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  1. 1. Hernia  A hernia occurs when an organ or fatty tissue squeezes through a weak spot in a surrounding muscle or connective tissue - fascia.
  2. 2. Types of Hernia  Inguinal hernia  Umbilical hernia  Hernia in cicatrice  Sports hernia  Internal hernia  Diaphragmal hernia
  3. 3. Types of Hernia
  4. 4. Anatomy  The inguinal canal is 4-6 cm long.  The inguinal canal starts in the abdomen from the point that the spermatic cord crosses the internal/deep inguinal ring in the transversalis fascia (in women the Round ligament).  This canal finally ends in the external/surface inguinal ring at the level of the abdominal muscles where the spermatic cord passes from the aponeurosis of the external oblique muscle.
  5. 5. Epidemiology  About 75% of all hernias happen in the inguinal region.  90% of them are in men and 10% in women.  70% of femoral hernia repairs occur in women (although the prevalence of inguinal hernia in women is 5 times that of femoral hernia.  The most common inguinal hernia in women and in men is the indirect inguinal hernia.  The prevalence of hernia in men has two peak ages: Under one and above 40.
  6. 6. Epidemiology  In the laparascopic repair of the hernia, the diagnosis of contralateral hernia can be made.  Femoral hernia in the elderly and in those who had a previous hernia repair is more common.  The prevalence of inguinal hernia increases with age (especially in men).  Inguinal hernia in adults is mainly from an acquired weakness in the abdominal wall (the most important one is a defect in the abdominal muscle).
  7. 7. Etiology  Inguinal hernia has two etiologies: A) Congenital B) Acquired A) Congenital Hernia: i. Congenital hernia consists most of the cases of pediatric hernias ii. In the descent of the testes from the abdomen to the scrotum in the third trimester, a part of the peritoneum descends with it which is called the processus vaginalis. i. In the weeks 36-40 of gestation this processus vaginalis closes. i. Lack of closure of processus vaginalis results in a patent processus vaginalis which is a reason for the high prevalence of inguinal hernia in the preterm neonates. i. A lot of the process vaginalises close in a few months after birth and its patency does not necessarily mean that a hernia will be formed.
  8. 8. Etiology B) Acquired Hernia: It seems that most cases of hernia come from an acquired defect in the abdominal wall and the reason for its formation is multifactorial: 1- Strenuous physical activity can be a factor but it is not known whether the hernia is just from physical activity or in the setting of a patent processus vaginalis. 2- A positive family history which can increase its incidence 8 times. 3- COPD increases the direct hernia risk. 4- Collagen deficiency associated diseases like collagen type I deficiency relative to type III. 5- An association exists between aneurisms and hernias. Being overweight is to some extent protective (maybe it is from the more difficult diagnosis of hernia)
  9. 9. Symptoms  The symptoms are variable from a hernia with no symptoms to one with strangulation.  Asymptomatic hernia is either found in physical exam, or the patient himself realizes the bulging, or it is found during laparascopy.  Symptomatic patients mostly present with inquinal pain.  Sometimes patients present with symptoms outside the inguinal region such as a change in bowel habits, and/or urinary symptoms (in the form of sliding hernia).
  10. 10. Symptoms  With pressure on the nearby nerves, hernia can cause different symptoms such as a general feeling of pressure, localized pain, and referred pain.  The feeling of pressure and weight on the inguinal region especially after a daily activity is common.  A sharp pain indicates nerve entrapment and does not have anything to do with physical activity.  Neurogenic pains may refer to the scrotum or inside the thigh.  A change in bowel habits or in the urinary symptoms can indicate involvement of the bladder inside the hernial sac.
  11. 11. Symptoms  Pain in the inguinal region without bulging is usually not due to a hernia.  The duration and the way the symptoms progress is important  Usually the patient can reduce the hernia but the bigger the hernia, the less likely it is to reduce.  The possibility of the incarceration of the hernia at the beginning of the progress of hernia, for example during the first year , is more likely.  The possibility of incarceration is neonates is more likely than in adults.
  12. 12. Physical Exam  The history is usually indicative of hernia but the physical exam is also an important part of the evaluation.  The examination in obese patients is difficult.  It is best that the patient is examined in an upright position so that the inguinal region and the scrotum is completely exposed.
  13. 13. Physical Exam  A) First we look to see the bulging. If we do not have a bulging, we place a finger inside the scrotum and raise it toward the external ring, and ask the patient to cough or do the Valsalva maneuver until the hernial contents fall. The valsalva maneuver causes an unusual bulging and it is possible to realize if this bulging can be reduced or not.  B) We examine the contralateral side and compare the two sides to each other. The extent of bulging on the two sides can be a criteria for the diagnosis of hernia on one or both sides.
  14. 14. Physical Exam  The differentiation between a direct and an indirect inguinal hernia in the physical exam: There are different techniques for differentiating a direct from an indirect hernia in physical exam. - If the finger is inside the inguinal canal and the patient exerts pressure or coughs and the hernia comes in contact with the tip of the finger it is a direct hernia. - If with closure of the internal ring with the finger while the patient strains (coughs) the hernial sac does not bulge out the hernia is an indirect one, and if the hernial sac bulges the hernia is a direct one.
  15. 15. Physical Exam the examination of the femoral hernia is difficult. This hernia presents under the inguinal ligament and the presence of too much or too little fat in the inguinal region can cause an error in the diagnosis. (Femoral Psuedohernia) Therefore even the presence of a smallest bulging under the inguinal ligament has to raise the suspicion for a femoral hernia.
  16. 16. Differential Diagnosis 1-Malignancy: Lipoma, metastasis, testicular tumors 2-Testicular primary conditions : Varicocele, Epididimitis, Testicular torsion, Hydrocele, Ectopic testes, undescended testes 3- Aneurism or pseudoaneurism of the femoral artery 4- Lymphadenopathy 5- Sebacious cyst 6- Hydroadenitis 7- Nuck canal cyst (in women) 8- Varices 9-Psoas Abcess 10- Hematoma 11- Ascites
  17. 17. Diagnosis  The diagnosis is based on history, physical exam and sometimes imaging. Imaging in hernia:  In some conditions physical exam cannot diagnose the hernia: 1- Overwieght individuals 2- Recurrent hernia 3- Hernias that are not found in the physical exam In these conditions imaging is important
  18. 18. Diagnosis  The most common radiologic conditions include sonography, CT, MRI, and each has its own pros. and cons. 1-Sonography: It is inexpensive and does not have radiation. In underweight individuals the movement of the posterior wall and spermatic cord toward the anterior wall of the abdomen can have false positive results (the false positive results of the sonography is more than in the phyisical exam and MRI)
  19. 19. Diagnosis 2- CT scan: Although it gives more information but the routine use of it is not recommended. In one determined evaluation among the imaging techniques, MRI was more truthful, and an accurate physical exam was more truthful than sonography.
  20. 20. Treatment of inguinal hernia  Bassini  Shouldice  Lichtenstein  Kirschner , Hackenbruch  TAPP  TEP  TIPP
  21. 21. Treatment  The final treatment of inguinal hernia is surgery.  Now using a mesh, hernia repair takes place.  Mesh is the golden standard because less tension is produced and there is less recurrency.  Because of the very good results of mesh the initial tissue repair is not used any more.  Laparascopic surgery is used in bilateral and recurrent conditions or when another surgery like prostate surgery has to take place at the same time.  The laparascopic procedure is not different from the open surgery method in the recurrency rate. It has less post-op complications and a sooner return to work. Intestinal obstruction and ileus is seen more often after a laparascopic procedure.
  22. 22. Treatment  Contraindications of laparascopy: 1- A previous surgery in the area (a surgery that the surgeon entered the abdomen such as prostatectomy) 2-Primary medical condition In recurrent cases, dissection in the scar tissue should not be made (due to inability in exactly differentiating the anatomic parts. In the treatment of hernia surgery is necessary, since with a conservative method, the wall defect is not removed but has the tendency to enlarge and cause incarceration.
  23. 23. Treatment  Indications of conservative surgery: 1-Bad coexisting medical condition 2-A small asymptomatic hernia 3-An elderly person who is asymptomatic Conservative treatment is not used in femoral hernia.
  24. 24. Anesthesia Method  Anterior surgery can be done with, local, regional, or general anesthesia.  Laparascopic surgery has to be done with general anesthesia.  Local anesthesia: Lidocaine, Marcaine with or without epinephrine.  The use of epinephrine in people with coronary problems is contraindicated.  Before incision or prep inguinal nerve has to be blocked.  Epidural anesthesia is also a proper method.
  25. 25. Complications  Incarceration  Hernia contents get stuck – and cannot be reduced  Requires EXPEDITED surgery  Obstruction  When bowel is extruded through a hernia and becomes so tight that  food cannot pass through that segment  Causes severe pain, nausea, vomiting  Requires URGENT surgery
  26. 26. Complications  Strangulation  When hernia contents – especially bowel – become stuck so tightly  that adequate blood flow cannot reach these contents  Causes necrosis (death) of the strangulated contents  Eventually results in perforation, peritonitis, sepsis, and death  Requires EMERGENT surgery
  27. 27. Emergency Surgery Strangulated Hernia: NO TAXIS 1-Fever 2-Leukocytosis 3- Hemodynamic instability 4- Tender and warm hernia contents 5- Erythema in hernial sac Important Point: Before surgery Serum and electrolytes, IV Antibiotics, and NG Tube
  28. 28. Recurrence  Depends on: 1-Patient condition: Nutrient deficiency, Immune deficiency, Diabetes, Steroid use, Smoking 2-Surgical Technique: Inexperienced surgeon, Not fixing the mesh, a Small mesh 3-Tissue: Infection, Tension, Ischemia To reduce recurrence use a mesh
  29. 29. Diagnosis of Recurrence  Bulging  Can have no bulging or mass and still suspect recurrence Sonography, CT, or MRI  DDX of hernia recurrence: 1-Cord lipoma 2-Seroma 3-Weakness of external oblique muscle 4-Cough
  30. 30. Complications of Hernia Surgery 1-Pain 2-Spermatic Cord Damage and Ischemic Orchitis 3-Vas deferans cut 4-Wound infection 5-Seroma 6-Urinary Retention
  31. 31. Sportsman’s Hernia  Occult hernia, pubic pain in sportsmen, sportsmen’s hernia Due to repetitive movement in lower extremity such as skiing, hockey, or American football, usually hernia is not found in physical exam other than the time of surgery.  Symptoms: Acute or chronic pain that gets worse with movement, coughing or sneezing and can reduce the sportsman’s function. In the physical exam no bulging or evidence of hernia is seen and pain and tenderness in the inguinal canal and the external ring is present.  Diagnosis: Best choice is MRI.  Treatment: Conservative, if after 6-8 weeks fails surgery inguinal canal repair.
  32. 32. Pediatric Hernia  Prevalence in children 0.8-44 % and in 10% bilateral.  Prevalence of hernia is higher in, premature and LBW and on the right side.  Hernia is more likely indirect in children.  Diagnosis: Made by observation and during crying.  DDx: UDT, Testicular Tumor, Hydrocele, Varicocele  Treatment: to some extent emergency even if with no symptoms. In premature neonates inguinal hernia repair before hospital discharge.  Surgery Herniotomy (Cut in the inguinal area)  Important Point: Method of exploring the opposite side is somewhat controversial. Now laparascopy is mostly used. But sonography has also been used.
  33. 33. Hernia in cicatrice  Occur mostly after laparotomy in the middle line  It also occut after laparoscopic operations
  34. 34. Hernia in cicatrice
  35. 35. Hernia in cicatrice
  36. 36. Hernia in cicatrice
  37. 37. Types of reconstruction  Mesh onlay  Mesh Sublay  Plug in  IPOM – laparoscopic - open
  38. 38. Hiatal hernia  It mostly occurs when the upper part of stomach pushes through an opening in diaphragm and up in to the chest.  Other side it can also happened by a protrusion of stomach through a tear or weakness in the diaphragm
  39. 39. Hiatal hernia  Normally, the esophagus or food tube passes down through the chest, crosses the diaphragm, and enters the abdomen through a hole in the diaphragm called the esophageal hiatus. Just below the diaphragm, the esophagus joins the stomach.
  40. 40. Hiatal hernia  There are 2 types of hiatal hernia  Sliding hiatal hernia: - The sliding type, as its name implies, occurs when the junction between the stomach and esophagus slides up through the esophageal hiatus during moments of increased pressure in the abdominal cavity. When the pressure is relieved, the stomach falls back down with gravity to its normal position. Approximately 90% of all hiatal hernias are the sliding type.
  41. 41. Hiatal hernia  Paraesophageal hiatal hernia  In paraesophageal hiatal there is no sliding up and down. A portion of the stomach remains stuck in the chest cavity.  These hernias remain in the chest at all times.  This type is less common
  42. 42. Hiatal hernia  Increased pressure within the abdomen caused by:  Heavy lifting or bending over.  Frequent or hard coughing.  Hard sneezing.  Pregnancy and delivery.  Vomiting.  Constipation.  Obesity.
  43. 43. Hiatal hernia – Clinical Manifestation  The patient with sliding hernia may have,  Heart burn  Regurgitation and  Dysphagia but at least 50% are Asymptomatic.  The patient with paraoesophageal hernia usually feels a sense of fullness after eating or may be asymptomatic.
  44. 44. Hiatal hernia - treatment  Medical treatment for hiatal hernia may include prescription- strength antacids & PPIs  When hernia symptoms are severe and chronic acid reflux is involved, surgery is sometimes recommended,  the surgical procedure used is called Nissen fundoplication. (also you can make Toupet, Dor)  In fundoplication, the gastric fundus(upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid.