© Shehab Anwer -2010

Surgery Herniotomy Herniorraphy

Inguinal Of Ing. H.
Hernia
Precis surgery - For congenital hernia. For adult and old patients.
- technique: sac removal Reinforcement is
Hernia Indirect/Oblique Direct techniques
without inguinal canal repair. technique dependent.
incidence Most common Less
Age Any age/sex More for old / ♂ Tension-free hernioplasty with a mesh at pre-peritoneal
Laparscopic space behind the defect, not in or over it. Advantages:
Pred. fac. Patent proc. vaginalis Weak abd.wall/fascia
Hernioplasty faster recovery – less painful.
Increased intra-abdominal pressure
Risk Herniotomy + posterior wall repair by autogenous/darning or
Like: Cough / Ascites.
heterogeneous/ synthetic (e.g. prolene mesh).
content Omentum ± intestines
*For: recurrent, weak wall, large defect.
Defect Internal/Deep ring Hesselbach/inguinal ∆
Inf. Epiga. ‘Tension’ Repair ‘Tension-free’ Repair
Lateral/Inferior Medial/Inferior
Art. Defect Edges are sutured together without implanting mesh to
Sac site Inside cord Outside cord reinforcement, e.g. Bassini’s (not standard now); strengthen region with
What’s around scrotum and What’s infront of abdominal or complete 4-layer reconstruction: Shouldice’s. repair.
covering
cord. wall.
- If uncomplicated: Femoral Hernia Similar to inguinal hernia, except for:
Painless, reducible inguinal swelling.
C/P
- Of the cause,e.g. asictes Defect thru femoral canal – under the inguinal lig.
- Complication (see table below) Acquired Congenital (Clouquet)
side Uni/bilateral > Bilateral - ~ 20-40 yr / More in ♀: ~ with cong. hip dislocation.
Site Inguinal/scrotal Inguinal * Wide pelvis C/P: *Reducible swelling at the
Size/Shape ~large/oblong ~ small/hemispherical * pregnancy:↑ abd. Pressure and upper thigh. Pain if complicated.
abd. Ms & tendons laxity. Descent: downwards / medial
Descent Down/forward/medial Forward
More at the right side. Reducibility: vice versa.
Reducibility Vice versa of its descent Risk factors for Strangulated Femo.H.:
scrotum reaches Rare Acute lymphadenitis – Abscess – Torsion of maldescended testes – adductor
Internal ring longus tendon rupture – Ant. Hip disclocation.
Doesn’t protrude Protrude
test
Investig. For ppt factors, complications and pre-op. Management Prophylactic Life style modifications
ttt Surgical approaches - Exercises: strengthen abd.ms.
*ttt of precipitating factors and complications.
- Avoid constipation / cough.
*Surgical repair: * Low: for elective repair. risk of
- Lose Weight & stop smoking.
- Herniotomy - Marcy/Shouldice repair of anomalous obtu. artery injury.
ttt - Avoid carrying heavy loads.
- ± repair of inguinal canal posterior wall. * Inguinal: risk of inguinal canal
posterior wall. - Mesh Herniplasty. weaknening .
- Herniorraphy - Truss for unfit * High/McAvedy: with strangulation.

Congenital mid gut is not inside abdomen. Infantile Umbilical H. Para-Umbilical H. Epigastric H.
Umbilical *Minor: < 5 cm-*Major: > 5 cm Wks/months after birth for Defect at linea alba Same as para-umb.
Hernia Covering : Amniotic membrane weak umbilical scar. Cover: skin, SC tissue, fat. but separate from
Management & wharton’s jelly. Cover: stretch umb. Scar C/P: swelling over/below umbilicus umbilicus.
After birth: surgery to undermine skin. ttt: * coin/plaster strap – backward reducibility – intertrigo. C/P: Asymptomatic
Hernia repair: delayed months or years. * surgical repair if large, > Late: impulse cough
Non-operable: 2% OH mercurochrome. 4yrs or strangulation. Surg.: Anatomical or mayo’s repair. ttt: like para-umb.
*Avoid ppt fact. / *use Others
Recurrent H. Incisional H. ttt non-absorbable Pantaloon: direct and indirect hernia on same side with inf. epig. Art. Inbetween.
After repair After surgery prolene sutures. Richter's: strangulation -> perforation without obstruction or any warning.
Anatomical/Keel repair Sliding (en glissade): when an organ drags among content, e.g. colon/urinary bladder.
Causes: Pre-Op, Op & Post-OP
Abd. corset inoperable Maydl (W): 2 intestinal loops are in 1 sac with a tight neck -> ischemia -> necrosis.
Pre Weak abd. Ms. – obesity – cough – constipation - anemia Littre's: contains Meckel's diverticulum.
Lumbar-Cooper's: with 2 sacs at fem. canal & superficial fascia defect.
Op Trauma –bad haemostasis–wrong sac removal - absorbable sutures.
Lumbar- Sciatic: at greater sciatic foramen as a gluteal mass.
Post Infection – vomiting – early back to work – presistent ppt. factors Spigelian: lateral ventral hernia, old female -> anatomical repair.

Complications Irreducibility Strangulation Obstruction Inflammation Hydrocoele

Blood vessels involvement Hernia content lumen - Of the content: Omentum or sac’s
Hernia fails to go back
Problem -> ischemia -> gangrene & obstruction by: Adhesions (appendix /meckel) obstruction -> fluid
into abdomen.
2ry infection. bands or Faecolith - Truss. retention.
- inguinal /femoral h. Adhesions or omentum
Cause - Adhesions
- Narrow neck Irreducible hernia Infection. block after content
Or risk factors - Narrow neck
- Uncorrected complication. reduction.
Intestinal obstruction:
Of intestinal obstruction Of intestinal obstruction
General *constipation, FAHM -ve
<< <<
*Distention - *Vomiting
- Painless swelling -> painful
Red hot painful swelling
Local + -> colicky stabbing pain --- +ve fluctuation
at the hernia’s site.
(ischemia).
Irreducibility + + + + ---
Tension + + -ve -ve -ve
Expansile impulse + -ve -ve / weak + -ve
URGENT surgery Surgical removal of
Surgery
Herniotomy / Hernioraphe Surgical to avoid inflammed tissue, e.g.
Management No truss -> avoid Excision
NEVER: Herniplasty for strangulation. by Appendectomy.
strangulation
probable infection.