3. INTRODUCTION
The abdominal wall has a complex
structure and many of the surgical
conditions affecting it are
embryological in origin
It developed laterally from the
vertebral coloumn,later than the
intestinal tract and ultimately fuses in
the midline to form the linea alba.
4. o This is pierced at the umbilicus by
the umbilical cord which in early
embryological life contain the yolk
sac and the entire gut.
o The testes develop in the
peritoneum of the posterior
abdominal wall and migrate through
the muscle just above the inguinal
lig. into the scrotum followed by the
spermatic cord.
5. RELEVANT ANATOMY
Anterior abd wall muscles
embryologically mesodermal
Muscles ;external oblique,internal
oblique,transversus abdominis,rectus
abdominis
Innervation:external oblique and
rectus abdominis T7-T12,Internal
oblique and transversus abdominis
same as above plus the iliohypogastri
and ilioinguinal nerve L1
6. Blood supply:intercoastal,epigastric
vessels inferior and superior,and lumbar
deep circumflex iliac arteries,the veins
runs correspondingly
Lymphatic drainage:superficial tissues
drain in quadrants to the pectoral group
of axillary lymph nodes above the
umblicus,below to the superficial inguinal
lymph nodes,deeper parts above
umblicus to the mediastinal
nodesmbelow to the external iliac and
para aortic nodes.
7. A hernia is a protrusion of a viscus or
part of a viscus through a weakness or
abdominal opening in the wall of its
containing cavity
It is the commonest condition
encountered in surgical practice. It is
the commonest cause of intestinal
obstruction. It affects both sexes and
also affect all age groups
10. AETIOLOGY
Predisposing and precipitating factors
PREDISPOSING FACTORS
(1)defect/weakness of the wall of the
abdominal cavity e.g embryological
defects
umbilical,diaphragmatic,persistent
processus
(2)defects through normal anatomical
passage e.g deep inguinal
ring,hasselbacks triangle,lumbar
11. (3)Weakness caused by risk factors:
such as ageing,infection,multiple
pregnancy,obesity,nerve
injury(ilioinguinal)straining
(4)Biological risk factors:defective
collagen formation as in alpha 1
antitrypsin deficiency
13. Composition of an hernia
THE SAC
it is a diverticulum of peritoneum
consisting of mouth, neck, body, and
fundus
The diameter of the neck is important
bcos strangulation of bowel is a likely
complication where the neck is narrow
as in femoral and paraumbilical
hernias
14. THE COVERINGS
Derived from the layers of the abdominal
wall through which the sac passes
Contents ;this may be
omentum(omentocoele),
intestine(enterocoele), a portion of the
circumference of the intestine(Richter’s
hernia), portion of the bladder, ovary with
or without the corresponding fallopian
tube, meckel’s diverticulum(Littre’s
hernia), apendix(amyands hernia)or fluid
15. CLASSIFICATION
1. Reducible: the hernia either reduces itself
when the patient lies down or can be
reduced by the patient or the physician. A
reducible hernia impart an expansible
impulse on coughing
2. Irreducible: in this case, the content cannot
be returned to the abdomen.Usually,due to
adhesions btw the sac and its contents or
from overcrowding within the sac.
Irreducibility without symptoms is almost
diagnostic of An omentocoele esp. in femoral
or inguinal hernia. Any degree of irreducibility
predisposes to strangulation
16. 3) Obstructed hernia: this is an irreducible hernia
containing intestine which is obstructed from
within, or without, but there is no interference
with bld supply to the bowel
4) Strangulated hernia: this occur when an
obstructed hernia is cut short of bld supply
rendering the content ischeamic.Femoral hernia
is more likely to strangulate than inguinal hernia
bcos of the narrowness of the neck and its rigid
surrounds.
5) Incarcerated hernia: means that contents are
literally imprisoned in the sac(usually by
adhesions) but are alive and functioning
normally. An incarcerated hernia is not tender
17. INGUINAL HERNIA
INGUINAL CANAL
This is an oblique passage directed
downwards, medially and forwards in the lower
part of the ant. Abdominal wall above the groin
through wish passes the spermatic cord,
testicular vessels.ilio inguinal nerve and the
genital branch of the genito femoral nerve and
the round lig. in the female
Embryologically,it is formed by the passage of
the gubernaculum testis which makes it
possible for the testis and spermatic cord to
pass from the abdomen to the scrotum in the
male and the round lig. in the female
It is about 4cm long in an adult
18. it begins with the internal inguinal ring
which is u-shaped, obliquely placed
evagination or opening in the transversalis
fascia, lies about 1.25cm above and
perpendicular to the mid inguinal point i.e a
point midway btw the ant. Sup. Iliac spine
and the pubic symphysis.The opening is
directed upwards and outwards and it is
about 12-20mm and 6-10mm wide
It is bounded above by the lower arching
fibres of the int. Oblique and below, and
medially by the inf. epigastric vessels
19. The ant. Wall of the inguinal canal is formed by
the ext. oblique aponeurosis and additionally in
the lat. Part by the muscular fibres of the int.
oblique as it takes origin from the inguinal lig.
And arches over the cord to lie above it.
The posterior wall is formed by the
transversalis fascia reinforced superficially by
aponeurotic fibres from the transversus
abdominis and buttressed in the med. Half by
the conjoint tendon(which is the fused common
insertion of the transversus abdominis and int.
Oblique muscles into the pubic crest)
20. the triangular part of the posterior wall
bounded laterally by the inf. Epigastric
artery which runs upwards and medially,
medially by the lateral border of the rectus
sheath, and inferiorly by the inguinal lig. Is
k.a hesselbach’s triangle; the fascia here is
not supported and forms a weak area. Its
fibres may rupture and allow the formation
of a direct inguinal hernia. It may also bulge
and form a diffuse or wide necked direct
hernia
21. The floor of the canal is formed by the
inguinal lig. Which is formed by the
reflected edge of the aponeurotic portion of
the ext. Oblique as it is inserted into the
pubic crest
And the roof by the arched lowest muscular
fibres of the internal oblique.
22. ~1. External oblique
aponeurosis
2. External ring
3. Ilio-lnguinal nerve
4. Pubic tubercle
5. Spermatic cord
6. Anterior superior iliac spine
7. Femoral artery
8. Femoral vein
9. Femoral canal
L0. Internal ring
11. Inferior epigastric
vessels
U. Internal oblique
133Transversalis fascia
K Conjoint tendon
IS. Rectus abdominis (lying
behind the conjoint tendon)
16. Adductor longus
17. m e u s =v
19. a l t o r i ~
23. INGUINAL HERNIA
Occurs in the inguinal canal
It is the commonest hernia in both sexes and
account for about 95% of hernia in the male
and 40-50% in the female
It may be indirect(oblique) or direct type. An
indirect type enters the inguinal canal through
the int. Inguinal ring and passes obliquely
downwards and medially into the canal. It may
therefore pass through the ext. Inguinal ring to
enter the scrotum or labium majus
Direct inguinal hernia on the other hand enters
the canal directly forwards through the post.
wall in the triangle of hesselbach and so
cannot normally pass through the ext. Inguinal
ring
24. Indirect inguinal hernia occurs in all age
groups. In the male, it is twice as common
on the right than on the left probably due to
the late descent of the testis on that side
with resulting increased abnormalities. In
the female, it is equally common on both
sides. Almost 10% are bilateral.
This is the most common of all forms of
hernia. It is most common in the young
whereas a direct hernia is most common in
middle life or after
25. Types of oblique inguinal
hernia
Three types of oblique inguinal hernia occur:
1. Bubonocele. When the hernia is limited to
the inguinal canal.
2. Funicular. The processus vaginalis is closed
just above the epididymis. The contents of
the sac can be felt separately from the testis,
which lies below the hernia.
3. Complete (syn. scrotal). A complete inguinal
hernia is rarely present at birth but is
commonly encountered in infancy. It also
occurs in adolescence or adult life, The
testis appears to lie within the lower part of
the hernia
26. Direct inguinal hernia
Between 10 and 15 per cent of inguinal hernias are
direct. Over half of these are bilateral.
A direct inguinal hernia is always acquired. The sac
passes through a weakness or defect of the
transversalis fascia in the posterior wall of the inguinal
canal.
In some cases the defect is small and closely related to
the insertion of the conjoint tendon, while in others there
is a generalized bulge.
Often the patient has poor lower abdominal
musculature, as shown by the presence of elongated
bulging (Malgaigne’s bulges). Women practically never
develop a direct inguinal hernia (Brown).
Predisposing factors are a chronic cough, straining, and
heavy work. Damage to the ilioinguinal nerve (e.g. by
previous appendicectomy) is another known cause.
27. Direct hernias sometimes attain a large size and
descend into the scrotum but this is rare.
In contradistinction to an oblique inguinal hernia, a
direct inguinal hernia lies behind the spermatic cord.
The sac is often smaller than the hernia mass would
indicate, the protruding mass mainly consisting of
extraperitoneal fat.
As the neck of the sac is wide, direct inguinal hernias
rarely strangulate
Funicular direct Inguinal hernia (syn. prevesical hernia)
is a narrow-necked hernia of prevesical fat and a
portion of the bladder that occurs through a small oval
defect in the medial part of the conjoined tendon just
above the pubic tubercle.
It occurs principally in elderly males, and occasionally it
becomes strangulated. Unless there are definite contra-
indications, operation should always be advised
28. Clinical features
The main symptoms are:
1. Swelling in the groin which may or may not
disappear when it is pushed back or the
patient lies down. It may at first only
appear on coughing or straining, but as it
gets bigger, it appears when the patient
stands up and may also go into the
scrotum.
2. Pain
3. At later stage, it can present with
constipation, vomiting, intestinal
obstruction leading to abdominal
distension and may go into shock
29. examination
Features to be determined are:
1) Position: this is to distinguish btw direct and
indirect hernia
2) Colour: skin colour over the hernia should be
normal reddening of the skin indicates the
hernia is strangulated.
3) Temperature: should be normal except the
hernia is strangulated
4) Tenderness: e.g strangulated hernia
5) Size: inguinal hernia varies from very small
bulges to very large masses sometimes
descending to the level of the knee. The larger
the hernia is the more likely it is to irreducible
30. 6) surface: vary according to the nature of the contents,
but it is usually smooth
7)composition: hernia that contain gut should be soft,
resonant, and fluctuant, and you may be able to hear
bowel sounds. If the content are tense, the hernia will
feel hard. Hernia containing omentum feels
firm(rubbery)non-fluctuant and dull to percussion.
8)cough impulse: a hernia will nearly always become
larger and more tense in all direction during coughing
which is referred to as expansible cough impulse.
9 compressibility: a hernia can be compressed by steady
pressure but it will not expand immediately the
compression is released unless some forces such as
gravity or coughing forces it out.
10 Reducibility? Possibility of returning the contents of the
hernia to their anatomical site.
31. Treatment.
Operative repair is the treatment as there is
always risk of strangulation.
Operative Treatment
Indirect inguinal hernia.
There are 3 essential requirements:
1. Excision of the hernial sac at the neck
(herniotomy).
2. Tightening of the internal inguinal ring around
the
spermatic cord.
3. Repair of the weak posterior inguinal wall in
those
aged over 15 (hernioraphy).
32. Numerous methods of repair have been devised. These
can be categorized as follows:
1. Open suture methods (Bassini repair and its variants)
involve the use of sutures to approximate the conjoint
tendon to the inguinal ligament.
2. Open mesh (Lichtenstein) method involves the use of
synthetic mesh to bridge the gap between the conjoint
tendon and the inguinal ligament.
3. Laparoscopic method. This involves the insertion of
trocars through three or four small incisions into the
abdomen after the abdomen has been inflated with
carbon dioxide to improve access and visibility. Repair
is done by the use of a mesh which is secured in place
by staples or sutures by means of the laparoscope and
other surgical instruments
33. Post-operative Complications after Herniorrhaphy
1. Retention of urine.
2. Hematomas. If slight, it is re-absorbed. If considerable,
it may require evacuation.
3. Scrotal swellings. In a complete inguinal hernia,
blood or fluid may collect in the tunica resulting in a
haematocele or hydrocele. Scrotal support is provided
and most cases resolve, but there may be a residual
swelling.
4. Infection of the wound. It may be trivial - a stitch
abscess which settles quickly after removal of the
affected suture, or infected subcutaneous hematoma or
deep-seated requiring drainage and often resulting in
prolonged discharging sinus which may necessitate
removal of non-absorbable sutures
34. 5. Testicular infarction may occur due to damage to
the testicular vessels or too much tightening of
the internal inguinal ring around the cord.
Orchidectomy may become necessary.
6. Testicular atrophy from the same causes as (5)
and the use of adrenaline-containing local
anesthetic.
7. Pain in the wound is a disability in a few. It may
be due to strangulation of nerves in the wound.
8. Impotence. In old patients the operation may
precipitate impotence.
9. General post-operative complications such as
chest infection and deep venous thrombosis may
occur.
10. Recurrence
35. Differential diagnosis
1) Femoral hernia
2) Vaginal hydrocoele
3) Infantile hydrocoele
4) Encysted hydrocoele of the cord
5) Undescended testis
6) Cyst of the epididymis
7) Inguinal lymphadenopathy
8) Sebaceous cyst
9) Lipoma
10)Cyst of the canal of nuck(in females)
36. FEMORAL HERNIA
Femoral hernia occurs more frequently in Europe and
America, where it accounts for 5% of all hernia, than in
Black Africa where it is responsible for only about 2%.
It is twice as common in females and accounts in North
America and Europe for 30-35% of all female hernia
and 2% of all male hernia.
In Black Africa, the corresponding proportions are 9%
and 1 % respectively. In women, it is more common in
the multiparous and the elderly than in the nulliparous
and the young.
The overriding importance of femoral hernia lies in the
facts that it cannot be controlled by a truss, and that of
all hernias, it is the most liable to become strangulated
mainly because of the narrowness of the neck of the
sac and the rigidity of the femoral ring.
37. Surgical anatomy
The femoral canal occupies the most medial
compartment of the femoral sheath, and it extends from
the femoral ring above to the saphenous opening
below.
It is 1.25cm long, and 1.25 cm wide at its base, which
is directed upwards.
The femoral canal contains fat, lymphatic vessels, and
the lymph node of Cloquet.
The femoral ring is bounded:
• anteriorly by the inguinal ligament;
• posteriorly by Astley Cooper’s (iliopectineal) ligament,
the pubic bone, and the fascia over the pectineus
muscle;
• medially by the concave knife-like edge of Gimbemat’s
(lacunar) ligament, which is also prolonged along the
iliopectineal line as Astley Cooper’s ligament;
• laterally by a thin septum separating it from the femoral
vein.
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38. Aetiology and Pathology
Femoral hernia is due essentially to stretching,
weakness and breach of the transversalis fascia near
the femoral ring from increased intra-abdominal
pressure
In people in whom the conjoint tendon is attached only
to the pubic crest and the medial part of the pectineal
line and not to the entire pectineal line, most of the
lower posterior inguinal wall is unprotected and the
transversalis fascia in that part is liable to be stretched
and weakened
Furthermore, the femoral ring in such people is wider
than normal, Sustained increased intra-abdominal
pressure such as occurs in pregnancy is, therefore,
more likely to force the relatively unsupported
peritoneum, extraperitoneal fat and fascia into the
femoral canal
39. Pressure of the neck of the sac leads to aggregation of
the fascia fibers forming the medial border of the ring
and their subsequent adherence to the firm crescenteric
lateral edge of the lacunar ligament
The lacunar ligament thus becomes the medial border
of the neck of the sac and is most often the cause of its
strangulation.
The sac, covered with extra peritoneal and connective
tissue, passes through the femoral ring into the femoral
canal emerging with continued progression through the
saphenous opening.
It then turns upwards in the subcutaneous tissue
because of the fusion of the superficial and deep
fasciae and may even come to lie in front of, or above,
the inguinal lig and can be confused with an inguinal
hernia.
40. The contents are commonly omentum and
small intestine, the bladder, colon, appendix
and even uterine adnexae may be found.
Occasionally, the neck of the sac is occluded
by adhesions or omentum and an encysted
hydrocele of the sac results.
At times only the protruding extraperitoneal
fat is in the femoral canal.
Because of the very narrow constricting ring
at the neck, the sharp medial margin of the
femoral ring, and the narrowness of the neck
of the sac.
A femoral hernia is more liable to
strangulation than any other hernia
41. Clinical features
The main symptoms are:
1. A swelling in the groin.
2. Discomfort or dragging pain in the
groin. When strangulation occurs,
acute pain in the hernia and, if it
contains bowel, colicky abdominal
pain with associated vomiting and
absolute constipation supervene
42. On examination
1. The swelling is below the inguinal
ligament i.e. the neck is below and
lateral to the pubic tubercle.
2. It has a visible and palpable cough
impulse; but this is not always present as
the narrow neck may be plugged with
omentum or the lump may consist of
extraperitoneal tissue.
3. The lump may not disappear when the
patient lies down and it may be reducible
or irreducible.
43. treatment
Operative repair is always undertaken
because of the high risk of strangulation.
Operation: The 2 basic requirements are:
1. Excision of sac.
2. Closure of the femoral ring through which the
sac enters the femoral canal.
There are 3 main meth& of femoral hernia
repair.
1. The high approach: pre-peritoneal: McEvedy.
2. The transinguinal approach: Lotheirsen.
3. The low approach: Lockwood.
Other methods include the use of prosthetic
mesh and laparoscopic techniques
44. UMBILICAL HERNIA
Exomphalos (syn. omphalocele) occurs once in every 6000
births; it is due to failure of all or part of the midgut to return to
the coelom during early fetal life. Sometimes a large sac
ruptures during birth. When the sac remains unruptured, it is
semi translucent , and although very thin it consists of three
layers — an outer layer of amniotic membrane, a middle layer
of Wharton’s jelly, and an inner layer of peritoneum.
There are two varieties of exomphalos:
Exomphalos minor. The sac is relatively small and to its
summit is attached the umbilical cord, Inadvertently loop of
small intestine or a Meckels diverticulum can be included in
the ligature applied to the base of an umbilical cord
containing this protrusion
Exomphlos major. The umbilical cord is attached to the
inferior aspect of the swelling, which contains small and large
intestine, and ,nearly always a portion of the liver, Half the
cases belong to this group.
45. Treatment
Exomphalos minor: It is necessary only to
twist the cord, so as to reduce the contents of
the sac through the narrow umbilical opening
into the peritoneal cavity, and to retain them
by firm strapping. Despite a seropurulent
discharge on no account must the strapping
be removed for fourteen days.
Exomphalos major: Operation within the first
few hours of life is the only hope, otherwise
the sac will burst. To prevent further
distension of the contents of the sac, the
infant should not be fed. A few newborn
infants with a ruptured sac have survived
following immediate operation and antibiotic
therapy
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46. Paraumbilical hernia of adults
(syn. supra- or infraumbiical
hernia). In adults the hernia does not occur through the
umbilical scar. It is a protrusion through the linea
alba just above or sometimes just below the
umbilicus.
As it enlarges, it becomes rounded or oval in
shape with a tendency to sag downwards.
Paraumbilical hernias can become very large.
The neck of the sac is often remarkably narrow
as compared with the size of the sac and the
volume of its contents, which consist of greater
omentum often accompanied by small intestine
and, alternatively or in addition, a portion of the
transverse colon.
In long-standing cases the sac sometimes
becomes loculated due to adherence of
omentum .
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47. Clinical features
Women are affected five times more frequently
than men. The patient is usually between the
ages of 35 and 50.
Increasing obesity, with flabbiness of the
abdominal muscles, and repeated pregnancy’ are
important antecedents.
These hernias soon become irreducible because
of omental adhesions within the sac. A large
umbilical hernia causes a local dragging pain by
its weight.
Gastrointestinal symptoms are common and are
probably due to traction on the stomach or
transverse colon. Often there are transient
attacks of intestinal colic due to sub acute
intestinal obstruction.
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48. Treatment
Untreated, the hernia increases in size, and
more and more of its contents become
irreducible.
Eventually, strangulation may occur.
Therefore without undue delay operation
should be advised in nearly all cases. If the
patient is obese and the hernia is
symptomless, operation can be postponed
with advantage until weight has been
reduced. When small, the deficiency can be
closed by a simple repair using interrupted
unabsorbable sutures: for larger hernias, a
Mayo technique is advisable
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49. Epigastric hernia
A midline epigastric hernia (syn. fatty hernia of the linea
alba) occurs through the linea alba anywhere between
the xiphoid process and the umbilicus, usually midway
between these structures.
Such a hernia commences as a protrusion of extra
peritoneal fat through the linea alba, where the latter is
pierced by a small blood vessel. Often more than one
hernia is present
A swelling the size of a pea consists of a protrusion of
extra peritoneal fat only (fatty hernia of the linea alba). If
the protrusion enlarges, it drags a pouch of peritoneum
after it, and so becomes a true epigastric hernia.
The mouth of the hernia is rarely large enough to
permit a portion of hollow viscus to enter it;
consequently, either the sac is empty or it contains a
small portion of greater omentum.
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50. Epigastric hernias are quite common in
children, often accompanying
diversification of the recti: both the
diversification and the hernia undergo
spontaneous cure in many cases.
It is probable that an epigastric hernia is
the direct result of a sudden strain
tearing the interlacing fibers of the linea
alba.
The patients are often manual workers
between 30 and 45 years of age.
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51. Clinical features.
• Symptomless. A small fatty hernia of the linea
alba can be felt better than it can be seen, and
may be symptomless, being discovered only in
the course of routine abdominal palpation.
• Painful. Sometimes such a hernia gives rise to
attacks of local pain (worse on physical exertion)
and also tenderness to touch and tight clothing;
possibly because the fatty contents become
nipped sufficiently to produce partial
strangulation.
•Referred pain (dyspeptic cases). It is not un-
common to find that the patient, who may not
have noticed the hernia, complains of pain
relating to digestion.
52. Treatment
If the hernia is giving rise to
symptoms, operation should be
undertaken.
It is essential to mark the hernia
before the anesthetic is given as it
may be impossible to locate the defect
if the fatty protrusion retracts into the
abdomen.
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53. Incisional hernia
It is a common complication of a weak
laparotomy scar, occurs after 5-10% of
laparotomies. it can occur in any
abdominal incision
It is in many cases due to dehiscence of
the deeper layer of the wound, while the
skin remains intact
As the wound heals herniation becomes
apparent.
It may also follow paired burst abdomen;
about 28% of such patients can develop
inscisional hernia
54. Causes are
Increased intra-abdominal pressure in the post-
operative period from:
a) Abdominal distension e.g. following paralytic ileus or
ascites.
b) Repeated bouts of hiccough or coughing from chest
infection
c) Straining from constipation or urinary difficulty.
Weak wound from delayed or poor healing due to:
a) Hematoma and/or infection
b) Use of catgut sutures for the rectus sheath
c) Poor bld supply from tension in suturing the
wound or re-inscision through scar tissue
d) Placement of drainage tube in the wound
55. Conclusion
It is the commonest condition
encountered in surgical practice. It is
the commonest cause of intestinal
obstruction. It affects both sexes and
also affect all age groups
Sound knowledge of this conditions is
thus important to pick them before
complications sets in.
