The document defines hernia as a protrusion of an organ through the body wall that contains it, discusses the most common types of hernias including their risk factors, classifications, clinical features, and management through both non-operative and operative approaches such as open and laparoscopic repair. Specific hernia configurations and other rare types are also reviewed, with comparisons in characteristics and treatments.

1. Hernia
Chea Chan Hooi
Surgeon
Sibu Hospital

2. Content
• Definition
• Epidemiology
• Risk factors
• Classification
• Clinical features
• Management
• Specific configurations
• Other types
• Q&A

3. Definition
• Protrusion, bulge or projection of organ
through the body wall which normally
contains it

4. Epidemiology
• Between 5 – 10% in the US
• Inguinal > femoral > other abdominal wall
hernias

5. Risk factors
Modifiable Non-modifiable
Obesity
Chronic straining on defecation or
urination
Chronic coughing
Chronic heavy lifting
Ascites
Previous surgery
Male
Prematurity
Patent procesus vaginalis
Maldescended testis
Associated urogenital disorders
(ambiguous genitalia, epispadias,
hypospadias)
Connective tissue disease
Aging
Family history of hernia

6. Classification
• Anatomical
– External
• Anterior abdominal wall
– Epigastric
– Spigelian
– Umbilical
– Inguinal
– Femoral
– Obturator
• Posterior abdominal wall
– Lumbar
– Sciatic
– Internal
• Hiatal hernia
• Cerebral herniation
• Clinical features
– Uncomplicated
– Complicated

7. Clinical features
• Impulse on coughing/straining
• Uncomplicated – easily reducible
• Complicated – usually irreducible
– Incarcerated
• Contents entrapped within hernia sac, usually large and for
years without much symptoms
– Obstructed
• Bowel luminal obstruction
– Strangulated
• Blood supply compromised
• Causative factors

8. Physical examination
• Location
– Femoral – infero-lateral to pubic tubercle
– Inguinal – supero-medial to pubic tubercle
• Extent
– Bubonocele, funicular, complete inguino-scrotal
• Deep ring occlusion test – indirect inguinal hernia
• Testes within scrotal sac
• Optional
– Little finger test
– Zimmer’s test

9. Management
• Non-operative
– Trusses, binders
– Criteria
• Young (<65 year-old)
• No significant co-morbidities
• Easily reducible bubonocele
• Minimal or no symptoms
• Understands the features of complications to present
quickly

10. • Operative
– Open
• Mesh repair (hernioplasty)
– Lichtenstein repair
– Kugel (pre-peritoneal) repair
• Tissue repair (herniorraphy)
– Bassini repair ± Tanner modification
– Shouldice repair
– Mc Vay repair
• Herniotomy
– Hernia sac ligation
– Reserved for paediatric patients
– Laparoscopic
• TEP
• TAPP

11. TEP
• Avoids the attendant risks
of entering peritoneal
cavity, therefore minimising
risk of adhesions, bowel
injury
TAPP
• Larger working space
• Ready access to both
inguinal regions
• Allows inspection of
peritoneal organs
• Possible for patients with
previous lower abdominal
surgery or hernioplasty

14. Specific configurations
• Richter
• Amyand
• Littre
• Maydl
• Reduction en-masse
• Intestinal stenosis of Garre

15. Other hernia types
n.b. incisional & parastomal hernia not included

16. Giant inguinal hernia
• Inguinal hernia that extends below the
midpoint of inner thigh when the patient is in
standing position
• Complications of reduction
– Abdominal compartment syndrome (loss of
domain >20%)
– Seroma
– Haematoma

17. Management
• Pre-operatively
– Increase intra-abdominal volume
• Progressive pneumoperitoneum
– Ensure adequate room in abdominal cavity by pneumoperitoneum before reduction of the
hernia contents
– Gradually insufflating gas into abdominal cavity via placed catheter in situ, usually in increments
of between 500 – 2000cc/day over 7 –14 days4
– Ambient air, oxygen, carbon dioxide and nitrous oxide
– Multiple sittings needed
• Intra-operatively
– Resection of contents
• Resected organs usually the colon, small bowel or omentum
• Single-stage operation
• Risk of anatomotic leak & mesh infection
– Rotation of viable tissue5, 6
• Scrotal skin flap, tensor fascia latae musculocutaneous flap & component separation
technique
• Single-stage procedure but specific surgical expertise required to prevent complications

20. Umbilical hernia
• Mid-abdominal location, centered around the
umbilicus
• Typically small
Umbilical (Direct) Paraumbilical (Indirect)
Patient Paediatric majority Adult majority
Clinical The whole umbilicus is symmetrically
effaced & it loses its characteristic
shape
Umbilicus has crescent appearance due to
an asymmetrical effacement
Defect Thru the umbilical ring Superior or inferior to the umbilical ring
Pathophysiology Failure of umbilical ring to close Congenital weak point between umbiical
ring and linea alba
Differential
diagnosis
Omphalocele Port site hernia post laparoscopic surgery
Adapted from Compendium of 100 Surgical Cases in Sibu Hospital

22. • Management
– Elective
• Open
– Mesh repair: Onlay vs. inlay vs. sublay repair
– Non-mesh repair: anatomical vs. Mayo repair
• Laparoscopic intraperitoneal onlay mesh repair (IPOM)
– Emergency
• Transverse incision feasible

23. Type Pros Cons
Onlay
Mesh placed anterior to fascia Relatively simple
Acceptable recurrence rate 5 – 15%
Skin flaps created to accommodate mesh
might be devascularised, predisposing to
seroma and infection
For large defects (>10cm), repair in
combination with component separation
Inlay
Mesh placed to bridge the fascial defect Relatively simple Abdominal pressure exerted directly on
mesh, detaching it away from fascial edges
Need a composite mesh (expensive) as
mesh in direct contact with peritoneal
content
Does not allow tissue-mesh integration
Obsolete due to high (3x) recurrence & SSI
rates
Sublay
Mesh placed posterior to recti muscles
where the force of abdominal pressure
holds the mesh against the posterior
surface of muscles
Lowest recurrence rate (3.5%)
Tissue integration superficial & deep to
mesh
Mesh protected from superficial SSI &
intra-abdominal adhesion/contamination
Technically challenging
Large dead space posterior to recti with
resultant seroma
Adapted from Compendium of 100 Surgical Cases in Sibu Hospital

25. Epigastric hernia
• AKA epiplocele
• Along linea alba
• Usually small
• Differentiate from divarication of recti

26. Obturator hernia
• Hyperesthesia or pain in the medial thigh or in the
region of the greater trochanter
• Relieved by thigh flexion
• Worsened by medial rotation, adduction, or extension
at the hip
• Typically an elderly, frail lady who had lost signifcant
body fat thus opening up the obturator foramen
• Management
– Elective
• Laparoscopic repair
– Emergency
• Laparotomy (bowel gangrene common)

28. Spigelian hernia
• Thru linea semilunaris
• Pain worsens with abdominal wall muscle
contraction
• Prone to incarcerate or obstruct
• Management
– Transverse incision over hernia sac
– Midline laparotomy seldom

29. Lumbar hernia
• Thru lumbar triangles
– Superior (Grynfeltt-Lesshaft)
– Inferior (Petit)
• Vague flank discomfort + mass
• Seldom incarcerate
• Management
– Non-operative
– Open posterior mesh repair via skin-line oblique
incision from 12th rib – iliac crest

31. Sciatic hernia
• Intestinal obstruction
• Ureteric obstruction
• Sciatic pain
• Tender mass in the gluteal area
• Differentials
– Lipoma
– Tuberculoma
– Soft tissue malignancy
• Management
– Elective
• Open transgluteal
– Emergency
• Open transperitoneal

32. TQ!
Q&A?