Simple notes on definition of abdominal hernias in general, as well as clinical features and management of inguinal hernias. Brief explanation of hernia repair methods (laparoscopic, open surgery)

1. DEFINITION & TYPES
OF HERNIA
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2. “‘HERNIA’
Greek - an offshoot / bulge
Latin - to tear / rupture
An abnormal protrusion of an organ
or part of an organ through
a defect / weakness in the wall of
the cavity normally containing it
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3. Structural weakness
Anatomy, congenital, collagen diseases,
aging, neurological & muscular diseases
Intra-abdominal pressure
Pregnancy, COPD, ascites, tumours,etc.
Injury
Trauma (Sharp / blunt), surgical incision
(defective healing, poor technique)
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CAUSES

4. DEFINITIONS
Reducible
Contents can be returned to
the abdomen when given
pressure on.
Irreducible
Contents cannot be reduced
or pushed back into the
abdomen but no complication.
Mild / absent symptoms
Obstructed
The herniated part of bowel is
irreducible but has good
blood supply.
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Incarcerated
Irreducible hernia with viable
contents, used synonymously
with obstructed hernia.
Contents of the hernial sac
are stuck to one another by
adhesions
Strangulated
Visceral contents of hernia
become twisted or entrapped
by narrow opening
Compromised blood supply,
ischaemic / necrotic contents
Painful / tender on palpation
Sliding
Part of a viscus (e.g. colon) is
adherent to the outside of the
peritoneum (extraperitoneal)
forming the hernial sac
beyond the hernial orifice)
Usually on the left.

5. COMPOSITION OF A HERNIA
Sac
Mostly the
diverticulum of
peritoneum
(Mouth, neck,
body, fundus)
Covering of
the sac
Composed of
the layers of
abdominal wall
through which
the sac passes.
Contents of
the sac
Depending on
the part of
abdomen that is
herniated
Omentum,
intestines, etc.
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6. TYPES OF HERNIA - ANATOMICALLY
Based on location
▰Inguinal Hernia
▰Femoral Hernia
▰Umbilical Hernia (14%)
▰Epigastric Hernia (7%)
▰Para-umbilical Hernia
▰Incisional Hernia (9%)
▰Hiatal Hernia
▰Spigelian Hernia
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}(70%)

7. TYPES OF HERNIA
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8. TYPES OF HERNIA
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9. INGUINAL
HERNIAS¾ of all abdominal wall hernias
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Direct
Indirect

10. DIRECT vs INDIRECT INGUINAL HERNIA
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11. TYPES OF INDIRECT INGUINAL HERNIAS
3) Bubonocele: Hernia does not
come out of the superficial
inguinal ring and is limited to the
inguinal canal.
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1) Complete Hernia: Hernial
sac is patent up to the bottom
of the scrotum (males)
or labia majora (females).
2) Incomplete Hernia: The
process vaginalis sac is
patent up to root of scrotum
but it comes out through the
superficial inguinal ring.

12. PHYSICAL EXAMINATION
Inspection:
▰Swelling: Pyriform shape
extending down – indirect;
circular shape – direct;
spherical shape, starts from
below the inguinal ligament –
femoral.
▰Skin: Normal (uncomplicated);
erythema (strangulated)
▰Impulses on coughing:
Momentary bulge (absent if neck
of the sac is obstructed )
Palpation:
▰Non-tender unless strangulated
▰Granular (omentocele); elastic
(enterocele)
Zieman’s Technique:
▰Differentiate
direct/indirect/femoral
Method: Place the index finger
(indirect) over the deep inguinal ring
the middle finger (direct) on the
superficial inguinal ring and the ring
finger (femoral) over the saphenous
opening and ask the patient to
Ring occlusion test:
▰Differentiate indirect/direct
Method: Performed in standing
position, ask patient to cough when
thumb is pressed on the deep
inguinal ring - bulge medial to thumb
(direct)
Percussion:
▰Resonance (enterocele); dullness
(omentocele or fatty tissue)
Auscultation: Not applicable
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Position of patient: First standing, then lie supine

13. CLINICAL FEATURES
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May be asymptomatic and found incidentally.
Site: Groin area
Onset: Gradual / acute (incarceration)
Character: Burning, gurgling, or aching pain with heavy or dragging sensation in
the groin
Radiation: Localized, may radiate to the scrotum
Associated symptoms: Weakness in groin, (if strangulated) nausea & vomiting,
fever and inability to pass gas / stool

14. CLINICAL FEATURES (continued)
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Time / Duration: Constant, worse toward the end of the day or after prolonged
activity
Exacerbating factors: Worsen with Valsalva maneuvers. Activities that increase
intra-abdominal pressure, i.e. coughing, lifting, or straining, cause more abdominal
contents to be pushed through the hernia defect.
Severity: Mild to severe
Progression: Bulge of the hernia gradually increases in size, suddenly intensified
pain may indicate strangulation
* If bulge disappears while patient is in the supine position, clinical suspicion of a hernia should be
increased.

15. Hernia repair techniques – indicated in irreducible, symptomatic cases
1) Open or conventional hernia repair
2) Laparoscopic hernia repair
Gold standard - Mesh Repair
▰ Hernioplasty – Herniotomy plus reinforcement of the posterior wall
of the inguinal canal with a synthetic mesh
▰ Herniorrhaphy – Herniotomy plus repair of the posterior wall of the
inguinal canal
▰ Herniotomy – Removal of hernia sac without any repair of the
inguinal canal
MANAGEMENT OF INGUINAL HERNIA
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16. OPEN INGUINAL HERNIA REPAIR
Mesh inserted to cover and support the
posterior inguinal canal. (Hernioplasty)
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* PHS – PROLENE hernia system
Before After

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LAPAROSCOPIC INGUINAL HERNIA
REPAIR
Performed under GA, extra-/ trans-peritoneally.
Not appropriate for large or irreducuble hernias.

18. ADVANTAGES OF REPAIR TECHNIQUES
▰Laparoscopic repair:
▻ Faster recovery times
▻ Less risk of long-term
pain
▻ Lower risk of another
hernia recurrence
after a previous
recurrence
▰Open hernia repair:
▻ Fewer internal injuries
▻ Lower recurrence
rates in the context of
primary inguinal
hernia
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THANK YOU!
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