FOR UNDER GRADUATES OF PHYSIOTHERAPY

1. B Y D R . H E T A P A T E L
HERNIA

2. CONTENTS…
 What is hernia?
 Causes of hernia
 Types and prevalence
 Management
 Types of surgeries
 Physiotherapy management
 Complications

3. Hernias
 A hernia is a protrusion of a viscus or part of a viscus
through an abnormal opening in the wall of the containing
cavity.

4. Contents of hernia
Sac – pouch of peritoneum which
comes out through the abdominal
muscles. divided in 4 part.
Mouth
Neck
Body
Fundus.

5.  Covering of sac: skin and muscles of the
abdomen.
 Derives from layers of abdominal wall through
which sac passes.
 After long time becomes stretched and
atrophied.
 Contents of the sac: Fluid, Omentum, Loop of
intestine, bladder, ovaries.

6. 6

7. Causes…
1. Weakness of the abdominal wall
 Congenital – incomplete obliteration of
umbilical may lead to infantile inguinal
hernia.
 Acquired – excessive fat in abdomen,
repeated pregnancy, surgical incision
leads to cutting of nerve followed by
muscle weakness.

8. 2. raised intra abdominal pressure
 lifting heavy weight
 Strenuous exercises
 Whooping cough in childhood
 Urethral obstruction straining in micturition
 Vomiting
 constipation

9. 9
TYPES OF HERNIA
 Inguinal hernia
 Femoral hernia
 Incisional hernia
 Umbilical hernia
 Paraumbilical hernia
 Hiatus hernia
 Spigelian hernia
 Strangulated hernia
 Obturator hernia
 Epigastric hernia

10. INGUINAL HERNIA
 Commonly males.
 Most common form of hernia
 Abnormal protrusion of abdominal organ into inguinal
canal through deep inguinal ring.

11. INDIRECT
 When herniation through deep inguinal ring.
 Occures at any age.
 Young adult, children.
 Descends in any direction.
 Piriform – complete, oval – incomplete

15. Causes
 increased intra abdominal pressure activities

16. Direct
 When content of hernia enter the inguinal ring and
passes through posterior wall through hesselbach’s
triangle.
 Elderly people
 Females not affected
 >1/2 cases bilateral
 Incomplete- spherical shape
 Causes: same

18. Femoral hernia
The femoral canal is the way that the femoral
artery, vein, and nerve leave the abdominal
cavity to enter the thigh.
Although normally a tight space, sometimes it
becomes large enough to allow abdominal
contents (usually intestine) into the canal.

19. This hernia causes a bulge below the inguinal
crease in roughly the middle of the thigh.
Rare and usually occurring in women, these
hernias are particularly at risk of becoming
irreducible and strangulated.

21. Incisional hernia
Abdominal surgery causes a flaw in the abdominal
wall that must heal on its own.
This flaw can create an area of weakness where a
hernia may develop.
This occurs after 2-10% of all abdominal
surgeries, although some people are more at risk.
After surgical repair, these hernias have a high rate
of returning (20-45%).

22. Umbilical hernia
10-30%. often noted at birth as a protrusion at the
bellybutton (the umbilicus).
This is caused when an opening in the abdominal wall,
which normally closes before birth, doesn’t close
completely.
Even if the area is closed at birth, these hernias can
appear later in life because this spot remains a weaker
place in the abdominal wall.
They most often appear later in elderly people and
middle-aged women who have had children.

23. Para umbilical hernia
 Protrusion of linea alba just above / below
umbilicus
 In obesity.
 Sac also consist of greater omentum, small
intestine, and portion of transverse colon.

24. Hiatus hernia
oA hiatus hernia occurs when the upper part of the
stomach, which is joined to the esophagus , moves up
into the chest through the hole (called a hiatus) in the
diaphragm.
oIt is common and occurs in about 10 per cent of
people.
oIt is most common in overweight middle-aged women
and elderly people.

25. It can occur during pregnancy.
The diagnosis is confirmed by barium meal X-rays or by
passing a tube with a camera on the end into the stomach
(gastroscopy).

28. Symptoms :
Heartburn
Sudden regurgitation
Belching
Pain on swallowing hot fluids
Feeling of food sticking in the
oesophagus

30. Spigelian hernia
This rare hernia occurs along the edge of the
rectus abdominus muscle, which is several inches
to the side of the middle of the abdomen.
Reducible – goes off in supine
Irreducible – due to adhesions in sac
Obstructed – contains intestine
Strangulated – blood supply to hernia is abscent

31. Strangulated hernia

33. Obturator hernia
This extremely rare abdominal hernia happens
mostly in women.
This hernia protrudes from the pelvic cavity
through an opening in your pelvic bone (obturator
foramen).
This will not show any bulge but can act like a
bowel obstruction and cause nausea and vomiting

34. Epigastric hernia
Occurring between the navel and the lower part
of the rib cage in the midline of the abdomen,
these hernias are composed usually of fatty tissue
and rarely contain intestine.
Formed in an area of relative weakness of the
abdominal wall, these hernias are often painless
and unable to be pushed back into the abdomen
when first discovered.

35. Treatment
 Conservative : indicated in a patient with
severe ill health, short life expectancy, those
who refuse for operation
Operative :
Herniotomy : neck of sac is transfixed, ligated
and then the hernial sac is excised.
Infant and children in whom there is congenitl
hernia present.
Young adult with very good inguinal muscles.
Incision : ½ inch above and parallel to the
medial of inguinal ring almost on inguinal canal.

36.  HERNIORRAPHY :
 Consist of herniotomy and repair of posterior
wall of the inguinal canal by apposing the
conjoin tendon to the inguinal ligament.
 Indicated in –
 direct hernia
 Recurrent hernia
 Fascia transversalis is weak

37. Bassini repair
 After extraction of the hernia sac, we are taking
spermatic duct on holders.
 Between the borders of transverse muscle, internal
oblique muscle, transverse fascia and inguinal ligament
interrupted sutures placed.
 Except that, couples sutures placed between border of
abdominal rectus muscle sheath and pubic bone
periosteum.

38.  In such way, inguinal space
closured and posterior wall
strengthened.
 Spermatic duct placed on
the new-formed posterior
wall of the inguinal
channel.
 Over the spermatic duct
aponeurosis restored by
interrupted sutures.

40. Hernioplasty
 Consist of herniotomy + repair of posterior wall
of inguinal canal by filling the gap between
conjoined tendon and inguinal ligament filled
by fibrius tissue.
 Indication –
all cases of direct hernia
Recurrent hernia
Indirect hernia with poor muscle tone

41. Assessment
 History – vomiting, intestinal obstruction, lump,
abdominal distension.
 Past surgical history
 O/O: local :
 Redness + around hernia
 Swelling
 Skin chnages
 Lump
 Effect of coughing

42.  O/P:
 Temperature
 Tenderness
 Swelling
 On percussion:
 Resonant : intestine
 Dull : omentum,
extraperitoneal fatty
tissue
 O/E:
 Pain
 ROM
 MMT
 ADL

43. Physiotherapy management
 AIM
Increase strength of abdominal muscles
Proper positioning
Soft tissue healing- 3-4 weeks, muscles – 7-12
days
 Pre operative
 Chest physiotherapy
 Exercise tolerance test
 Improve muscle strength

44. POST-OPERATIVE MANAGEMENT
Day 0
• Assessment
• Operation notes
• Level of consciousness
• Level of pain
• Analgesia
• Wound site

45. • Attachments
• Position of patient
• Auscultation
• Homan’s sign
Treatment
 More emphasis on respiratory and circulatory
functions. Patient should repeat exercise hourly.

46. Day 1
• Mobility exercise: rolling to side lying, pushing
up to sitting position.
• Deep breathing exercises every hourly.
• Supported coughing.
• Calf stretch and ankle pumps every quarter
hourly.

47. • Unilateral upper limb movements to improve
chest expansion every hourly.
• Abdominal massage in the direction of large
bowel helps to reduce abdominal pain due to
‘gas’.

48. Day 2
 Encourage walking for short distance with
assistance.
 Continuation of day 1 exercises.
 Add pelvic rocking and abdominal drawing in
exercises.

49. Day 3 onwards
 Longer periods of sitting out and walking.
 Continuation of previous exercises.
 Pelvic floor exercises if there is no catheter in
situ. 5 repetition of five sec hold.
 Posture and back care advises.

50. Femoral hernia…
 Lower limb mobility is more important.
 Wear inguinal belt
 Squatting, weight lifting after 3 months

51. Complications…
DURING OPERATION
 Injury to vein or nerve
 Urinary bladder
 Inferior epigastric vessels
 Contents of sac
EARLY POST OPERATIVE
 Retention of urine
 Inflammation of spermatic cord, scrotum
 Wound infection

52. LATE POST OPERATIVE
 Reccurance
 Neurologic pain due to involvement of
ilioinguinal nerve in suture
 Painful scar
 Atrophy of testis due to testicular nerve due to
compression of spermatic cord
 Epidermal cyst

53. Thank you