Abdominal Hernia

Last updated 20.09.12

 

Definition

-  Protrusion of organ or its fascia through the wall of the cavity which normally contains it

-  Usually referred to in terms of abdominal hernias containing mesentery +/- bowel

 

Features

-  One of most common surgical conditions

-  10% of population

-  Female hernias may involve ovaries

-  Leading cause of bowel obstruction in the world

 

Types

-  Inguinal: 72%

-  Direct or indirect

-  Most common hernia type in men & women

-  Direct Inguinal Hernia

-   Herniates through the abdominal wall at the point of the Hesselbach triangle (inguinal ligament, inf epigastric a., conjoined tendon)

-   More common in elderly pts (weakened abdo wall)

-  Indirect Inguinal Hernia

-  Herniates through inguinal canal via a patent persistent process vaginalis

-  Bowel may herniated into scrotum

-  Most common hernia in men & women

-  Possible increase incidence post appendectomy or femoral vascular procesures

-  Femoral: 3%

-  Often become incarcerated & strangulated

-  Female more common++ than male

-  Medial thigh/groin pain

-  Hiatus

-  Incisional: 10%

-  Herniates through prev operation site through fascial closure

-  Recurrence rate 20-45%

-  Incidence 2-10% of abdo surgery

-  Umbilical

-  Herniates through umbilicus (fibromuscular ring)

-  Congenital

-  Periumbilical

-  Obturator

-  Herniates through obturator foramen

-  Female 6:1 male

-   Larger canal in women

-  Commonly presents as bowel obstruction

-  Swelling may be concealed

-  May present w abdo pain, weight loss, recurrent episodes of bowel obstruction

-   Medial thigh pain (obturator n.)

-   Relieved by thigh flexion

-   Exacerbated by hip extension or external rotation (Howship-Romberg sign)

-  Spigelian

-  Rare

-  Herniates through defect in spegelian fascia (lateral edge of rectus at semilunar line)

-  Epigastric

-  Oomphalocoele (infant)

-  Gastrochesis (infant)

 

Hernia

 

Classification

-  Reducible

-  Hernia is able to be returned into the abdominal cavity spontaneously or manually

-  Incarcerated

-  No longer reducible

-  Vascular supply not compromised

-  Small bowel obstruction common

-  Strangulated

-  Vascular supply copmpromised

-  Occurs in incarcerated hernias

-  Pain out of proportion to findings

-  Fever or toxic appearance

-  Pain post reduction

 

Risk Factors

-  Obesity

-  Heavy lifting

-  Coughing

-  Constipation/obstipation: obstruction

-  Straining at urination or defecation

-  Ascities

-  PD

-  Ventriculoperitoneal shunt

-  COPD

-  Family Hx

-  Collagen disorders: Ehlers-Danlos, Marfan syndrome..

 

Associated S/S

-  Asymptomatic

-  Pain/tenderness/aching: ? incarceration or strangulation

-  If pain persisits post reduction think strangulation

-  Abdo mass

-  Enlarges w increased abo pressure (Cough, sitting forward..)

-  Bowel sounds in mass

-  Small bowel obstruction, nausea, vomiting

-  Strangulation --> ischaemia/necrosis

-  --> Bowel perforation: pneumoperitoneum

-  Peritonitis

-  Septicaemia

-  Cough w palpation for impulse conduction

 

Ix

-  FBE: WBC: elevated in strangulation

-  US

-  Abdo US, groin US

-  Bowel in mass

-  Testicular sources of swelling

-  ? Spigellan or obturator hernia

-  CXR: pneumoperitoneum: perforation of strangulated hernia

-  AXR: small bowel obstruction

 

Mx

-  Prevention

-  Stool softeners: Coloxyl..

-  Reduction

-  Sedation + analgesia

-  Pt supine w knees bent

-  Trendelenburg position (15-20o) for inguinal hernia

-  Externally rotate & flex ipsilateral leg

-  Pressure from most distal part of hernia w medial compression

-  Do not use repeated forceful attempts

-  Abx: Ischaemic bowel/strangulation

-  Surgery

-  Laparotomy vs laparoscopy repair

-  LA vs GA

-  Reduction or excision of hernia sac

-  Closure of defect with minimal tension

-  +/- polypropylene mesh: overlay, underlay, sandwhich

-  Bassini-type repair: inguinal hernia

-  Cooper repair: femoral hernia