1. Hernias
Presented by Abdurahman Maashi

2. Objectives
• Anatomy of abdominal wall and their hernias
• Ventral hernias types and their presentation ,clinical features , risk
factors, differential diagnosis
• Anatomy of groin and their hernias
• Groin hernias types and their presentation ,clinical features , risk
factors, differential diagnosis
• Clinical presentation of hernias
• Baseline Management

3. What is hernia ?
a protrusion, bulge, or projection of an organ or part of an organ
through the body wall that normally contains it
CLASSIFICATION
They classified based on location and etiology

4. Abdominal wall hernias are most commonly classified by location :

5. • Ventral hernia – Ventral hernias occur anteriorly and include primary
ventral hernias (epigastric, umbilical, Spigelian), parastomal hernias,
and most incisional hernias (ventral incisional hernias).
• Groin hernia – The groin is the region at the lower margin of the
abdomen where the thigh meets the hip. Groin hernias are
subclassified into inguinal and femoral hernias
• Pelvic hernia – Pelvic hernias protrude through one of the pelvic
foramina (sciatic and obturator hernia) or the pelvic floor (perineal
hernias).
• Flank hernia – Flank hernias protrude through weakened areas of
back musculature and include the superior and inferior lumbar
triangle hernias

8. Abdominal wall hernias can also be classified by etiology:
• Congenital hernia : congenital abdominal wall defects ,the most
common are omphalocele and gastroschisis.
• Acquired hernia: primary hernias and incisional hernias

9. ANATOMY
The abdominal wall is comprised of a complex fusion of overlapping
layers of muscles and connective tissues that contain and protect the
intra-abdominal organs while facilitating movement and breathing
Layers of abdominal wall:
1-SKIN AND SUBCUTANEOUS TISSUE
2-MUSCLES(rectus abdominis, ext. and int. oblique ,transversus
abdominis, pyramidalis)
3-FASCIA(rectus sheath , transversalis fascia ,linea alba)

12. Blood supply of abdominal wall
Deep arteries
Epigastric arteries (inferior and superior)
Deep circumflex iliac arteries
Musculophrenic arteries
Superficial arteries
consists of branches of the femoral artery, including the superficial
epigastric (or superficial inferior epigastric), superficial external
pudendal, and superficial circumflex arteries.

15. NERVES
• Intercostal nerves
• Iliohypogastric nerves
• Ilioinguinal nerve
• Genitofemoral nerve
• Lateral femoral
cutaneous nerve

16. Differential diagnosis of abdominal wall hernia
• Rectus abdominis diastasis (RAD)
• Rectus sheath hematoma (RSH)
• Abdominal wall cellulitis/abscess
• Lipomas
• Scar endometriosis
• Urachal anomalies
• Neurofibromas
• Desmoid tumors
• Seromas

17. Epigastric hernia
• Pathogenesis: congenitally
weakened linea alba
,forceful diaphragmatic
contraction
,perforation of the linea alba
by vascular lacunae
• Risk factors: extensive training
or coughing, obesity
smoking, chronic steroid use
diabetes , old age
and male gender

18. • Asymptomatic, but most patients present because of a small, slightly
uncomfortable lump between the umbilicus and the xiphoid. The
defects are often no more than 1 cm in diameter .Up to 20 percent of
epigastric hernias are multiple. Bowel incarceration or strangulation is
rare.
• Repair of an epigastric hernia is reserved for symptomatic patients For
open repair, a small midline or transverse incision is made overlying
the hernia. The hernia contents are either reduced or resected, and
the defect is closed with interrupted sutures or mesh.

19. Umbilical hernia
• Found in 23 to 50 percent of
individuals screened by
physical exam or ultrasound
• More commonly in females
than in males with a 3:1 ratio.
In men, umbilical hernias most
often present incarcerated,
whereas females, particularly
those close to their ideal body
weight, are more likely to have
an easily reducible mass

20. • Umbilical hernia can usually be
diagnosed with palpation of a
soft mass either at, slightly
above, slightly below, or to one
side or another of the
umbilicus. Larger umbilical
hernias may be associated with
skin erythema, ulceration, or
ischemia.
• Recurrence rates range from 0
to 3 percent after a mesh repair
to up to 14 percent after a
sutured repair

21. Incisional hernia
• 10 to 15 percent of patients
with a prior abdominal incision
• Midline incisions have the
highest incidences of incisional
hernias (3 to 20 percent)
• Risk factors: old age, obesity,
smoking, malnutrition,
immunosuppressive therapy,
and connective tissue
disorders, also infection,
tension, technique.

22. • Incisional hernias typically develop
in the early postoperative period
• Presentation: bulge in the
abdominal wall at the site of a
prior incision with varying degrees
of discomfort and/or be a
cosmetic concern only, aggravated
by coughing or straining with a
protrusion of the abdominal wall
at the site of a previous incision.
• Diagnostic imaging : CT and
ultrasound

23. Spigelian hernia
• Occurs through a defect in the Spigelian
aponeurosis, which is the aponeurosis of
the transverse abdominal muscle bounded
by the linea semilunaris laterally and the
lateral edge of the rectus muscle medially.
• Preperitoneal fat emerges through the
defect, bringing an extension of the
peritoneum with it through the Spigelian
fascia.
• Surgical repair is generally recommended
once a Spigelian hernia is diagnosed.

24. • The patient most often
presents with a swelling
in the mid to lower
abdomen, just lateral to
the rectus muscle. The
patient may also
complain of a sharp pain
or tenderness at this site.
Suspected Spigelian
hernias .
• Diagnosis: (CT) or
ultrasound

25. The optimal method of ventral hernia repair
would
• Prevent hernia recurrence
• Have a low rate of surgical site infection
• Provide dynamic muscle support
• Provide a repair with physiologic tension
• Prevent eventration or abdominal wall bulging
• Incorporate the abdominal wall

28. Recurrence rate of ventral hernias
• Recurrence rate of primary ventral hernia repair is 5 to 10 percent at
two years.
• The recurrence rate of ventral incisional hernias can be as high as 25
to 43 percent at three years.

29. Miscellaneous hernias

31. Anatomy of groin area

32. Inguinal canal
• The inguinal canal is a slit-like space in
between the muscles of the anterior
abdominal wall, above the medial half
of the inguinal ligament.
• The deep inguinal ring is a defect in the
transversalis fascia about 1cm above
the midpoint of the inguinal ligament.
• The superficial inguinal ring, which is
above and medial to the pubic tubercle,
is a defect in the external oblique
aponeurosis.

33. Boundaries of inguinal canal
• Anterior – Ext. oblique
aponeurosis & conjoined muscle
laterally.
• Posterior – Fascia transversalis &
the conjoined tendon.
• Superiorly – conjoined muscle.
• Inferiorly – inguinal ligament.

34. Contents of inguinal canal
• Vas deferens
• 3 arteries ( testicular artery , artery
to vas deferens from inferior
vesical , cremasteric artery)
• 3 nerves ( genital branch of
genitofemoral , ilioinguinal and
sympathetic)
• lymphatics drain to para-aortic
• Pampiniform venous plexus
• Processus vaginalis

35. Hasselbalch triangle
• The inguinal triangle is located
within the inferomedial aspect of
the abdominal wall. It has the
following boundaries:
• Medial – lateral border of the
rectus abdominis muscle.
• Lateral – inferior epigastric
vessels.
• Inferior – inguinal ligament.

36. Femoral triangle
• Borders(SAIL):
Lateral border: sartorius muscle
Medial border: adductor longus muscle
Base or superior border: inguinal
ligament
• Contents (NAVEL):Femoral nerve,
femoral artery, femoral vein, femoral
canal (empty space), lymphatics

37. Differential diagnosis of lump in groin
• Inguinal hernia
• Femoral hernia
• Enlarged LN
• Saphena varix
• Ectopic testis
• Femoral aneurysms
• Hydrocele of the cord or canal of nuck
• Lipoma
• Psoas bursa or abscess

38. Groin hernias
• Groin hernias are classified anatomically as inguinal (indirect or
direct) or femoral
• Approximately 96 percent of groin hernias are inguinal and 4 percent
are femoral
• Indirect inguinal hernia is the most common groin hernia in both
sexes
• Direct inguinal hernia accounts for 30 to 40 percent of groin hernias
in men .but approximately 14 to 21 percent of groin hernias in
women

39. • Femoral hernias account for <10 percent of all groin hernias and only
2 to 4 percent of all groin hernia repairs . Femoral hernias represent
20 to 31 percent of repairs in women compared with only 1 percent
in men. Femoral hernias occur later in life than inguinal hernias. Over
the age of 70, femoral hernias represent 52 percent of repairs in
women and 7 percent of repairs in men.

40. Risk factors:
• History of hernia or prior hernia repair (including childhood)
• Older age
• Male sex
• Caucasian race
• Chronic cough
• Chronic constipation
• Abdominal wall injury
• Smoking
• Family history of hernia

41. • A common symptom associated with hernia is a heaviness or dull
discomfort in the groin, which may or may not be associated with a
visible bulge. Groin hernias in women can also result in vague pelvic
discomfort. Moderate-to-severe pain with hernias is unusual and,
when present, should raise the possibility of incarceration or
strangulation.
• Women are more likely to present emergently due to a higher
incidence of femoral hernias, which are more likely to strangulate
• Two thirds of groin hernias are located on the right side

42. • Male patients – Many groin hernias in men are obvious on physical
examination.
• Female patients – Groin hernias in women often do not have a visible
bulge. the layers of the abdominal wall absorb the hernia impulse,
making the external ring difficult to locate. Ultrasound or diagnostic
laparoscopy may be needed to detect hernias in women.
• Although the data are limited, one study reported a sensitivity of 75
percent and specificity of 96 percent for a diagnosis of inguinal hernia
on physical exam by surgeons

43. • Indirect hernia – the abdominal
contents herniation occurs
through the deep ring into the
inguinal canal.
• Comes out through the superficial
ring.
• It may extend into the scrotum.
• Depending upon extent it may be
complete or incomplete.

45. • Direct hernia – contents herniate
directly through the posterior wall of
the inguinal canal through the
Hesselbach’s triangle
It is a weakness in posterior wall of
the inguinal canal
• Femoral herniae are
relatively uncommon but are are an
important problem due to their high
rate of strangulation
• Femoral hernia occur when abdominal
viscera or omentum passes through
the femoral ring and into the potential
space of the femoral canal.

47. Clinical presentations of hernia
• Reducible –contents can be returned into the abdominal cavity.
• Irreducible – contents cannot be returned into the abdominal
cavity.
• Obstructed – irreducibilty + intestinal obstruction, but the blood
supply is not impaired.
• Strangulated- irreducibilty + intestinal obstruction+ arrest of the
blood supply.
• Inflammed- rare condition. Occurs when contents eg.
Appendix,meckel’s diverticulum is inflamed

48. Types of hernia conditions:

49. Laparoscopic view
of groin area

53. Recurrence rate of groin hernias
• Recurrence rates for primary hernia repair range from 0.5 to 15
percent depending upon the hernia site (direct, indirect, femoral),
type of repair (mesh, no mesh, open, laparoscopic), and clinical
circumstances (elective, emergent)
• Hernia recurrence is less common with repair of inguinal compared
with femoral hernia repair due to the higher rates of emergency
surgery and complications associated with femoral hernia

54. Thank you