This document discusses different types of hernias including common hernias like inguinal, umbilical, femoral, and incisional hernias as well as rare hernias. It covers the anatomy, causes, signs and symptoms, and treatment options for various hernias. The most common hernia is the inguinal hernia. Treatment is generally surgical though some hernias can be managed conservatively with a truss. Strangulated hernias require emergency surgery.

1. HERNIA

2. • “Protrusion of a part or whole of viscus
through an abnormal opening in the wall of
the cavity that contains it”

3. • Common Hernias
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INGUINAL
UMBILICAL
FEMORAL
EPIGASTRIC
INCISIONAL
• Rare Hernias
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SPIGELIAN
LUMBAR
GLUTEAL
SCIATIC
OBTURATOR

4. Factors: Weakness of abdominal
musculature
• Congenital
– Persistence of
processus vaginalis
– Patent canal of Tuck
– Incomplete
obliteration of
umbilicus
• Acquired
– Fat
– Pregnancy
– Incision
– Infection
– Connective tissue –
smoking, aging, CTD,
systemic illness

5. Increased abdominal pressure
• Chronic constipation
• Chronic cough
• Bladder outlet obstruction – stricture,
prostrate
• Straining – weight lifting
• Intra-abdominal malignancy
• Vomiting
• Repeated pregnancy

6. • Sac
• Covering
• Contents
– Omentocoele
– Enterocoele
– Cystocoele
– Ovary

7. • Richter’s
• Littre’s
• Maydl’s

8. Classification
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•
•
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Reducible
Irreducible
Obstructed/ Incarcerated
Strangulated

9. Reducible Hernia
• Characteristic signs
– Reducibility
– Cough impulse

10. Irreducible Hernia
• Due to
– Adhesions
– Narrowing of neck
– Incarceration
– Massive hernia inside scrotum

11. Obstructed Hernia
• Irreducibility + Intestinal obstruction
• Features
– No cough impulse
– Irreducible
– Painless
– Non tender
– Features of intestinal obstruction

12. Strangulated Hernia
• Blood supply of its contents impaired
• Intestinal obstruction ±
• Pathology
– Intestinal obstruction
– Dilation of hernial contents
– Impairment of venous return
– Stasis --------- Arterial impairment

13. • Appearance
– Congested and bright red
– Ecchymosis
– Extravasation of blood into lumen/ sac
– loss of tone
– Translocation of gut bacteria – peritonitis/ sepsis
– Gangrene

14. • Symptoms
– Pain, vomiting
– Ceases with onset of gangrene, ileus
• Signs
– Ill looking
– Tense, tender
– Irreducible, no cough impulse
– Acute intestinal obstruction
– Peritonitis

15. Strangulated Omentocele
• No features of intestinal obstruction
• Gangrene onset delayed

16. Strangulated Richter’s Hernia
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•
•
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Features mimic gastroenteritis
Obstruction > 50 % of circumference
Colic, diarrhoes
Constipation - ileus

17. Maydl’s Hernia
• Retrograde strangulation
• On opening sac – contents appear normal
• Generalized peritonitis may set in early

18. Inflamed Hernia
• Outside
– Abrasion, ill fitting truss
• Inside
– Diverticulitis, appendicitis
• Signs of inflammation +
• Not associated with intestinal obstruction

19. INGUINAL HERNIA

20. Anatomy

21. Inguinal canal
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•
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Triangular slit 3.75 cm long
Above the inner half of inguinal ligament
Deep to superficial inguinal ring
Developed due to the descent of testis in
embryonic life

22. Deep Inguinal Ring
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•
•
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Opening in the fascia transversalis
1.25 cm above mid inguinal point
Medially – inferior epigastric artery
Spermatic cord in males; round ligament in
females

23. Superficial Inguinal Ring
• Aponeurosis of external oblique – crurae
• Above and lateral to pubic crest
• Spermatic cord/ round ligament and illioinguinal nerves

24. • Anteriorly – skin, fascia, EO
aponeurosis, lateral third – IO aponeurosis
• Posteriorly – transversalis fascia, medial ½ conjoint tendon
• Above – transversus abdominins and internal
oblique fibres
• Below – inguinal ligamnet

25. Contents
• Illioinguinal nerves
• Spermatic cord
– Vas defrens
– Testicular artery, art to vas defrens, cremasteric
– Pampiniform plexus of veins
– Lymph vessels
– Testicular plexus of sympathetic nerves, genital
branch of genitofemoral

26. Hassenbach’s Triangle
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Site of direct hernia
Medially – lateral border rectus abdominis
Laterally – inferior epigastric vessel
Inferiorly – inguinal ligament
Floor – fascia transversalis
Umbilical fold – obliterated umbilical artery

27. Mechanisms for preventing hernia
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Obliquity of inguinal canal
Shutter mechanism of fibres of IO, TA
Sphincter action of TA, IO at deep inguinal ring
Ball valve action of cremasteric
Fibres of internal oblique over deep inguinal
ring
• Conjoint tendon

29. INDIRECT INGUINAL HERNIA
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•
•
•
More common
Young individuals
More common on the right side
On basis of extent
– Bubonocele
– Funicular hernia
– Complete hernia

30. • Coverings
– Peritoneum
– Extraperitoneal fat
– Internal spermatic fascia
– Cremasteric fascia
– External spermatic fascia
– Superficial fascia
– skin

31. DIRECT INGUINAL HERNIA
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•
•
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Directly through the hasselbach’s triangle
Acquired (ex- Oglive hernia)
More common in elderly, malgaigne bulgings
Rarely gets strangulated

32. • Symptoms
– Pain/ discomfort
– Lump
– Systemic symptoms – obstruction, strangulation
– Predisposing factors – constipation, chronic
bronchitis, urinary obstruction
– Past history

33. • Signs
– REDUCIBILITY
– COUGH IMPULSE
– Position – d/f femoral hernia
– Get above the swelling
– Invagination test
– Ring occlusion test

34. Rare Varieties
• Interstitial hernia
– Between muscle layers of abdominal wall
– Commonly associated with undescended testis
– Preperitoneal
– Intraperitoneal
– Extraperitoneal

35. Rare Varieties
• Sliding hernia
– Older men
– Extraperitoneal bowel with sac of peritoneum
– Caecum, pelvic colon, bladder
– Strangulation of intestine within and outside the
peritoneum
• Richter’s
• Maydl’s
• Littre’s

36. TREATMENT
• Conservative management
• Surgical management

37. Conservative management :
No Treatment
• Indications
– Severe ill health
– Short life expectency
– Refuse operation

38. Conservative management : Truss
• Indications
– Refuse operation
– Old patients with severe co morbidities
– Children ( c/I – undescended testis)
• Contraindications
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Irreducible hernia
Undescended testis
Chronic bronchitits, strenous labour
Associated with large hydrocele
Not intelligent enough to position properly

39. • Dangers
– Pressure atropht of muscles of inguinal region
– Ostruction or strangulation
– Used with partially reduced hernia – may cause
trauma
– Improper cleanliness – unhealthy skin
– Adhesions between sac and canal
– Chance of strangulation remains

40. Operative treatment
• Herniotomy
– Neck of sac transfixed, ligated and excised
– Infants and children; young men with good
musculature
• Herniorrhaphy
– Herniotomy + repair of postrior wall
– Indirect hernias
– Adults with good muscle tone

41. Hernioplasty
• Herniotomy + reinforcement of posterior wall
• Autologous
– Fascia lata
– External oblique aponeurosis
– Anterior rectus sheath flap
– Skin flap – dermoplasty/ skin ribbon
• Heterogenous
– Prolene
– Stainless steel

42. • Indications
– Indirect hernia – poor muscle tone
– Direct hernia
– Recurranthernia
– Predisposing factors – chronic cough,etc

43. Treatment of Strangulated Hernia
• Emergency surgery
• Resuscitation
• Reduction of hernia
– Foot end elevation
– Ice pack
– NG, IV fluids
– Analgesia, antibiotic

44. • Assess viability
– Green/ black color
– Flaccid , lustureless appearance
– No peristalssis
– Blood stained, foul smelling fluid in sac
• Bowel viable - HERNIORRHAPHY

45. • Bowel nonviable
– Linear patch of gangrene – invagination
– Loop of bowel – resection and anastomosis if gen
condition permits
– Bowel large intestine – exteriorisation

46. RECURRENT INGUINAL HERNIA
• Types of hernia
– Sliding
– Large/ long standing
– Large direct hernia
• Types of patients – chronic cough
• Inadequate preoperative preparation

47. RECURRENT INGUINAL HERNIA
• Operative faults
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Failure to ligate sac
Tension in repair
Use of absorbable sutures
Bleeding – infection
Fault in selection of operation
• Postoperative care
– Wound infection
– Lifting heaavy weights
– Persistence of predisposing factors
• Appearance of new hernia

48. FEMORAL HERNIA

49. • Femoral ring – femoral canal – saphenous
opening
• More common in
– Females
– Old age
• Most liable to strangulate

50. Anatomy

51. Coverings of the sac of femoral hernia
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Skin
Superficial fascia
Cribriform fascia
Anterior layer of femoral sheath
Fatty contents of femoral canal
Femoral septum
Peritoneum

52. Rare types of femoral hernia
• Prevascular
hernia(Velpeu’s) – ass with
posterior dislocation
(Narath’s hernia)
• Retrovascular hernia Serafini
• Pectineal hernia –
Cloquet’s
• External femoral hernia –
Hesselbach’s
• Lacunar hernia – Lingier’s

53. • Symptoms
– Swelling
– Pain
– Systemic symptoms
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•
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Zeimenns technique
Invagination technique
Ring occlusion test
Position of swelling

54. Treatment
• No conservative management
• Surgery – herniorrhaphy
– High operation(McEvedy’s)
– Lottheissen’s
– Lockwood

55. UMBILICAL HERNIA
• Three major types
– Exomphalos
– Umbilical hernia in infants and children
– Paraumbilical hernia in adults

56. Exomphalos
• Minor
– Small sac
– Summit attached to the umbilical cord
– Treatment
• twisting of umbilical cord and strapping

57. Exomphalos
• Major
• Umbilical cord attached to inferior
aspect of swelling
• Contains intestines, liver
• Surgical emergency
• Immediate decompression and
reduction

58. Umbilical hernia in children and infants
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Weak umbilical scar following neonatal sepsis
Usually asymptomatic
90% cured within 12 – 18 months
> 18 months – surgery

59. Paraumbilical hernia of adults
• Supraumbilical or infraumbilical
• Adhesions - seldom reducible
• Predisposing factors –
– Women
– Obesity
– Repeated pregnancy
• Treatment – Mayo’s operation

60. EPIGASTRIC HERNIA
(Fatty Hernia of Linea Alba)
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•
•
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Through fibres of linea alba
Blood vessels pierce linea alba
Initially extraperitoneal fat only
M.c. – young muscular men with strenous
activity
• Usually irreducible, no cough impulse
• If symptomatic - surgery

61. INCISIONAL HERNIA
(Ventral Hernia)
• Defect with patient
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Obesity
Chronic cough perioperative period
Undue abdominal distention
Malnutrition
• Operative
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Injury to nerves
Careless wound closure
Hemorrhage – infection
Tube drainage through laparotomy wound
Midline infraumbilical

62. • Postoperative
– Infection
– Postop cough, distention
– Postop peritonitis
– Early removal of sutures
– Postop steroid therapy

63. Types of incisional hernia
• Type 1
– Upper abdomen/ midline lower abdomen
– Wide gap in musculature
– Low risk of strangulation
• Type 2
– Lateral part of abdomen
– Small defect
– Strangulation risk high

64. Treatment
• Prevention of incisional hernia
– Weight reduction
– Correct nutritional defects
– Treat chronic cough
– Careful closure of abdomen
– Prevent post op wound infection

65. • Conservative management
– Reducible type 1
• SURGICAL MANAGEMENT

66. LUMBAR HERNIA
• Superior lumbar
hernia
• Inferior lumbar
hernia

67. Incisional lumbar hernia
• Renal surgery with post op infection
• Paralysis of lumbar muscles(phantom hernia)
• Treatment
– Primary hernia – herniorrhaphy
– Incisional hernia

68. OBTURATOR HERNIA
• Rare; old women
• Through obturator
foramen
• Thigh flexed, abducted and
externally rotated
• Referred pain to knee joint
• Strangulation - surgery

69. SPIGELEAN HERNIA
• Interparietal hernia
• At level of arcuate line,
lateral to rectus
• Treatment - surgery

70. • Gluteal hernia
• Sciatic hernia

71. CONCLUSION
• Protrusion of a part or whole of viscus through
an abnormal opening in the wall of the cavity
that contains it
• Inguinal hernia most frequent
• Usual mode of treatment is surgical

72. THANK YOU