Abdomin

al hernias
Reuben Rhubarbs
Tang
Introduction
Definition
External/internal
Contents
Intestine
Omentum
Ovary/bladder Images courtesy of McGraw-Hill and Childrens Hospital of
Wisconsin
Introduction (cont.)
Sac
Richters/Maydl/Littres
Aetiology
Weakened abdominal wall
Raised intra-abdominal pressure
Congenital/acquired
Reducible/incarcerated/strangulated
Image courtesy of Surgwiki.com
Types of hernias
Groin hernias
Inguinal
Direct/indirect/Pantaloon
Femoral
Anterior abdominal
Umbilical
Epigastric
Incisional
Spegelian
Pelvic hernias
Obturator
Gluteal/sciatic
Image courtesy of Wikipedia.org
Posterior abdominal wall
Lumbar
Principles of treatment
Watch and wait
Truss
Reduction
Decrease intra-abdominal pressure
Strengthen abdominal wall

Image courtesy of Oppo Inc.

Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO, et al. Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men: A
Randomized Clinical Trial. JAMA. 2006;295(3):285-292. doi:10.1001/jama.295.3.285.
Incidence
Relative occurrence of Sex distribution of abdominal hernias
external abdominal hernias in
adults Male (%) Female (%)
Hernia Percentage Inguinal
96 45
Inguinal 80 hernia

Incisional 10 Femoral
2 39
hernia
Femoral 5
Umbilical
Umbilical >4 1 15
hernia
Epigastric <1 Other 1 1
Other <1

Abramson JH, et al. J Epidemiol Community Health. 1978;32:59-67. Available at http://www.ncbi.nlm.nih.gov/pubmed/95577.

Goroll AH, et al. Primary care medicine: office evaluation and management of the adult patient, 5th ed. Philadelphia, Lippincott
Williams & Wilkins; 2005:431-434.
Nicks BA. Hernias. Medscape Reference: Drugs, Diseases, and Procedures. Last Updated June 6, 2012. Available at
http://emedicine.medscape.com/article/775630-overview. Accessed April 30, 2013.
Inguinal hernias

Image courtesy of Mc-Graw Hill

Nyhus classification
Type 1 - indirect inguinal hernia with normal internal ring
(congenital, as seen in infants and children).
Type 2 - indirect hernia with dilated internal ring but normal
posterior inguinal wall (usually seen in children and young adults).
Type 3 - posterior wall (inguinal floor) defects:
3A: Direct hernia.
3B: Indirect hernia with dilated internal ring associated with or caused by
weakness of posterior wall; includes sliding hernia. Type 3B hernias are
acquired, not congenital.
3C: Femoral hernia.
Type 4 - Recurrent inguinal hernia.

Nyhus, Lloyd Milton, and Henry Nelson Harkins, eds. Hernia. Lippincott, 1964.
Indirect hernia types

Image courtesy of learnanatomy.com

Symptoms and signs
SBO
Overlying erythema/swelling
Pain
Reducible lump
Cannot get above lump
Finger invagination test
Deep ring occlusion test
Ziemans test
Special tests

Image courtesy of Dr Nithin

Surgical options
Herniorraphy
Bassini
Shouldice
McVay
Hernioplasty
Lichtenstein repair
Plug and patch
Laparoscopic
TAPP
TEP
Images courtesy of McGraw-Hill, Medscape and Dr Harshalp
Inguinal triangles

Images courtesy of McGraw-Hill

Complications
General surgical/anaesthetic risk
DVT, PE, infection etc.
Urinary obstruction
Haematoma
Swelling of testicle and scrotum
Damage to vas/testicular vessels
Chronic pain
Nerve
Scarring
Recurrence of hernia
Formation of new hernia
Outcomes
Outcome Surgery Favored Calculated Differences (95% CI)

Hernia recurrence Open surgery RR = 1.43 (1.15 to 1.79); 2.49% recurrence

after open versus 4.46% recurrence after
laparoscopy
Length of hospital stay Approximate Summary difference in means =
equivalence -0.33 days (-0.52 to -0.14)
Return to normal daily Laparoscopic SWMD in days = -3.9 (-5.6 to -2.2)
activities
Return to work Laparoscopic SWMD in days = -4.6 (-6.1 to -3.1)
Long-term pain Laparoscopic OR = 0.61 (0.48 to 0.78)
Epigastric vessel injury Open OR = 2.1 (1.1 to 3.9)
Hematoma Laparoscopic OR = 0.70 (0.55 to 0.88)
Wound infection Laparoscopic OR = 0.49 (0.33 to 0.71)

Treadwell J, Tipton K, Oyesanmi O, et al. Surgical Options for Inguinal Hernia: Comparative Effectiveness Review. Comparative Effectiveness Review No. 70 (Prepared by the ECRI Institute Evidence-
based Practice Center under Contract No. 290-2007-10063). AHRQ Publication No. 12-EHC091-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2012. Available at
www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.
Femoral hernias
From disruption of
transversalis fascia
overlying femoral canal
More in LOL in NAD
Must be treated
Options
open vs laparoscopic
Lockwood's infra-inguinal
Lotheissen's trans-
inguinal
McEvedy's high approach
Image courtesy of Surgwiki.com
Incisional hernia
Protrusion of hernia through defect at scar post-
abdominal operation
Incidence of 5% at 5 years, 10% at 10 years post
operation
Predisposing factors:
Poor surgical technique
Local wound complications
Impaired wound healing
Raised intraabdominal pressure
Should be repaired when discovered
Epigastric hernia
Protrusion of extraperitoneal
fat through defect in linea
alba
Typically young fit males with
epigastric pain
Surgery to relieve symptoms
Keel repair

Image courtesy of Surgwiki.com

Umbilical/paraumbilical hernias
Umbilical
Congenital
5-10% at birth
Repair typically at 3-4 year old
Para-umbilical
Acquired
Protrusion through umbilical
ring
Effacement of umbilicus due to
pressure from hiatal contents
Should be surgically managed
Mayo/Mesh Image courtesy of Surgwiki.com
Spigelian hernia
Hernia through
trasnversus
abdominis
aponeurosis
Typically at
halfway between
umbilicus and
inguinal ligament
Typically in LOL
Must be
surgically closed Image courtesy of McGraw-Hill
Lumbar hernia
Rare (<300 in literature)
Associated with poor muscle
tone, following trauma or any
paralysis of paravertebral
muscle
Occur through
Inferior lumbar triangle (Petits)
Superior lumbar triangle
(Grynfeltts)
Prosthetic mesh repair
encouraged
Image courtesy of Radiopaedia.org
Obturator hernia
Rare hernia
Protrusion through obturator
canal/foramen
Compression of obturator
nerve
More in LOL who have lost
weight rapidly
Laparotomy required: risk of
damage to obturator nerve
Image courtesy of Radiopaedia.org
Gluteal/Sciatic hernia
Very rare
Occur through
Greater sciatic foramen (Gluteal)
Lesser sciatic foramen (Sciatic)
Sciatic nerve compression
Sciatica
Some guidelines do not
recommend closure of defect
due to risk of damage to
sciatic nerve Image courtesy of Mc-Graw Hill