HERNIAS

Marcelyn Coley
Mount Sinai School of Medicine
Basic Science Lecture
 Historical Perspective
 15th century -
Castration with wound
cauterization or hernia
sac debridement

 recommended a truss
Father of Modern Inguinal Hernia
Repair

EDUARDO BASSINI
 Hernia
 Latin for rupture

 an abnormal protrusion of an organ or tissue

through a defect in its surrounding walls

 Occur at sites where aponeurosis and fascia

are not covered by striated muscle
Which of the following statements is/are true
regarding incidence of the abdominal wall hernia?

A. Two-thrirds of all inguinal hernias are

classified as indirect.
B. Femoral hernias are more common in
females than in males.
C. Direct hernias are common in females.
D. Hernias generally occur with equal
frequency in males and females
E. Premature babies have a 10% incidence of
having inguinal hernia.
 Epidemiology
 700,000 hernia repairs year
 Inguinal hernias -75% of all hernias
 2/3 Indirect, remainder are direct
 Incisional hernias – 15 to 20%
 Umbilical and epigastric – 10%
 Femoral – 5%
 Epidemiology
 Prevelance of hernias increases with age
 Most serious complication – strangulation
 1 to 3% of groin hernias
 Femoral – highest rate of complications 15%
to 20%
 recommended all be repaired at time of discovery
Abdominal Wall
Anatomy
 Anatomy
 Inguinal ligament
(Poupart’s) – inferior edge
of external oblique
 Lacunar ligament –
triangular extension of the
inguinal ligament before
its insertion upon the pubic
tubercle
 conjoined 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.
Inguinal Canal
 Between deep and
superficial inguinal rings

 Boundaries
 Superifical – external
oblique aponeurosis
 Superior – internal and
transversus
 Inferior – shelving edge of
inguinal ligament and
lacunar ligament
 Posterior (floor) –
transversalis fascia and
aponeurosis of transversus
abdominis muscle
 Inguinal Canal
 Contains the spermatic
cord and round ligament
of the uterus
 Spermatic cord
 Cremasteric muscle fibers
 Testicular vessels
 Genital branch of
genitofemoral nerve
 Vas deferens
 Cremasteric vessels
Components of Hesselbach’s triangle include which
of the following anatomic landmarks?

A. Pectineal ligament
B. Lateral border of the rectus sheath
C. Cooper’s ligament
D. Inguinal ligament
E. Inferior epigastric vessels
 Terminology
 Reducible – can be replaced within
surrounding musculature

 Incarcerated – cannot be reduced

 Strangulated – compromised blood supply to

its contents
Sends sensory branches to the inner thigh and
medial aspect of the scrotum

A. Ileoinguinal nerve
B. Genitofemoral nerve
C. Both
D. Neither
A sliding inguinal hernia on the left side is likely to
involve which of the following?

A. Jejunum composing the posterior wall of the

sac
B. Ovary and fallopian tube in a female infant
C. Omentum
D. Sigmoid colon composing the posterior wall
of the sac
E. Cecum composing the anteromedial wall of
the sac
 Terminology
 Pantaloon – direct and indirect components
 Richter’s – contains antimesenteric portion of
small bowel
 Sliding – involves visceral peritoneum of an
organ , i.e. bladder, ovary
 Littre’s – hernia contains Meckel’s diverticulum
 Petit – hernia at inferior lumbar triangle
 Grynfelt – hernia at superior lumbar triangle
 Groin Hernias
 Indirect
 Direct
 Femoral
 Inguinal Hernia
 Classified as congenital vs. acquired

 commonly thought that repeated increases in

intra-abdominal pressure contribute to hernia
formation

 collagen formation and structure deteriorates

with age, and thus hernia formation is more
common in the older individual.
 Clinical Presentation
 Groin bulge
 Often asymptomatic
 Dull feeling of discomfort or heaviness in the
groin
 Focal pain – raise suspicion for incarceration
or strangulation
 Symptoms of bowel obstruction
 Inguinal hernia

Male inguinal hernia Female inguinal hernia

 Diagnosis
 Physical Exam
 74.5% sensitive and
96.3% specific
 examine the patient in
the standing and supine
positions
 difficult to distinguish
direct and indirect on
exam on alone
 Diagnosis
 Radiologic Investigations
 Herniography
 Suspected hernia, but clinical dx unclear
 Procedure done under flouroscopy following injection
of contrast medium
 Frontal and oblique radiographs are taken with and
without increased intra-abdominal pressure
 Ultrasonography
 MRI
 CT
 Herniography

Left indirect inguinal

hernia

Right direct inguinal hernia

Direct Inguinal Hernia
 Direct Inguinal Hernia
 Medial to the inferior
epigastric artery and
vein, and within
Hesselbach's triangle

 acquired weakness in
the inguinal floor
 Indirect Inguinal hernia
 Abdominal contents protrude through internal
inguinal ring
 Indirect Inguinal Hernia
 Accepted hypothesis:
incomplete or defective
obliteration of the
processus vaginalis
during the fetal period
 remnant layer of
peritoneum forms a sac
at the internal ring
 more frequently on the
right
Femoral
 More common in females
 Up to 40% present as
emergencies with hernia
incarceration or
strangulation
 Passes medial to the femoral
vessels and nerve in the
femoral canal through the
empty space
 Inguinal ligament forms the
superior border
 Femoral
 palpation of the femoral canal just below the
inguinal ligament in the upper thigh

 NAVELS
Which of the following statements is/are true
regarding direct inguinal hernias?

A. The most likely cause is destruction of connective

tissue resulting form physical stress.
B. Direct hernias should be repaired promptly because
of the risk of incarceration.
C. A direct hernia may be a sliding hernia involving a
portion of the bladder wall.
D. A direct hernia may pass through the external
inguinal ring.
E. Colon carcinoma is a known cause of direct
inguinal hernias.
 Treatment
 Non-Operative
 Observation
 Trusses can provide symptomatic relief
 Hernia control in ~30% of patients
 Operative
 Bassini
 Shouldice
 McVay
 Lichtenstein
 Preperitoneal
 Laparoscopic
 Bassini (early 20th Century)
 Transversus abdominis to Thompson’s ligament and
internal oblique musculoaponeurotic arches or
conjoined tendon to the inguinal ligament
 Shouldice (1930s)
 Multilayer imbricated repair of the posterior wall of the
inguinal canal
 McVay (1948)
 Edge of the transversus abdominis aponeurosis to
Cooper’s ligament; incorporate Cooper’s ligament and
the iliopubic tract (transition suture)
BASSINI MCVAY

SHOULDICE
 Lichtenstein
 First pure prosthestic, tension-free repair to
achieve low recurrence rates
 Prosthetic Repair
 Polypropylene mesh most common and
preferred
 allows for a fibrotic reaction to occur between the
inguinal floor and the posterior surface of the
mesh, thereby forming scar and strengthening the
closure of the hernia defect
 Polytetrafluoroethylene (PTFE) mesh
 often used for repair of ventral or incision hernias
in which the fibrotic reaction with the underlying
serosal surface of the bowel is best avoided
 Prospective study
 Danish Hernia database
of over 13,000 hernia
repairs
 Compared re-operations
for recurrent hernia
 Results: After 5 years
significantly lower (1/4
less) recurrence with
mesh vs. sutured repair
Laparoscopic
The cause of neuropathic postherniorrhaphy
inguinodynia includes which of the following?

A. Formation of scar tissue

B. Transection of the ilioinguinal,
iliohypogastric, or the genitofemoral nerves
C. Suture entrapment of nerves
D. Staple entrapment of nerves
E. Periosteal reaction
 Surgical Complications
 Recurrence
 Infection
 Neuralgia
 Bladder injury
 Testicular injury
 Vas Deferens injury
Other Hernias
Which of the following is/are true statements
regarding umbilical hernias?

A. They are embryonic equivalent of a small

omphalocele
B. Repair in infants is usually deferred until
approximately 4 years of age
C. Repair in adults is usually indicated
D. The “vest-over-pants” type of repair is stronger than
simple approximation of fascial margins
E. They are most common in Caucasian infants
 Umbilical
Incidence
 Reported ~10%

 several times greater in Black children

 more common in premature children all races

 Most close spontaneously by age 2 or 3

 Acquired rather than congenital in adults

 Female to male ratio 3:1

 Epigastric
 midline junction of the
aponeuroses (linea alba)
between the xiphoid
process and umbilicus
 Paraumbilical hernia -
epigastric hernia that
borders the umbilicus
 Estimated frequency 3-5%
 More common in Males 3:1
 20% may be multiple
 Epigastric
 Clinical
 Often asymptomatic, incidental finding
 If symptomatic, vague abdominal pain above the umbilicus
exacerbated by standing or coughing; relieved in supine position
 Severe pain secondary to incarceration/strangulation of preperitoneal
fat (often no peritoneal sac) or omentum
 Exam: palpate small, soft, reducible mass superior to the umbilicus

 RARE to have strangulated bowel

 Tx
 Excise fat and sac, close primarily
An 82-year-old previously healthy woman has a 12-hour history of severe
epigastric pain associated with nausea and vomiting. She has had no previous
abdominal operations. Her WBC count is 21,000/cu mm. The plain films and
abdominal CT shown are obtained.
Which of the following best
describes this patient’s diagnosis?
A. Pain in the medial thigh and knee is
uncommonly associated with this condition
B. It is unusual in women
C. It is unusual in elderly patients
D. It is seldom associated with intestinal
necrosis
E. It is usually unilateral
Obturator
 Rare form of hernia
 Protrusion of intra-abdominal
contents through obturator
foramen
 F:M ratio 6:1
 The obturator foramen is formed
by the ischial and pubic rami
 obturator vessels and nerve lie
posterolateral to the hernia sac in
the canal
 Small bowel is the most likely
intraabdominal organ to be
found in an obturator hernia
 Obturator
 4 cardinal signs :
 intestinal obstruction (80%)
 Howship-Romberg sign (50%) –History of repeated
episodes of bowel obstruction that resolve quickly and
without intervention
 Palpable mass (20%)

 Tx: Sugical Repair

 Spigelian Hernia
 occurs along the semilunar
line, which traverses a
vertical space along the
lateral rectus border

 where more than 90% of

spigelian hernias are found
 Spigelian Hernia
 Clinical
 Swelling in middle to
lower abdomen lateral to
rectus muscle
 Usually reducible
 Up to 20% present with
incarceration
 Tx: surgical
 Mesh not required
 Recurrence is uncommon
Lumbar

 Acquired lumbar hernias –

 back or flank trauma,
poliomyelitis, back surgery,
and the use of the iliac crest
as a donor site for bone grafts
 Contains to anatomic
triangles, inferior and
superior lumbar triangles
 Grynfelt’s
 Petit’s
 Strangulation is rare
 Soft swelling in lower
posterior abdomen
 Sciatic
 Via greater or lesser sciatic
notch
 greater sciatic notch is
traversed by the piriformis
muscle, and hernia sacs can
protrude either superior or
inferior to this muscle
 suprapiriform defect 60%
 Infrapiriform 30%
 subspinous (through the
lesser sciatic foramen) 10%
Which of the following hernias is most likely to recur
after primary repair?

A. Epigastric hernia
B. Spigelian hernia
C. Indirect hernia
D. Femoral hernia
E. Incisional hernia
 Ventral wall (Incisional)
 Highest incidence in midline and
transverse incisions
 Up to20% after laparotomy
 1/3 present in 5-10 years
postoperatively
 Risk factors
 obesity, DM, ascites, steroids,
smoking malnutrition, wound
infection
 Technical aspects of wound
closure
 Type of incision
 Excessive tension (prone to
fascial disruption)
Which of the following hernias represent an
incarceration of a limited portion of small bowel?

A. Spigelian hernia
B. Grynfelt’s hernia
C. Petit’s hernia
D. Richter’s hernia
E. Littre’s hernia