Hernia
INTRODUCTION
•Hernia means—To bud' or 'to protrude', 'offshoot‘ [Greek], 'rupture'
[Latin].
•Hernia is defined as an abnormal protrusion of a viscous or a part of a
viscous through an opening, artificial or natural with a sac covering it.
•Inguinal is the commonest hernia [73%] because the muscular anatomy
in the inguinal region is weak and also due to the presence of natural
weakness like deep ring and cord structures.
•Femoral is 17%; Umbilical is 8.5%.; Others are 1.5%.
ETIOLOGY
• Straining.
• Lifting of heavy weight.
• Chronic cough ( Tuberculosis , chronic bronchitis, bronchial asthma, emphysema).
• Chronic constipation (Habitual, rectal stricture)
• Urinary causes
- Old age: BPH, carcinoma prostate
- Young age: Stricture urethra
- Very young age: Phimosis, meatal stenosis.
• Obesity.
• Pregnancy and pelvic anatomy (especially in femoral hernia in females).
• Smoking.
• Ascites.
•Appendicectomy through McBurney's incision may injure the ilioinguinal nerve
causing right sided direct inguinal hernia.
• An indirect inguinal hernia occurs in a congenital, preformed sac, i.e.the remains of
processus vaginalis. Chances of presence of bilateral preformed sac is 60%.
• Familial—collagen disorder -Prune Belly syndrome.
PARTS OF HERNIA
Hernia comprises of:
i. Covering.
ii. Sac.
iii. Content.
Sac is a diverticulum of peritoneum with mouth, neck, body and fundus.
Coverings of the sac are the layers of the abdominal wall through which the
sac passes.
Contents of Sac
Omentum—Omentocele (Epiplocele).
Intestine—Enterocele— commonly small bowel, but sometimes even large
bowel.
Richter’s hernia: A portion of circumference of bowel is the content.
Urinary bladder may be the content or part of the posterior wall of the sac—
cystocele.
Ovary, often with fallopian tube.
Meckel’s diverticulum—Littre’s hernia.
GENERAL CLASSIFICATION OF HERNIA
Classification I: (clinical)
1. Reducible hernia: Hernia get reduced on its own or by the patient or by the
surgeon. Intestine reduces with gurgling and first portion is difficult to reduce.
Omentum is doughy and last portion is difficult to reduce. Expansile impulse on
coughing present.
2. Irreducible hernia: Here contents cannot be returned to the abdomen due to
narrow neck, adhesions, overcrowding etc. Irreducibility predisposes to strangulation.
3. Obstructed hernia: It is an irreducible hernia with obstruction but blood supply to
the bowel is not interfered. It eventually leads to strangulation.
4. Inflamed hernia: It is due to inflammation of the contents of the sac e.g.
appendicitis, salpingitis. Here hernia is tender but not tense; overlying skin is red and
edematous.
5. Strangulated hernia: It is due to obstruction causing blockage of blood supply
leading into gangrene of the content. It is a surgical emergency . Patient will be toxic ,
with irreducibility and pain and tenderness . Emergency surgery, resection of the
bowel and anastomosis should be done.
Classification II
Anatomical classification [in inguinal hernia]
Indirect hernia - It arises through internal ring along with the cord. It is lateral to the
inferior epigastric artery.
Direct hernia - It occurs through the posterior wall of the inguinal canal. Sac is medial
to the inferior epigastric artery.
Classification III
According to the extent.
Bubonocele : Here sac is confined to the inguinal canal.
Funicular: Here sac crosses the superficial inguinal ring but does not reach the bottom
of the scrotum.
Complete: Here sac descends to the bottom of the scrotum.
Diagram showing the differences between indirect and
direct sacs.
Classification IV
i. Congenital.
ii. Acquired.
Classification V
According to the contents.
iii. Omentocele—omentum.
iv. Enterocele—intestine.
v. Cystocele—urinary bladder.
vi. Litter's hernia—Meckel's diverticulum.
vii. Sliding hernia - When the wall of the hernial sac (usually the posterior wall) is
formed by a viscus then it is called a sliding hernia. On the right cecum or urinary
bladder may form the posterior wall of the sac and on the left side sigmoid or
urinary bladder may form the posterior wall of the hernial sac
viii. Richter's hernia—part of the bowel wall.
INGUINAL HERNIA
SURGICAL ANATOMY OF INGUINAL CANAL
Superficial inguinal ring is a triangular opening in the external oblique aponeurosis
and is 1.25 cm above the pubic tubercle. Normally the ring does not admit the tip of
little finger.
Deep inguinal ring is a U-shaped condensation of the transversalis fascia, lies 1.25 cm
above the inguinal ligament midway between the symphysis pubis and the
anterosuperior iliac spine.
Inguinal (Poupart’s) ligament: It is formed by the lower border of the external
oblique aponeurosis which is thickened and folded backwards on itself, extending from
anterosuperior iliac spine to pubic tubercle.
Inguinal canal: It is an oblique passage in lower part of abdominal wall, 4 cm long,
situated above the medial ½ of inguinal ligament, extending from deep inguinal ring to
superficial inguinal ring.
In infants both superficial and deep rings are superimposed without any obliquity of
the inguinal canal. Inguinal canal in female is called as ‘canal of Nuck.’
Contents of inguinal canal
1. Spermatic cord in males
2. Round ligament in females
3. Ilioinguinal nerve
Contents of spermatic cord
i. Vas deferens
ii. Artery to vas
iii. Testicular and cremasteric artery
iv. Genital branch of genitofemoral nerve
v. Pampiniform plexus of veins
vi. Remains of processus vaginalis
vii. Sympathetic plexus around the artery to vas
Boundaries
In front: External oblique aponeurosis and conjoined muscle laterally.
Behind: Inferior epigastric artery, fascia transversalis and conjoined tendon
medially.
Above: Conjoined muscle (Arched fibres of internal oblique).
Below: Inguinal ligament.
Clinical Features
Prevalence of inguinal hernia is 25% in males; 2% in females.
It is more common in males (20 : 1 :: Male : Female).
Patient presents with dragging pain and swelling in the groin which is better seen
while coughing and stan ding; and felt together with an expansile impulse.
In complete type, the content descends down to the scrotum completely.
Contents are either small bowel, large bowel, omentum or combination of all these.
In females, sometimes ovary and tubes may be the content. In infants, swelling
appears when the child cries and is often translucent.
It is usually reducible, but can go for irreducibility, inflammation, obstruction,
strangulation.
Internal ring occlusion test:
After reducing the contents, in lying down
position, internal ring is occluded using
the thumb. Patient is asked to cough.
If a swelling appears medial to the thumb,
then it is a direct hernia. If swelling does
not appear and on releasing the thumb
swelling appears during coughing, then it
is an indirect hernia confi rmed in
standing position.
Expansile impulse on coughing
On inspection patient is asked to cough—the expansile impulse on cough may be seen
over the swelling. This is visible expansile impulse on cough.
On palpation: keep thumb in front and index and middle fingers behind the swelling at
the root of the scrotum and ask the patient to cough. The expansile impulse can be
appreciated by the palpating finger as the thumb and other fingers get separated
Palpate with the thumb infront and the index and middle finger
behind and ask the patient to cough. Expansile impulse may be
appreciated by the palpating fingers
Get above the swelling
Start palpating the swelling from the bottom of the scrotum between the thumb in
front and index and middle fingers behind and gradually palpate upward toward the
root of the scrotum.
In case of the inguinoscrotal swelling the thumb and other two fingers do not meet at
the root of the scrotum as the swelling continues in the groin. So it is not possible to
get above the swelling in case of inguinoscrotal swelling.
In case of a scrotal swelling the thumb and other two fingers meet each other at the
root of the scrotum and only the spermatic cord is palpable inbetween the fingers;
suggesting this to be a scrotal swelling
Zieman’s test
Hernia is reduced. Three fingers are
placed—index finger over the deep
ring, middle finger over the superficial
ring and ring finger over the femoral
ring and the patient is asked to cough
If impulse touches the index finger
—indirect inguinal hernia
If impulse touches the middle
finger—direct hernia
If impulse touches the ring finger—
femoral hernia
Abdominal, respiratory, urological examination is done to look for any precipitating
factors like chronic bronchitis, ascites, stricture urethra, BPH.
Per rectal examination is a must.
Palpation of bulbar urethra for stricture (thickening).
Investigations
Chest X-ray to rule out chronic bronchitis.
pulmonary functiontest to exclude any obstructive or restrictive pulmonary disease.
Ultrasound of abdomen.
Blood for Hb%. Total count and differential count (TLC–DC)
Blood for sugar, urea and creatinine
Urine for routine examination
12-lead-ECG
Treatment
Always Surgery
In infants: Whether it is hernia or hydrocele, only herniotomy is done.
In adults: It includes herniotomy, i.e. excision of hernial sac and herniorrhaphy or
hernioplasty (ideal) (strengthening of the posterior wall of inguinal canal either by
repair or mesh).
Precipitating causes should be treated fi rst, like TURP for BPH, dilatation of stricture
urethra, treat ment of chronic bronchitis. Patient is advised to avoid smoking.
Complications of herniorrhaphy
•Haemorrhage
•Haematoma, seroma
•Infection—1-5%
•Hyperaesthesia over the medial side of inguinal canal due to injury to iliohypogastric
nerve—neuralgia (15%)
•Recurrence—10-15%
