Hernias (as an inguinal hernia, umbilical hernia, or spigelian hernia) in which an anatomical part (as a section of the intestine) protrudes through an opening, tear, or weakness in the abdominal wall musculature.

1. HERNIA
By
SHAHRUKH SULTAN AHMED
KYIV MEDICAL UNIVERSITY
Department of Surgery

2. Topics to Be Covered
• Definition of Hernia
• Parts of Hernia
• Classifications of Hernia
• Etiology, Development & Treatment of Different Types of Hernias
• Acute & Chronic Complications of Hernia

3. Definition
• Hernia means “ To Protrude “.
• Hernia is defined as an abnormal protrusion of a viscus or a part
of a viscus through an opening, artificial or natural with a sac,
covering it.

5. Parts of Hernia
Hernia Comprises of :
Covering: Are the layers of Abdominal Wall through which sac passes.
Sac: Is a diverticulum of peritoneum with mouth, neck, body & fundus.
Content: Can be Omentum, Intestine, Ovary Meckel’s Diverticulum

7. Classification : Clinical
• Reducible
• Irreducible
• Obstructed
• Inflamed
• Strangulated

8. Classification : Based on Sites
• COMMON HERNIAS
• INGUINAL ( 73% )
• INCISIONAL
• FEMORAL ( 17% )
• UMBILICAL ( 8.5% )
• EPIGASTRIC

10. INGUINAL HERNIA
• 73% of all Hernias are Inguinal Hernia
• An Inguinal Hernia is a protrusion of abdominal-cavity contents
through the Inguinal canal.
• Male : Female : 20 : 1

11. Surgical Anatomy
• BOUNDARIES OF INGUINAL CANAL
• Anterior: External oblique aponeurosis and a few fibres of the
conjoined muscle (especially of internal oblique) laterally.
• Superior: Arched fibres of the conjoined muscle.
• Inferior: Inguinal ligament and the lacunar ligament on the
medial side (Gimbernat's ligament).
• Posterior: Fascia transversalis and the conjoined tendon medially.

13. SURGICAL ANATOMY
CONTENTS OF INGUINAL CANAL
 Spermatic Cord in Males
 Round Ligament in Females
 Ilioinguinal Nerve

14. Surgical Anatomy
Hesselbach's triangle
• It is bounded
• Medially by lateral border of
Rectus Abdominus Muscle,
• Laterally by inferior epigastric artery and
• Inferiorly by inguinal ligament.

15. CAUSES of INGUINAL HERNIA
• 1. Congenital
Persistent processus vaginalis sac: chief cause of indirect hernia.
• 2. Collagen fibre disorder
• Smoking: Acquired collagen deficiency
• 3. Obesity
• 4. Chronic causes of increased intra-abdominal pressure
• Chronic cough • Chronic constipation • Ascites
• 5. Weakness of conjoined tendon/rupture of a few fibres
• Lifting heavy weight • Post appendicectomy-injury to ilioinguinal nerve.
• Chronic illness/debilitating disease causing weakness of transversalis fascia in the
Hesselbach's area.

16. Classification of Inguinal Hernia
• INDIRECT HERNIA : It comes out through internal ring along with
the cord. It is lateral to the inferior Epigastric Artery.
• DIRECT HERNIA : It occurs through posterior wall of Inguinal Canal
through “HESSELBACH’S TRIANGLE”

17. INDIRECT INGUINAL HERNIA
• Most common type of Hernia : 65%
• More common in younger age group.
• It’s bilateral in 30% cases.
• Sac is thin & Neck is narrow

18. DIRECT INGUINAL HERNIA
• 10 - 15% of Hernias are Direct.
• 50% Direct Hernia occurs bilaterally.
• 35% Inguinal Hernias are Direct.
• Uncommon n Females & Children.
• Its always acquired, due to weakening of posterior wall of
Inguinal Canal.
• Sac is thick with wide neck.
• Occurs through Hesselbach’s Triangle.

20. INVESTIGATIONS
Physical Examination
• 1. Ask the patient to cough-expansile impulse is felt at the root of scrotum.
• 2. Getting above the swelling• should be done in the standing position.
• 3. Reducibility-ask the patient to lie down. If the swelling becomes smaller or
disappears, it is a hernia
• 4. External ring invagination test: On asking the patient to cough, the impulse
touches the pulp of the finger in direct hernia and the tip in indirect hernia
• 5. Internal ring occlusion test: After reducing swelling, on asking patient to cough
a. If impulse and the swelling are seen, it is a direct hernia
b. If the swelling is not seen, it is an indirect hernia.

21. INVESTIGATIONS
• ULTRASOUND: To detect the contents of Hernia & its reducibility.
• MRI : To know the anatomy, helpful in inflamed hernia.
• Chest X-Ray : To rule out chronic bronchitis

22. TREATMENT
• 1. Herniotomy : Excision of the sac alone is done in patients up to
14-16 years of age (children). Hernia occurs due to preformed
sac. Hence, no repair is necessary.

23. TREATMENT
• 2. Herniorrhaphy : It involves a surgeon making a long incision
directly over the hernia then using surgical tools to open the cut
enough to access it. Tissues or a displaced organ are then
returned to their original location, and the hernia sac is removed.

24. TREATMENT
• 3. Hernioplasty : It is the type of hernia repair surgery where a
mesh patch is sewn over the weakened region of tissue

25. FEMORAL HERNIA
• Herniation of intra-abdominal contents through the femoral
canal is described as femoral hernia.
• Commonly the hernia is unilateral, the right side being affected
more often than the left side.
• It is bilateral in about 15-20% of the patients.
• Men : Women – 1 : 2

27. SURGICAL ANATOMY
• Anatomy of Femoral Canal and Femoral Ring
• The femoral canal extends from the femoral ring to the saphenous ring. It is 1.6
inches below and lateral to the pubic tubercle. It is the innermost compartment of
femoral sheath.
• Contents of femoral canal are
Fat, Fascia & Lymphatics
 Femoral sheath:
• Fascia transversalis make anterior layer of the femoral sheath.
• Fascia iliaca : make posterior layer of the femoral sheath.
• Femoral vein is in the middle compartment of the femoral sheath
• Femoral artery is in the lateral compartment.

28. SURGICAL ANATOMY
 Boundaries of femoral ring
• • Anterior: Inguinal ligament
• • Posterior: Ligament of Cooper, iliopectineal ligament.
• • Medial: Lacunar ligament (Gimbemat's ligament)
• • Lateral: Thin septum which separates the femoral canal from femoral vein (silver fascia).

29. COURSE OF DEVELOPMENT
• As the hernia comes into the femoral canal, it is an oblong
swelling due to the rigid femoral canal. When it comes out
through the saphenous opening, it expands and becomes retort
shaped.
• CAUSES:
1. Repeated Pregnancy
2. Wide Femoral Canal

30. TREATMENT
• Low operation of Lockwood
• High operation of McEvedy
• Henry's approach

31. Umbilical Hernia
• Umbilical hernia occurs when intestine, fat, or fluid pushes
through a weak spot in the belly. This causes a bulge near the
belly button, or navel
• May be Congenital which appear in infancy or
Acquired- increased in intra- abdominal pressure, commonly seen
in obese or pregnant women.

32. TREATMENT
• In 93-95 % of congenital cases it disappear after some months of
birth.
INDICATION OF SURGERY
o If persists even after age of 2 Years
o If the defect is more than 2cm in size
o Acquired Umbilical Hernia

33. TREATMENT
SURGERIES
 Primary closure of defect
 Umbilectomy
 Laparoscopic Repair
 Sublay Mesh repair : >3 cm

34. EPIGASTRIC HERNIA
• Common in Males.
• Extraperitoneal fat protrudes through a defect in the decussation
of the fibers of Linea Alba. Anywhere between Xiphoid Process &
Umbilicus.
• It is Sacless Hernia, but later can enlarge & protrude part of
peritoneum. Presenting as a true Epigastric Hernia.
• Often Asymptomatic
• Impulse with coughing

36. TREATMENT
• Through a vertical incision.
• Large defect is supported with preperitoneal mesh.

37. HERNIA SIGN & SYMPTOMS
• Small to moderate size hernia don’t usually causes any
symptoms.
• Large hernia may be noticeable and cause same discomfort.
- Pain when lifting heavy object
- Tenderness
- Bulging
• Severe symptoms
- Severe and sudden pain
- Nausea
- Vomiting

38. ABDOMINAL HERNIA
PHARMACOLOGICAL MANAGEMENT
 1. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
(for patients with mild to moderate pain)
i.) Ibuprofen ii.) Diclofenac
 2. ANTIBIOTICS
(used if the patient has strangulated hernia or before open surgeries)
i) Gentamicin + Ampicillin
 3. Antianxiety Agents
(indicated for patients who may experience significant anxiety before
a surgery)
i) Lorazepam
ii) Midazolam

39. ACUTE COMPLICATIONS
• Strangulation Hernia Formation
• Inflammation or Inflamed Hernia Formation
• Irreducible Hernia Formation
• Obstruction of any lumen, such as bowel obstruction in intestinal
hernias
• Hemorrhage/ Haematoma Formation
• Autoimmune problems
• Irreducibility

41. CHRONIC COMPLICATIONS
• Postoperative Pain Syndrome
• Hernia Recurrence
• Foreign body reaction
• Mesh Infection & Erosion to bladder, bowel & vessels
• Wound Infection
• Ischemia
• Necrosis