HERNIA

IN PEDIATRIC AND ADULT

dr.Budi Arnofyan Sp.B Sp.BA(K)
 DEFINITION

• Protrusion of a part or whole of viscus

through an abnormal opening in the wall
of the cavity that contains it
Common Hernias Rare Hernias

Inguinal Spigelian
Umbilical Lumbar
Femoral Gluteal
Epigastric Sciatic
Incisional Obturator
 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
 Increased Abdominal
Pressure
• Chronic constipation

• Chronic Cough

• Bladder outlet obstruction – stricture, prostrate

• Straining – weight lifting

• Intra Abdominal malignancy

• Vomiting

• Repeated Pregnancy
 HERNIA

• Covering

• Sac

• Content

• Omentocoele

• Enterocoele

• Cystocoele

• Ovary
• Richter’s

• Littre’s

• Maydl’s
 Classification

• Reducible

• Irreducible

• Obstructed/ Incarcerated

• Strangulated
 Reducible Hernia

• Characteristic Signs

• Reducibility

• Cough Impulse
 Irreducible Hernia

• Due to

• Adhesion

• Narrowing of neck

• Incarceration

• Massive Hernia Inside Scrotum

 Obstructed Hernia

• Irreducibility + Intestinal Obstruction

• Features

• No Cough Impulse

• Irreducible

• Painless

• Non Tender

• Features of Intestinal Obstruction

 Strangulated Hernia

• Blood supply of its contents impaired

• Intestinal Obstruction

• Pathology

• Intestinal Obstruction

• Dilation of hernia contents

• Impairment of venous return

• Stasis —> Arterial Impairment

• Appearance

• Congested and bright red

• Ecchymosis

• Extravasation of blood into lumen / sac

• Loss of tone

• Translocation of gut bacteria - Peritonitis / sepsis

• Gangrene
• Symptoms:

• pain, vomitting

• Ceases with onset of gangrene, ileum

• Signs:

• Ill looking

• Tense, tender

• Irreducible, no cough impulse

• Acute intestinal obstruction

• Peritonitis
 Strangulated Omentocele

• No features of intestinal obstruction

• Gangrene onset delayed

Strangulated Richter’s Hernia

• Features mimic gastro enteritis

• Obstruction >50% of circumference

• Colic, diarrhea

• Constipation - ileus
 Maydl’s Hernia

• Retrograde strangulation

• On opening sac - contents appear normal

• Generalized peritonitis may set in early

 Inflamed Hernia

• Outside:

• Abrasion, ill fitting truss

• Inside:

• Diverticulitis, appendicitis

• Signs of inflammation (+)

• Not associated with intestinal obstruction

INGUINAL HERNIA
Anatomy
 Inguinal Canal

• Triangular slit 3.75

cm long

• Above the inner half

of inguinal ring

• Developed due to
the descent of testis
in embryonic life
 Deep Inguinal Ring

• Opening in the fascia

transversals

• 1.25 cm above mid

inguinal point

• Medially - inferior
epigastric artery

• Spermatic cord in
males; round ligament
in females
 Superficial Inguinal Ring

• Aponeurosis of external oblique - crural

• Above and lateral to pubic crest

• Spermatic cord / round ligament and illii-inguinal

nerves
 Borders

• Anteriorly - skin, fascia, EO, aponeurosis, lateral

third - IO aponeurosis

• Posteriorly - transversals fascia, medial 1/2 -

conjoint tendon

• Above - Transversus abdominins and internal

oblique fibers

• Below - inguinal ligament

• Illioinguinal nerves
Contents
• Spermatic cord

• Vas defrens

• Testicular artery, art to vas deferens, cremasteric

• Pampiniform plexus of veins

• Lymph vessel

• Testicular plexus of sympathetic nerves, genital branch of

genitofemoral
 Hassenbach’s Triangle
• Site of direct hernia

• Medially - lateral border

rectus abdomens

• Laterally - inferior
epigastric vessel

• Inferiorly - inguinal
ligament

• Floor - fascia
transversalis

• Umbilical fold -
obliterated umbilical
artery
 Mechanisms for Preventing
Hernia
• 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 obliques over deep inguinal ring

• Conjoint tendon
 Indirect Inguinal Hernia

• More common

• Young individuals

• More common on the right side

• On basis of extent

• Bubonocele

• Funicular hernia

• Complete hernia
• Coverings:

• Peritonium

• Extraperitoneal fat

• Internal spermatic fascia

• External spermatic fascia

• Superficial fascia

• Skin
 Direct Inguinal Hernia

• Directly through the Hasselbach’s Triangle

• Acquired ( ex- Oglive hernia )

• More common in elderly, malgaigne bulging

• Rarely gets strangulated

• Symptoms

• Pain/ discomfort

• Lump

• Systemic symptoms - Obstruction,

strangulation

• Predisposing Factors - Constipation, chronic

bronchitis, urinary obstruction

• Past history
• Signs

• Reducibility

• Cough impulse

• Position - d/f femoral hernia

• Get above the swelling

• Invagination test

• Ring occlusion test

 Rare Varieties

• Intersititial Hernia

• Between muscle layers of abdominal wall

• Commonly associated with undescendended testis

• Preperitoneal

• Intraperitoneal

• Extraperitoneal
 Rare Varieties

• Sliding hernia

• Older men

• Exztraperitoneal bowel with sac of peritoneum

• Caecum, pelvic colon, bladder

• Strangulation of intestine within and outside the

peritoneum
 Rare Varieties

• Richter’s

• Maydl’s

• Littre’s
 Treatment

• Conservative Management

• Surgical Management
 Conservative Management :
No Treatment

• Indications

• Severe ill health

• Short life expectancy

• Refuse operation
 Conservative Management :
Truss
• Indications

• Refuse operation

• Old patients with severe co morbidities

• Children ( c/i Undescended testis

• Contraindications

• Irreducible hernia

• Undescended testis

• Chronic bronchitis, stenos labour

• Associated with large hydrocele

• Not intelligent enough to position properly

 Dangers

• Pressure atrophy of muscles of inguinal region

• Obstruction or Strangulation

• Used with partially reduced hernia - may cause

trauma

• Improper cleanliness - unhealthy skin

• Adhesion between sac and canal

• Chance of strangulation remains

 Opertive Treatment
• Herniotomy

• Neck of sac transfixed, ligated and excised

• Infants and children; young men with good

musculature

• Herniorrhaphy

• Herniotomy + repair of posterior wall

• Indirect hernias

• Adults with goof muscle tone

 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
• Indications

• Indirect hernia - poor muscle tone

• Direct hernia

• Recurrant hernia

• Predisposing factors - chronic cough, etc

 Treatment of Strangulated
Hernia
• Emergency surgery

• Resuscitation

• Reduction of hernia

• Foot end elevation

• Ice Pack

• NGT , IVFD

• Analgesia

• Antibiotic
• Assese viability

• Green/ Black color

• Flaccid, lusterless appearance

• No peristalsis

• Blood stained, foul smelling fluid in sac

• Bowel Viable - HERNIORHAPHY

• Bowel non viable

• Linear patch of gangrene - invagination

• Loop of bowel - resection and anastomosis if

condition permits

• Bowel large intestine - exteriorization

 Recurrent Inguinal Hernia

• Types of hernia

• Sliding

• Large / Long standing

• Large direct hernia

• Types of patients - chronic cough

• Inadequate preoperative preparation

 Reccurent Inguinal Hernia

• Operative faults

• Failure to ligate sac

• Tension in repair

• Use absorbable suture

• Bleeding - infection

• Fault in selection of operation

• Postoperative care

• Wound infection

• Lifting heavy weight

• Persistence of predisposing factors

• Appearance of new hernia

Femoral Hernia
• Femoral ring - Femoral Canal - Saphenous opening

• More common in

• Females

• Old age

• Most liable to strangulate

Anatomy
 Coverings of the Sac of
Femoral Hernia
• Skin

• Superficial fascia

• Cribriform fascia

• Anterior layer of femoral sheath

• Fatty contents of femoral canal

• Femoral septum

• Peritoneum
 Umbilical Hernia

• Three major types

• Exomphalos

• Umbilical hernia in infants and children

• Paraumbilical hernia in adults

 Exomphalos

• Minor

• Small sac

• Summit attached to the umbilical cord

• Treatment

• Twisting of umbilical cord and strapping

 Exomphalos

• Major

• Umbilical cord attached to inferior

aspect of swelling

• Contains intestines, liver

• Surgical emergency

• Immediate decompresso and reduction

 Umbilical Hernia in Children
and Infants

• Weak umbilical scar following neonatal

sepsis

• Usually asymptomatic

• 90% cured within 12 -18 month

• > 18 month - Surgery

Paraumbilical hernia of adults

• Supraumbilical of Infraumbilical

• Adhesions - seldom

• Predisposing factors

• Women

• Obesity

• Repeated pregnancy

• Treatment - Mayo’s operation

 Epigastric Hernia
(Fatty Hernia of Linda Alba)
• Through fibres of lines alba

• Blood vessels pierce linea alba

• Initially extraperotonial fat only

• M.c - young muscular men with

strenuous activity

• Usually irreducible, no cough impulse

• If symptomatic - surgery
 Incisional Henia
(Ventral Hernia)
• Defect with patient

• Obesity

• Chronic cough preoperative period

• Undue abdominal distention

• Malnutrition

• Opertive

• Injury to nerves

• Careless wound closure

• Hemmorrhage - infection

• Tube drainage through laparotomy woundMidline infra umbilical

• Postoperative

• Infection

• Post cough, distention

• Post peritonitis

• Early removal of sutures

• Post steroid therapy

 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

 Treatment

• Prevention of incisional hernia

• Weight reduction

• Correct nutritional defects

• Treat chronic cough

• Careful closure of abdomen

• Prevent post op wound infection

• Conservative management

• Reducible type 1

• Surgical Management
 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