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Types of hernia MB TypeDescription IncisionalHerniation IncisionalHerniation through an area weakened by a scar UmbilicalCongenital UmbilicalCongenital defect of the abdominal wall seen in infants as a swelling at the umbilicus ParaumbilicalAcquired ParaumbilicalAcquired defect above or below the umbilicus EpigastricOften EpigastricOften small painful swelling in the midline of abdomen above the umbilicus caused by a defect in linea alba, usually contains extrapentoneal fat FemoralHerniation FemoralHerniation through the femoral canal which appears 'below and lateral to the pubic tubercle'. More common in women than men InguinalTy InguinalTypically pically seen 'above and medial to the pubic tubercle' swelling is caused by weakness in the abdominal wall in the area of Hasselbach's triangle. Risk of strangulation is low. low. Indirect This is the most common. There are two types. First, congenital, which is caused by a patent processus vaginalis. Second, acquired, herniates through the deep ring and travels along the inguinal canal within the coverings of the spermatic cord. It can go into the scrotum. Risk of strangulation is high.
Risk of strangulation Low Low
High
Highest
Low
High
INGIUNAL HERNIA I.
Inguinal Hernia
1
B.
1.
Small Indirect Hernia may slightly tap end of finger
2.
Large Indirect Hernia may be palpable as mass
3.
Direct Inguinal Hernia may be felt on pad of finger
Inguinal Canal components 1.
2.
3.
II.
Internal inguinal ring a.
Lateral to inferior epigastrics
b.
Landmark: Middle of inguinal ligament
Canal a.
Follows spermatic cord course in men
b.
Follows round ligament in women
External inguinal ring a.
Located at pubic tubercle
b.
Occurs just above inguinal ligament
c.
Medial and inferior to internal inguinal ring
Epidemiology A.
Accounts for 96% groin hernias (other 4% are femoral)
2
III.
B.
Bilateral in 20% of cases
C.
Gender predisposition: Male by 9 to 1 ratio
D.
Lifetime risk of inguinal herniation: 10%
Types A.
Indirect inguinal hernia (most common) 1.
Course a.
IV.
Boundaries of Hasselbach's Triangle A.
Medial boundary: Rectus abdominis
B.
Lateral boundary: Inferior epigastric vessels
C.
Inferior boundary: Inguinal ligament 1.
Herniates via Inguinal Canal :
2.
Internal inguinal ring
3.
4.
a.
Lateral to inferior epigastrics
b.
Landmark: Middle of inguinal ligament
Canal a.
Follows spermatic cord course in men
b.
Follows round ligament in women
External inguinal ring a.
Located at pubic tubercle
b.
Occurs just above inguinal ligament
c.
Medial and inferior to internal inguinal ring
d. 5.
D.
V.
Hernia sac passes outside Hasselbach's Triangle:
i.
Enters through Internal Inguinal Ring
ii.
Lateral to inferior epigastrics
May result in scrotal hernia in males
Pathophysiology a.
Nonobliterated processus vaginalis (congenital)
b.
Internal abdominal ring weakened fascia
Direct inguinal hernia 1.
Hernia sac passes within Hasselbach's Triangle
2.
Breaches posterior inguinal wall
3.
Passes medial to inferior epigastrics
4.
Pathophysiology a.
Usually occurs in males
b.
Acquired deficiency in transversus abdominis muscle
Symptoms
3
VI.
A.
Often asymptomatic (especially in direct hernias)
B.
Pain or dull sensation in groin
Signs A.
Palpable defect or swelling may be present 1.
Indirect Hernia may bulge at Internal Inguinal Ring a.
2.
B.
a.
Look for bulge site at pubic tubercle
b.
Occurs just above inguinal ligament
c.
Seen medial and inferior to indirect hernia bulge
Experienced clinicians are incorrect in 30% of cases
C.
Indirect inguinal hernia palpation difficult in women
D.
Inguinal hernias difficult to palpate in children
Differential Diagnosis A.
VIII.
Direct Hernia may bulge at External Inguinal Ring
Distinguishing indirect and direct hernias difficult 1.
VII.
See Groin Pain
Radiology: Inguinal Ultrasound A.
B.
Technique: Ultrasound in various patient positions 1.
Supine
2.
Upright
3.
Valsalva maneuver
Efficacy 1.
High Test Sensitivity (>90%)
2.
High Test Specificity a.
IX.
Look for bulge site at mid-inguinal ligament
Distinguish Incarcerated Hernia from firm mass
Complications A.
Bowel incarceration and strangulation
B.
Small Bowel Obstruction
FEMORAL HERNIA I.
Epidemiology A.
Accounts for 4% of Groin Hernias (96% are inguinal)
B.
More common in elderly women
4
C.
Gender predisposition: Female by 3 to 1 ratio 1.
II.
Femoral seen less than Inguinal Hernia even in women
Pathophysiology A.
Associated with increased intra-abdominal pressure
B.
Hernia sac bulges into femoral canal 1.
Femoral canal is continuation of femoral sheath
2.
Femoral canal lies immediately medial to femoral vein
Symptoms and Signs
III.
A.
Groin Pain and tenderness often absent 1.
B.
Hernia sac neck location palpable 1.
C.
Even strangulation occurs often without pain Lateral and inferior to pubic tubercle
Large femoral hernias may bulge over inguinal ligament 1.
May be difficult to distinguish from Inguinal Hernia
Differential Diagnosis
IV.
A.
Inguinal Hernia
B.
Inguinal Lymphadenopathy
C.
Varix of Saphenous Vein
D.
V.
1.
Thrill on palpation
2.
Fills on standing and empties while supine
Infectious Bubo 1.
Chancroid
2.
Syphilis
3.
Lymphogranuloma venereum
Complications A.
Strangulated Hernia (common) 1.
Patients unaware of hernia before strangulation (50%)
EPIGASTRIC HERNIA II.
Pathophysiology A.
Type of Ventral Hernia
B.
Consists of properitoneal fat (rarely peritoneal sac)
C.
Location
5
1.
Occurs through linea alba (midline)
2.
Occurs below xiphoid process and above Umbilicus
Symptoms
III.
A.
Epigastric Pain
B.
Pulling sensation on leaning backward
Signs
IV.
V.
VI.
A.
Difficult to detect in obese patients
B.
Examine patient in standing position 1.
Run finger down course of linea alba
2.
Detects small midline Nodule
Differential Diagnosis: Epigastric Incarcerated Hernia A.
Peptic Ulcer Disease
B.
Biliary Colic
Management: Surgery A.
Suture closure of defect
B.
Multiple epigastric hernia defects often exist 1.
Adequate linea alba exposure required
2.
Surgeons explore for occult hernias
INCISIONAL HERNIA I.
Pathophysiology A.
Type of Ventral Hernia
B.
Develops in scar of prior laparotomy or drain site
C.
Risks for post-operative hernia development 1.
Vertical scar more commonly affected than horizontal
6
II.
2.
Wound infection
3.
Wound dehiscence
4.
Malnutrition
5.
Obesity
6.
Tobacco abuse
Signs A.
Provocative maneuvers to locate hernia 1.
Hernia sac will appear adjacent to scar
2.
Hernia sac may be obvious with patient standing
3.
Valsalva maneuver
4.
Raise head from pillow while supine
B.
Large incisional hernias are often asymptomatic
C.
Often multiple defects present with several rings
D.
Often Irreducible Hernia due to adhesions
SPIGELIAN HERNIA I.
Pathophysiology A.
Type of Ventral Hernia
B.
Hernia contains peritoneal sac and extreperitoneal fat
C.
Hernia of posterior lateral abdominal wall fascia
D.
II.
Perforates through linea semilunaris
2.
Inferior and lateral to Umbilicus a.
Edge of rectus sheath in mid-abdomen
b.
Immediately below arcuate line
Covering tissues 1.
Skin
2.
Subcutaneous fat
3.
External abdominal oblique muscle aponeurosis
Symptoms A.
III.
1.
Asymptomatic until strangulation
Signs: Strangulation A.
Examine with patient standing
B.
Tender mass in abdominal wall
7
C.
Localized to 3-5 cm above inguinal ligament
UMBILICAL HERNIA I.
Pathophysiology A.
Type of Ventral Hernia
B.
Infants 1.
C.
II.
Umbilical ring usually closes by age 2 years
Predisposing factors in adults (paraumbilical hernia) 1.
