Abdominal Hernia ~~~~~~~~~~~~~~~~ Definition of a hernia An abnormal protrusion of an organ through the walls of the cavity that normally contains it History Known since ancient times Hernia cutter (legal contracts) First appendix was removed from a hernia sack Derivation Hernia - Her-n-ia Anatomy Surface anatomy; Anterior superior iliac spine; Run your finger up from the antero-lateral thigh until you feel the bone of the iliac crest, trace this forwards until you feel the bone come to a point; this is the anterior superior iliac spine. Pubic symphysis; This joins the two halves of the pelvis together in the midline. Run your finger from the abdomen below the umbilicus to the pelvis. Stop when you feel the boney pelvis, this is the pubic symphysis. Pubic tubercle; This is about 2.5 cm from the midline Run your finger about 2.5 cm from the midline along the pubic bone. It is very difficult to feel the pubic tubercle, even if the patient is extreemly thin. Mid inguinal point; Half way between the anterior superior iliac spine and the pubic symphysis. This is the location of the femoral artery. Mid-point of the inguinal ligament; Half way between the pubic tubercle and the anterior superior iliac spine. 2.5 cm above this point is the location of the deep inguinal ring. Inguinal canal; Boundries; Below; the inguinal ligament Superficial; Aponeurosis of External oblique Deep; Laterally; Transversalis fascia Medially; Conjoined tendon Reflected Part of inguinal ligament Above; Medially; Arching fibres of conjoined tendon Laterally; Transversus Abdominus muscle Contents; - Continuation of the transversalis fascia as the internal spermatic fascia containing o Vas deferens o Testicular artery surrounded by pampiniform plexus of veins o Some extraperitoneal fat - Continuation of the transversus abdominus and internal oblique muscles o Cremesteric muscle o The Ilio-inguinal nerve runs on the cremesteric muscle o The cremesteric artery comes from the inferior epigastric artery and supplies the cremesteric muscle; it gives some collateral supply to the testes - Continuation of the external oblique aponeurois o Becoms the external spermatic fascia at the superficial inguinal ring Hasselbach's triangle; The importance of this triangle is that a direct inguinal hernia emegers through this Laterally; The inferior epigastric artery Medially; The edge of the rectus abdominus muscle Below; The inguinal ligament Femoral canal; Space medial to the femoral vein, this space allows expansion of the vein when needed. The top end of the canal is the femoral ring; the importance of the femoral ring; - Narrowest part which forms the neck of a femoral hernia - An artery may run from the obturator artery to the inferior epigastric artery around the lacunar ligament, this artery may bleed if the lacunar ligament is cut to widen the neck of a femoral hernia. The bounderies of the femoral ring (top end of the canal); Medially; The lacunar ligament Laterally; The femoral vein Anteriorly; The inguinal ligament Posteriorly; The Pectineal Ligament (Coooper's ligament) Below the femoral ring the canal contains some fat and lymphatics; Anteriorly; The femoral sheath Posteriorly; The pectineal fascia over the pectineus muscle Laterally; The femoral vein Medially; The femoral sheath fuses with the pectineal fascia Parts of a hernia; Sack; The peritoneal lining exiting through the defect Neck; narrow area through which hernia emerges Body; The sack between the neck and the fundus Fundus; The most distal end of the sack Cause of hernia; Unknown The following may play a role; - Weak connective tissues, congential syndromes, Ehrles Danlos, Marfan's, association with aortic aneurysm - Potential weakness in wall of cavity enlarges; site of indirect inguinal hernia - Increased pressure pushing; constipation, coughing, bladder outlet obstruction Clinical classification of hernia; - Reducible - Irreducible - Obstructed - Strangulated Eponymous Hernia - Littre's - Maydl's - Spigelian Acute complications Acute irreducibility Intestinal Obstruction Strangulation Presentation Discomfort Pain; Mass; Intestinal obstruction Acute Abdomen Differential of mass in the groin - Hernia - Hydrocoele (Infantinle, Encysted) - Lymph node - Aneurysm - Sarcoma - Carcinoma - Cold Abscess - Ectopic breast tissue Examination Do not forget to examine the patient standing If there is a scrotal mass; see if you can get above it Locate neck of hernia and pubic tubercle; if the neck is below and lateral to the pubic tubercle the hernia is femoral, if the neck is above and lateral to the pubic tubercle the hernia is inguinal If the hernia is reducible; See if you can control it by pressure over the deep ring; thus differentiating indirect from direct inguinal hernia Consider examining the patient for the presence of bladder outlet obstruction and rectal cancer Treatment Acute irreducibility; bed rest and pain relief, avoid taxis Chronic heria; consider day case repair Operations Inguial hernia; Open repair Herniotomy, herniorraphy and hernioplasty Cord debulking Ilio-inguinal nerve Herniotomy Deep ring repair Posterior wall repair; Bassini, Maloney, Shouldice, Lictenstein Complications; Early Haematoma Urinary retention Wound infection Intermediate Testicular atrophy Late Pain Recurrance Laparopscopic repair Pre-peritoneal approach Trans-peritoneal approach (superceeded by pre-peritoneal) Problem areas Bilateral Inguinal hernia Recurrant hernia (Consider Posterior Pre-peritoneal approach) Post operative pain % vim: set ai ts=3 tw=78: