Abdominal Hernias

in Adult
Kiki Lukman
Division of Digestive Surgery
Medical School, Padjadjaran
University
Specific learning objectives :

• Describe the definition, incidence, and types of

abdominal hernias.
• Describe the abdominal wall anatomy, in
conjunction with the pathogenesis of abdominal
hernias.
• Discuss the ethiology, clinical manifestions,
diagnosis, and treatment of inguinal hernias.
• Describe 9 other types of hernia
Definition :

• Protrusion of abdominal content through a defect

or weakness part on the abdominal wall
• Weak site : musculo -aponeurotic part
• Hernias consist of :
– ring
– sacc
– content.
Types of Hernias of
Abdominal wall
• INGUINAL ABDOMINAL WALL
– Indirect inguinal, Direct inguinal, Femoral
• ANTERIOR ABDOMINAL WALL
– Umbilical, Epigastric, Spigelian, Supravesical
• PELVIC
– Obturator, Sciatic, Perineal
• LUMBAR
– Superior lumbar triangle (Grynfelt)
– Inferior lumbar triangle (Petit)
Anatomy of abdominal wall :
Inguinal Anatomy
Inguinal Hernia :

• Incidence
– Not known
– Western countries : 10-15%, Male : female = 12:1
– Peak incidence : infant , adult : 40 - 60 years old
– Lichtenstein 1993: 700000 operations/year in USA
Etiology

• Congenital or Acquired
• Three important factors
– Existing “preformed sac”
– Repetition of increased intraabdominal
pressures
– Weakness of muscle & aponeurotic tissues
~ time (age)
Types of Inguinal Hernia :
Clinical Manifestations :

• Predisposition : occupation  weight lifting

• Local symptoms:
– reducible - irreducible lump
– groin dyscomfort, pain

• Systemic symptoms: Cardinal signs of

obstruction
– Colicky abdominal pain, vomiting, abdominal
distenstion, and constipation.
 Clinical Grading

Reduction pain Obstruction toxic

Grade
• reponible + - - -
• irreponible - - - -
• incarceration - colic + -
• strangulation - steady + ++
increase
leucocytosis
Physical Examination

• Position
• Temperature
• Pain
• Size
• Shape
• Tensile strength
•
•
Composition (solid, gas, liquid)
Changes with cough X
Differential Diagnosis

• Femoral hernia
• Vaginal hydrocele
• Hydrocele of cord / canal of Nuck
• Undescended testis
• Lipoma of the cord
Treatment

• Indication of Surgery
– All groin/inguinal hernias
• Minimal operative risks (~0)
• Risk of untreated hernia :
Strangulation with attendant risks

concomitant medical problems do not

preclude the need of undergoing surgery
Treatment :

• 1500 BC First reported case of groin hernia

• 700 AD Paul from Aegina
– Hernial sacc ligation
– Excision of hernial sacc
Treatment :

• 1884 Edoardo Bassini (Italy)

– “Father of Modern Herniorrhaphy”
– Dissection and reconstruction of the inguinal canal
– Splitting of obliqus externus aponeurosis
– Dissection & high ligation of hernial sacc
– Suturing the obl. int m., transv. Fascia, to inguinale
ligament
Eduardo Bassini Herniorhhapy
Chester B McVay, MD, PhD
1940 (Cooper’s ligament repair)
S EE Shouldice, 1945

– multilayer repair
– recurrence rate < 1%
– complicated,
– extensive dissection
Tension Free =Mesh Graft

• 1987 : Gilbert
Ger 1990, Velez und Klein 1990
Laparoscopic Inguinal Hernia Repair

• Transperitoneal / preperitoneal
Femoral Hernia :

• Incidence :
– Female : Male = 4/1
– Multiparous woman
– Elderly woman

• Frequent complications : Strangulation, Richter

hernia
• Treatment : Mc Vay herniorrhapy
Umbilical Hernia

• Protrusion of abdominal content through the

umbilical ring into the abdominal wall.
• Congenital defect
•  > 2 cm :
Regression (-)
• Often incarcerated
• Th/ : Vest over pan,
mesh graft
 Epigastric hernia :

• Protrusion of
abdominal content
through a defect in
the linea alba.
• May mimic
peptic ulcer
• Th/ reposition
the sacc, close the
defect
Ventral Hernia

• Incisional hernia :
post operative
• Predispostion :
– wound infection
– faulty technique
– wound dehiscence
– obesity
– malnutrition
Spigelian hernia :

• Hernia at linea
semilunaris Spigeli
• D/: USG
• Th/ Herniotomy and
close the defect
Lumbar hernia :

• Hernia :
– Grijnfelt
– Petit

• Th :
– Herniotomy
– Hernioplasty
Pelvic Hernia

• Obturator hernia,:
– Howship Romberg
sign
– DRE : hernial lump

• Sciatic hernia
• Th/: operative
Perineal hernia

• protrusion of tissues
through the muscles and
fasciae of the pelvic
diaphragm.
• Anterior hernia: labial,
pudendal, or vaginolabial
• Posterior hernia
• Th:transabdominal
Other Hernias :

• Littre Hernia, Scrotal hernia

• Internal Hernia :
– paraduodenal
– mesenteric
– Foramen of Winslow Hernias
– Diaphragmatic hernia