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Alaa Shabkah

on 1 February 2014

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Transcript of Hernia

Causes of hernia
Complications of hernia
Groin hernia
Umbilical hernia
Incisional hernia
Causes & Complications
Groin hernia
Umbilical &
Done by:
Alaa Shabkah

What is Hernia?
Abnormal protrusion of intra-abdominal tissue though a fascial defect in the abdominal wall.
What Types of Abdominal Hernia do You Know?
What are the layers of the abdominal wall?
What compose the hernia mass?
Covering tissue
(skin, subcutaneous tissue etc)
Peritoneal sac
The contained viscera
(intra-abdominal content)

What are the ligaments of inguinal region?
Inguinal ligament (Poupart’s)
– inferior edge of external oblique
Lacunar ligament
– triangular extension of the inguinal ligament before its insertion upon the pubic tubercle
Conjoint tendon (5-10%)

- Internal oblique fuses with transversus abdominis aponeurosis
Cooper’s Ligament
- formed by the periosteum and fascia along the superior ramus of the pubis

What is the inguinal canal? & What are its boundaries?
A canal that extends between deep and superficial inguinal rings
What are the contents of the spermatic cord?
Can you describe the femoral sheath?
Beneath the inguinal ligament:
Iliacus muscle
Femoral Nerve
Femoral sheath
The femoral sheath contains:
Femoral vessels
Femoral Canal
The functions of the femoral canal:
Space for venous expansion
Upper end defined by femoral ring.

What is Hesselbach's triangle?
What is the difference between Mid-inguinal point & Midpoint of inguinal ligament?
What is the clinical significance of each one?
What are the causes of hernia?
Congenital Factors
(persistent processus vaginalis, collagen synthesis disorder, osteogenesis imperfecta, Marfan syndrome, Ehlers-Danlos syndrome,)
Acquired Factors
increased intra-abdominal pressure 
(in pregnancy, intra-abdominal tumors, chronic obstructive lung disease, ascites, constpation)

What are the possible complications?
Acute: fascial margins
Chronic: adhesions
(of the lumen of the bowel).
(obstruction of the lumen and blood supply  gangrene).*Narrow neck at greatest risk: indirect inguinal, femoral, and umbilical

What is Nyhus classification of groin hernia?

How will the patient present to you?
Symptoms of the
Symptoms of the
Symptoms of the

A 20 years old male came to your clinic complaining of groin swelling.

What is your differential?

How can you differentiate between the different types by history?
How can you differentiate between the different types by examination?
What is the treatment?
Tension Repair
Cutting adjacent muscle, then pulling it together using sutures or wire.
Bassini Repair
The conjoined is sutured to the inguinal ligament
McVay Repair
The conjoined tendon is sutured to Cooper’s ligament
Shouldice Repair
Multilayer imbricated repair of the posterior wall of the inguinal canal

Tension Free Repair
With or without mesh
Lichtenstein Repair
A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord

TransAbdominal PrePeritoneal (TAPP)

Total ExtraPeritoneal (TEP)

Less postoperative discomfort/pain
Decrease recovery time
Easy repair for

Umbilical Hernia
What are the risk factors?
Risk factors:
Flabbiness of the abdominal muscles.
Congintal factors (navel, or belly button)

What is the treatment?
Mayo repair
Subumbilical incision
Mayo repair
Dissection around the sac down to the aponeurotic layer (encircling the sac)
Opening the sac/reposition of its content
Mayo repair
Removal of the sac
Mayo repair
Closure of the fascia
Mayo repair
Fixation of the umbilicus to the fascia
Mayo repair
Incisional Hernia
What are the risk factors?
Risk Factors:
Wound infection
Technical aspects of wound closure
[Type of incision, Excessive tension]

A 20 years old construction worker is complaining of pain and intermittent bulge in his left groin. He indicates that the symptoms have been worsening over the past 3 months and beginning to affect his activities. On examination, he appears to have a small indirect inguinal hernia. Which of the following is the most appropriate management?
A. Wait an re-evaluate the patient in one month.
B. Advice the patient to undergo Lap. hernia repair because a large RCT showed superior outcome.
C. Perform open left inguinal hernia repair with prosthetic mesh.
D. Perform open left inguinal herniorrhaphy with primary suture repair
A 40 years old man presents with recurrent bulge in the left groin 2 years following open left inguinal hernia repair with mesh. The physical examination showed a moderately dilated external inguinal ring with a small bulge produced by valsalva maneuver. Which of the following is the most appropriate treatment approach?
A. Obtain a CT to rule out a femoral hernia, followed by elective hernia repair.
B. Schedule patient for left groin exploration and hernia repair with prosthetic mesh.
C. Advice the patient to limit his physical activeties and re-evaluate in 6 months.
D. Send the patient to an immunologist for evaluation of possible wound healing and tissue collagen defect.
An 80 years old woman who resides in a nursing home has several pound weight loss over the past several months. She presents with 3 days history of vomiting and anorexia. Her abdominal examination reveals distention and tympany. There is a firm soft tissue mass measuring approximately 4cm in the medial aspect of her left upper thigh. Her abdominal CT scan reveals fluid-filled dilated small bowel loops and evidence of decompressed ileum and colon. Which of the following is the most appropriate treatment?
A. Exploration of left groin & repair of her femoral hernia.
B. Exploratory laparotomy.
C. Observe for 5 days. If not resolved, proceed with exploratory laparotomy.
D. Comfort care
Thank You
What is the difference between Mid-inguinal point & Midpoint of inguinal ligament?
What is the clinical significance of each one?
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