangulated – compromised blood supply to its contents Sends sensory branches to the inner thigh and Sends sensory branches to the inner thigh and medial aspect of the scrotum
D. Ileoinguinal nerve Genitofemoral nerve
Neither A sliding inguinal hernia on the left side is likely to A sliding inguinal hernia on the left side is likely to involve which of the following?
E. Jejunum composing the posterior wall of the sac
Ovary and fallopian tube in a female infant
Sigmoid colon composing the posterior wall of the sac
Cecum composing the anteromedial wall of the sac Terminology
Terminology Pantaloon – direct and indirect components
Richter’s – contains antimesenteric portion of small bowel
Sliding – involves visceral peritoneum of an organ , i.e. bladder, ovary
Littre’s – hernia contains Meckel’s diverticulum
Petit – hernia at inferior lumbar triangle
Grynfelt – hernia at superior lumbar triangle Groin Hernias
Groin Hernias Indirect
Femoral Inguinal Hernia
Inguinal Hernia Classified as congenital vs. acquired commonly thought that repeated increases in intraabdominal pressure contribute to hernia formation collagen formation and structure deteriorates with age, and thus hernia formation is more common in the older individual. Clinical Presentation
Clinical Presentation Groin bulge
Dull feeling of discomfort or heaviness in the groin
Focal pain – raise suspicion for incarceration or strangulation
Symptoms of bowel obstruction Inguinal hernia
Inguinal hernia Male inguinal hernia Female inguinal hernia Diagnosis
Diagnosis Physical Exam 74.5% sensitive and 96.3% specific
examine the patient in the standing and supine positions
difficult to distinguish direct and indirect on exam on alone Diagnosis
Diagnosis Radiologic Investigations Herniography Suspected hernia, but clinical dx unclear Procedure done under flouroscopy following injection of contrast medium Frontal and oblique radiographs are taken with and without increased intraabdominal pressure Ultrasonography MRI CT Herniography
Herniography Left indirect inguinal hernia Right direct inguinal hernia Direct Inguinal Hernia
Direct Inguinal Hernia Direct Inguinal Hernia
Direct Inguinal Hernia Medial to the inferior epigastric artery and vein, and within Hesselbach's triangle acquired weakness in the inguinal floor Indirect Inguinal hernia
Indirect Inguinal hernia Abdominal contents protrude through internal inguinal ring Indirect Inguinal Hernia
Indirect Inguinal Hernia Accepted hypothesis: incomplete or defective obliteration of the processus vaginalis during the fetal period remnant layer of peritoneum forms a sac at the internal ring more frequently on the right Femoral
Femoral More common in females Up to 40% present as emergencies with hernia incarceration or strangulation Passes medial to the femoral vessels and nerve in the femoral canal through the empty space Inguinal ligament forms the superior border Femoral
Femoral palpation of the femoral canal just below the inguinal ligament in the upper thigh NAVELS TABLE 1 TABLE 1 Nyhus Classification of Groin Hernias Type Iindirect inguinal hernia Internal inguinal ring normal (i.e., pediatric hernia) Type IIindirect inguinal hernia Dilated internal inguinal ring with posterior inguinal wall intact Type IIIposterior wall defects Direct inguinal hernia Indirect inguinal hernia: dilated internal ring with large medial encroachment on the transversalis fascia of the Hesselbach's triangle (i.e., massive scrotal, sliding hernia) Femoral hernia Type IVrecurrent hernia Which of the following statements is/are true Which of the following statements is/are true regarding direct inguinal hernias?
E. The most likely cause is destruction of connective tissue resulting form physical stress.
Direct hernias should be repaired promptly because of the risk of incarceration.
A direct hernia may be a sliding hernia involving a portion of the bladder wall.
A direct hernia may pass through the external inguinal ring.
Colon carcinoma is a known cause of direct inguinal hernias. Treatment
Treatment NonOperative Observation Trusses can provide symptomatic relief Hernia control in ~30% of patients Operative
Laparoscopic Bassini (early 20th Century) Shouldice (1930s) Transversus abdominis to Thompson’s ligament and
internal oblique musculoaponeurotic arches or
conjoined tendon to the inguinal ligament
Multilayer imbricated repair of the posterior wall of the
inguinal McVay (1948) Edge of the transversus abdominis aponeurosis to
Cooper’s ligament; incorporate Cooper’s ligament and
the iliopubic tract (transition suture) BASSINI MCVAY SHOULDICE Lichtenstein Lichtenstein First pure prosthestic, tensionfree repair to achieve low recurrence rates Prosthetic Repair
Prosthetic Repair Polypropylene mesh most common and preferred allows for a fibrotic reaction to occur between the inguinal floor and the posterior surface of the mesh, thereby forming scar and strengthening the closure of the hernia defect Polytetrafluoroethylene (PTFE) mesh often used for repair of ventral or incision hernias in which the fibrotic reaction with the underlying serosal surface of the bowel is best avoided Prospective study
Danish Hernia database of over 13,000 hernia repairs
Compared reoperations for recurrent hernia Results: After 5 years significantly lower (1/4 less) recurrence with mesh vs. sutured repair Laparoscopic
Laparoscopic The cause of neuropathic postherniorrhaphy The cause of neuropathic postherniorrhaphy inguinodynia includes which of the following?
E. Formation of scar tissue
Transection of the ilioinguinal, iliohypogastric, or the genitofemoral nerves
Suture entrapment of nerves
Staple entrapment of nerves
Periosteal reaction Surgical Complications
Surgical Complications Recurrence
Vas Deferens injury Other Hernias
Other Hernias Which of the following is/are true statements Which of the following is/are true statements regarding umbilical hernias?
E. They are embryonic equivalent of a small omphalocele
Repair in infants is usually deferred until approximately 4 years of age
Repair in adults is usually indicated
The “vestoverpants” type of repair is stronger than simple approximation of fascial margins
They are most common in Caucasian infants Umbilical
Incidence Reported ~10% several times greater in Black children more common in premature children all races Most close spontaneously by age 2 or 3 Acquired rather than congenital in adults Female to male ratio 3:1 Epigastric
Epigastric midline junction of the aponeuroses (linea alba) between the xiphoid process and umbilicus
Paraumbilical hernia epigastric hernia that borders the umbilicus
Estimated frequency 35%
More common in Males 3:1
20% may be multiple Epigastric
Epigastric Clinical Tx Often asymptomatic, incidental finding
If symptomatic, vague abdominal pain above the umbilicus exacerbated by standing or coughing; relieved in supine position
Severe pain secondary to incarceration/strangulation of preperitoneal fat (often no peritoneal sac) or omentum
Exam: palpate small, soft, reducible mass superior to the umbilicus
RARE to have strangulated bowel
Excise fat and sac, close primarily An 82yearold previously healthy woman has a 12hour history of severe An 82yearold previously healthy woman has a 12hour history of severe epigastric pain associated with nausea and vomiting. She has had no previous abdominal operations. Her WBC count is 21,000/cu mm. The plain films and abdominal CT shown are obtained. Which of the following best Which of the following best describes this patient’s diagnosis?
E. Pain in the medial thigh and knee is uncommonly associated with this condition
It is unusual in women
It is unusual in elderly patients
It is seldom associated with intestinal necrosis
It is usually unilateral Obturator
Obturator Rare form of hernia
Protrusion of intraabdominal contents through obturator foramen
F:M ratio 6:1
The obturator foramen is formed by the ischial and pubic rami obturator vessels and nerve lie posterolateral to the hernia sac in the canal Small bowel is the most likely intraabdominal organ to be found in an obturator hernia Obturator
Obturator 4 cardinal signs : intestinal obstruction (80%) HowshipRomberg sign (50%) –History of repeated episodes of bowel obstruction that resolve quickly and without intervention Palpable mass (20%) Tx: Sugical Repair Spigelian Hernia
Spigelian Hernia occurs along the semilunar line, which traverses a vertical space along the lateral rectus border where more than 90% of spigelian hernias are found Spigelian Hernia
Spigelian Hernia Clinical Swelling in middle to lower abdomen lateral to rectus muscle
Up to 20% present with incarceration Tx: surgical Mesh not required
Recurrence is uncommon Lumbar
Lumbar Acquired lumbar hernias – Contains to anatomic triangles, inferior and superior lumbar triangles back or flank trauma, poliomyelitis, back surgery, and the use of the iliac crest as a donor site for bone grafts Grynfelt’s
Petit’s Strangulation is rare
Soft swelling in lower posterior abdomen Sciatic
Sciatic Via greater or lesser sciatic notch greater sciatic notch is traversed by the piriformis muscle, and hernia sacs can protrude either superior or inferior to this muscle suprapiriform defect 60%
Infrapiriform 30% subspinous (through the lesser sciatic foramen) 10% Which of the following hernias is most likely to recur Which of the following hernias is most likely to recur after primary repair?
E. Epigastric hernia
Incisional hernia Ventral wall (Incisional)
Ventral wall (Incisional) Highest incidence in midline and transverse incisions Up to20% after laparotomy
1/3 present in 510 years postoperatively
Risk factors obesity, DM, ascites, steroids, smoking malnutrition, wound infection Technical aspects of wound closure Type of incision Excessive tension (prone to fascial disruption) Which of the following hernias represent an Which of the following hernias represent an incarceration of a limited portion of small bowel?
E. Spigelian hernia
Littre’s hernia ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.
- Fall '11