is defined as protrusion of whole or part of a viscus through the wall that contains it.
this term can also be applied to protrusion of muscle through its fascial covering or brain through fracture skull or through foramen magnum into the spinal canal.
Most commonest type of hernia is protrusion of viscus or part of it through the abdominal wall.
There are different type of hernia some of common types are
1. Inguinal hernia, its again divided into 2 types direct and indirect inguinal hernia.
2. Femoral hernia
3. umbilical hernia
4. Incisional hernia
5. Epigastric hernia
some less common varieties are
1. Obturator hernia
2. lumber hernia
3. Gluteal hernia
4. Spigelian hernia
5. Para-umbilical hernia
Causes : causes include any condition that increase the intra abdominal pressure.
eg: Obesity , heavy weight lifting , severe cough , any chronic lung disease , fluid in the abdominal cavity , difficulty in the passage of urine and stool etc
parts of hernia:
covering
sac
content
Sac: sac is mostly the diverticulum of peritoneum its composed of mouth neck body and a fundus.
if the sac is direct the neck is going to be wide, but in case of indirect inguinal hernia the neck is going to be narrow and there is increase chance of strangulation which can lead to ischemia and necrosis, in case of direct and incisional hernia no neck is present.
sometime there is no sac present like in case of Epigastric hernia.
Covering: covering is composed of the layers of abdominal wall through which the sac passes.
content of sac: the content of sac can be of different type depending on the part of abdomen that is herniated like it could be a Omentocele (omentum), Enterocele ( intestine), Richter hernia ( part of wall of gut) little's hernia ( meckel's diverticulum).
Classification:
1.Reducible: its means that the content can be returned into the abdominal cavity by laying down but sac remain in its position. normally an uncomplicated hernia is reducible.
2.Irreducible : in this type hernia content can't be returned to abdominal cavity by laying down but there is no other complication. Irreducibility is mostly due to either the adhesion of content to each other or to the sac or due to adhesion of one part of the sac to other part etc.
mostly student confused this type with strangulated hernia because strangulated hernia is also irreducible.
3.Obstructed: in this type irreducibility is there but obstruction of intestine is also there due to occlusion of bowel lumen , but the blood supply is not compromised. This type of hernia produce severe colicky pain abdominal distension vomiting and step ladder peristalsis.
mostly obstruction is due to narrow neck, irreducibility or due to present of too many content in the sac.
4.Strangulated hernia: this is emergency situation in this type not only irreducibility and obstruction is there but also the blood supply is also compromised. commonly occur in femoral and indirect inguinal hernia. initially the venous return is occluted lead to part of the gut congested that lead to the congestion of arteries and perforation of bacteria lead to gangrene. The content of blood decomposed in which gram negative bacteria multiply they produce Endotoxin that result in endotoxin shock, due to perforation peritonitis can also occur. patient id present with severe sudden pain with features of shock ( feeble pulse , Hypotension ).
Inguinal hernia: inguinal hernia are classified as direct or in direct inguinal hernia,
inguinal hernia re more common in males because they have prominent inguinal canal as compare to females.
Anatomy:
Inguinal ligament: The most superficial muscle in the abdominal wall is External oblique. the lower border of the external oblique aponeurosis forms the inguinal ligament. The aponeurosis folds under itself forming this ligament it extend from anterior superior iliac spine to the pubic tubercle.
Inguinal canal: the inguinal canal is a oblique passage just above and parallel to the inguinal ligament extend from the deep inguinal ring to the superficial inguinal ring, its length is about 4 cm.
Deep inguinal ring: also known as internal inguinal ring. It lies 1.25 cm above the inguinal ligament and lateral to the inferior epigastric vessels midway between the anterior superior iliac spine and the pubic symphysis. It is a U shaped condensation of the Transversalis fascia.
Superficial inguinal ring: It is a triangular opening in the external oblique aponeurosis and is 1.25 cm above the pubic tubercle. the ring is bounded by the superomedial and inferolateral crus. normally it does not admit the tip of the little finger.\
Content of Inguinal canal: the content of the canal are
- Genital branch of genitofemoral nerve.
- Spermatic cord in males.
- round ligament of uterus in females.
- ilio-inguinal nerve passes through the part of the canal.
Anterior wall: is formed by the aponeurosis of the external oblique muscle. It is also reinforced by the lower fibers of the internal oblique, this add the additional covering over the deep inguinal ring.
Posterior wall: is formed by the transversalis fascia and reinforced along its medial one third by the conjoint tendon (combine insertion of the transversus abdominis and internal oblique muscles into pubic crest).
Roof: is formed by the arching fibers of the transversus abdominis and internal ablique muscles.
Floor: is formed by the medial one half of the inguinal ligament. The lacunar ligament reinforces most of the medial part.
Direct Inguinal Hernia: It enter the inguinal canal through the medial half of its week posterior wall Hessesl bach's triangle and become superficial through superficial inguinal ring. it is always acquired and may disrupt the floor of of the inguinal canal.
Boundaries of Hessel Bach's triangle are medially lateral border of the rectus abdominis, laterally inferior epigastric vessels.
Covering of the Hernia: (outside to inside)
Skin, two layers of superficial fascia, external oblique aponeurosis, conjoining tendon fascia transversalis and peritoneum.
Indirect Inguinal Hernia: comes out of the abdominal cavity through the deep inguinal ring transverses all along the inguinal canal and become superficial through the superficial inguinal ring. this the most common type of hernia are more common in younger group. it is more common on right side and bilateral in 30 % of cases. sac is thin neck is narrow and lies lateral to the inferior epigastric vessels. it can be congenital or acquired.
Types:
Complete Hernia:when the sac is patent up to the bottom of the scrotum in males and up to the bottom of labia majora in females.
Incomplete Hernia: the process vaginalis sac is patent up to root of scrotum but it comes out through the siperficial inguinal ring.
Bubonocele: when hernia does not come out of the superficial inguinal ring and limited to the inguinal canal.
Covering of hernia:( inside out)
peritoneum, extera peritoneal tissue, internal spermatic fascia, cremasteric fascia external spermatic fascia and skin.
Femoral Hernia : it is a protusion of extraperitoneal tissue, peritoneum and somtime abdominal content through the femoral canal.
The hernia comes out superficially through the saphenous opening situated 1 and half inches belowand laterally to the pubic tubercle.
Femoral hernia is common in women, right side is affected twice as common as left side, 20%cases the condition is bilateral.
The neck of the femoral hernia is narrow so irreducibility and strangulation is more common, however in women inguinal hernia is the most common hernia followed by Incisional hernia. The 3rd most common hernia is femoral hernia in women.
Femoral Canal: Extend from femoral ring to saphenous ring and it is 1.5 inches below and lateral to the pubic tubercle. the gap is normally about 1.5 cm in length. Which just admints tip of little finger. This lies at the medial extremity of femoral sheath containing the femoral artery and vein.
Boundaries :
Anterior: inguinal ligament.
Medially: Lacunar ligament.
Laterally: femoral vein.
Posteriorly: ligament of cooper, ileopectneal ligament.
Content of femoral canal: include fat fascia and lymph node.
Epigastric Hernia: Protrusion of extra-peritoneal fat and sometimes samall peritoneal sac through a defect in the linea alba.
The main symptoms is epigastric pain and swelling. Pain is located over hernia. It begains after eating probably due to epigastric distension . this type of hernia do not have impulse on coughing and cannot be reduced. 20% of cases hernia are multiple and is more common in man the women.
It is placed somewhere between xiphisternum and umbilicus, most of the time are Asymptomatic pain vomiting nausea and aggravated by eating.
Differential diagnosis include peptic ulcer Gall bladder disease pancreatitis and subcutaneous lipoma.
Incisional Hernia: Also called ventral hernia or postoperative hernia.
Hernia that occur through a weak scar. Injury to motor nerve predisposes hernia formation. This type of hernia is more common in old age and in obese multiparous females with a poor muscle tone .
Vertical incision has got higher chances than horizontal incision. Continues closure got higher chance than interrupted closure. Using absorbable suture material has got higher chances of hernia than does non absorbable sutures. Causes mostly include coughing smoking in postoperative period and constipation.
Clinical features include pain swelling in the scar region impulse on coughing gurgling sound often bowel peristalsis may be visible under skin. Eventually features of irreducibility obstruction and strangulation is seen.
Differential diagnosis includes Tumor endometriosis and Hematoma.
Umbilical Hernia: Appears to be closely related to the umbilicus.
Four definite varieties are seen
Obese women are more commonly affected and risk factors are obesity and pregnancy.
Richter’s Hernia: Only part of circumference of bowel becomes strangulated. It may spontaneously reduce. Features ofintestinalobstruction there will be diarrhea and often blood in stools.
Example includes femoral and obturator hernia.
Little’s hernia: is a type of hernia which contain Mickel’s diverticulum.
INVESTIGATION:
Routine investigation like CBC, urine examination, chest X ray,ECG, USG And PFT may be necessary.
Physical Examination :
Position of patient: first examine the patient in standing position then in supine position.
Inspection:
Swelling: if swelling is present note the shape and size of that swelling. An indirect hernia present as pyriform shape with a stalk it extend down to scrotum or labia majora . A direct hernia is circular in shape. Femoral hernia is spherical in shape and starting from below the inguinal ligament. In uncomplicated hernia the skin should be normal. If strangulation is there that may lead to redness of the skin.
Impulses on coughing: ask the patient to cough and look carful for the swelling momentary bulge may be seen it is almost diagnostic of hernia, which is due to increase intra-abdominal pressure, but if neck of the sac is obstructed then you may not get the expansile cough impulse. A large indirect hernia in scrotum may push the penis to opposite direction.
Palpation: Examine the swelling by palpation. A swelling in scrotum or labia majora give the diagnosis of inguinal hernia, a swelling in the groin region give a clue toward femoral hernia. Inguinal hernia always present above the inguinal ligament and medial to pubic tubercle whereas a femoral hernia always located below the inguinal ligament and lateral to the pubic tubercle. The swelling is going to be granular if hernia contains omentum (omentocele ). It is elastic if it contains intestine ( enterocele). A strangulated hernia is tender on palpation.
Zieman’s Technique:
To differentiate whether the case is of direct, indirect or femoral hernia we can use Zieman’s Technique.
This technique is applied only when there is no swelling or after the hernia has been reduced.
Method: Place the index finger over the deep inguinal ring the middle finger on the superficial inguinal ring and the ring finger over the saphenous opening and ask the patient to cough. When impulse is felt on the index finger the case is one of indirect hernia, when impulse isfelt on the middle finger the case is one of direct hernia and when it is felt on the ring finger the case is one of femoral hernia.
Ring occlusion test:
To differentiate an indirect hernia from a direct hernia.
Method: test is performed in standing position and hernia must be reduced.
A thumb is pressed on the deep inguinal ring the patient is ask to cough. A direct hernia will show a bulge medial to the occluding finger but an indirecthernia will not find access. In case of femoral hernia if pressure is exerted over femoral canal the hernia will not be able to come out.
Percussion: A reconant note over a hernia means it contain Intestine (enterocele) whereas if note is dull it contains omentum (omentocele)or fatty tissue.
Auscultation: This does not give much clue.
Treatment:
1)Herniotomy:
2)Herniorrhaphy: it includes 2 types:
Boundaries of Hessel Bach's triangle are medially lateral border of the rectus abdominis, laterally inferior epigastric vessels.
Covering of the Hernia: (outside to inside)
Skin, two layers of superficial fascia, external oblique aponeurosis, conjoining tendon fascia transversalis and peritoneum.
Indirect Inguinal Hernia: comes out of the abdominal cavity through the deep inguinal ring transverses all along the inguinal canal and become superficial through the superficial inguinal ring. this the most common type of hernia are more common in younger group. it is more common on right side and bilateral in 30 % of cases. sac is thin neck is narrow and lies lateral to the inferior epigastric vessels. it can be congenital or acquired.
Types:
Complete Hernia:when the sac is patent up to the bottom of the scrotum in males and up to the bottom of labia majora in females.
Incomplete Hernia: the process vaginalis sac is patent up to root of scrotum but it comes out through the siperficial inguinal ring.
Bubonocele: when hernia does not come out of the superficial inguinal ring and limited to the inguinal canal.
Covering of hernia:( inside out)
peritoneum, extera peritoneal tissue, internal spermatic fascia, cremasteric fascia external spermatic fascia and skin.
Femoral Hernia : it is a protusion of extraperitoneal tissue, peritoneum and somtime abdominal content through the femoral canal.
The hernia comes out superficially through the saphenous opening situated 1 and half inches belowand laterally to the pubic tubercle.
Femoral hernia is common in women, right side is affected twice as common as left side, 20%cases the condition is bilateral.
The neck of the femoral hernia is narrow so irreducibility and strangulation is more common, however in women inguinal hernia is the most common hernia followed by Incisional hernia. The 3rd most common hernia is femoral hernia in women.
Femoral Canal: Extend from femoral ring to saphenous ring and it is 1.5 inches below and lateral to the pubic tubercle. the gap is normally about 1.5 cm in length. Which just admints tip of little finger. This lies at the medial extremity of femoral sheath containing the femoral artery and vein.
Boundaries :
Anterior: inguinal ligament.
Medially: Lacunar ligament.
Laterally: femoral vein.
Posteriorly: ligament of cooper, ileopectneal ligament.
Content of femoral canal: include fat fascia and lymph node.
Epigastric Hernia: Protrusion of extra-peritoneal fat and sometimes samall peritoneal sac through a defect in the linea alba.
The main symptoms is epigastric pain and swelling. Pain is located over hernia. It begains after eating probably due to epigastric distension . this type of hernia do not have impulse on coughing and cannot be reduced. 20% of cases hernia are multiple and is more common in man the women.
It is placed somewhere between xiphisternum and umbilicus, most of the time are Asymptomatic pain vomiting nausea and aggravated by eating.
Differential diagnosis include peptic ulcer Gall bladder disease pancreatitis and subcutaneous lipoma.
Incisional Hernia: Also called ventral hernia or postoperative hernia.
Hernia that occur through a weak scar. Injury to motor nerve predisposes hernia formation. This type of hernia is more common in old age and in obese multiparous females with a poor muscle tone .
Vertical incision has got higher chances than horizontal incision. Continues closure got higher chance than interrupted closure. Using absorbable suture material has got higher chances of hernia than does non absorbable sutures. Causes mostly include coughing smoking in postoperative period and constipation.
Clinical features include pain swelling in the scar region impulse on coughing gurgling sound often bowel peristalsis may be visible under skin. Eventually features of irreducibility obstruction and strangulation is seen.
Differential diagnosis includes Tumor endometriosis and Hematoma.
Umbilical Hernia: Appears to be closely related to the umbilicus.
Four definite varieties are seen
- Exomphalos : abdominal content are protruded into the umbilical cord being covered by a transparent membrane.
- Congenital umbilical hernia.
- Acquired umbilical hernia.
- Para-umbilical hernia.
Obese women are more commonly affected and risk factors are obesity and pregnancy.
Richter’s Hernia: Only part of circumference of bowel becomes strangulated. It may spontaneously reduce. Features ofintestinalobstruction there will be diarrhea and often blood in stools.
Example includes femoral and obturator hernia.
Little’s hernia: is a type of hernia which contain Mickel’s diverticulum.
INVESTIGATION:
Routine investigation like CBC, urine examination, chest X ray,ECG, USG And PFT may be necessary.
Physical Examination :
Position of patient: first examine the patient in standing position then in supine position.
Inspection:
Swelling: if swelling is present note the shape and size of that swelling. An indirect hernia present as pyriform shape with a stalk it extend down to scrotum or labia majora . A direct hernia is circular in shape. Femoral hernia is spherical in shape and starting from below the inguinal ligament. In uncomplicated hernia the skin should be normal. If strangulation is there that may lead to redness of the skin.
Impulses on coughing: ask the patient to cough and look carful for the swelling momentary bulge may be seen it is almost diagnostic of hernia, which is due to increase intra-abdominal pressure, but if neck of the sac is obstructed then you may not get the expansile cough impulse. A large indirect hernia in scrotum may push the penis to opposite direction.
Palpation: Examine the swelling by palpation. A swelling in scrotum or labia majora give the diagnosis of inguinal hernia, a swelling in the groin region give a clue toward femoral hernia. Inguinal hernia always present above the inguinal ligament and medial to pubic tubercle whereas a femoral hernia always located below the inguinal ligament and lateral to the pubic tubercle. The swelling is going to be granular if hernia contains omentum (omentocele ). It is elastic if it contains intestine ( enterocele). A strangulated hernia is tender on palpation.
Zieman’s Technique:
To differentiate whether the case is of direct, indirect or femoral hernia we can use Zieman’s Technique.
This technique is applied only when there is no swelling or after the hernia has been reduced.
Method: Place the index finger over the deep inguinal ring the middle finger on the superficial inguinal ring and the ring finger over the saphenous opening and ask the patient to cough. When impulse is felt on the index finger the case is one of indirect hernia, when impulse isfelt on the middle finger the case is one of direct hernia and when it is felt on the ring finger the case is one of femoral hernia.
Ring occlusion test:
To differentiate an indirect hernia from a direct hernia.
Method: test is performed in standing position and hernia must be reduced.
A thumb is pressed on the deep inguinal ring the patient is ask to cough. A direct hernia will show a bulge medial to the occluding finger but an indirecthernia will not find access. In case of femoral hernia if pressure is exerted over femoral canal the hernia will not be able to come out.
Percussion: A reconant note over a hernia means it contain Intestine (enterocele) whereas if note is dull it contains omentum (omentocele)or fatty tissue.
Auscultation: This does not give much clue.
Treatment:
1)Herniotomy:
2)Herniorrhaphy: it includes 2 types:
- Bassini's Herniorrhaphy (now a days we use modified bassini's herniorrhaphy)
- Shoulder Repair
