HERNIAS

Posted by e-Medical PPT
Inguinal HerniaClassified 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

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
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 Hernia
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

Non-Operative
Observation
Trusses can provide symptomatic relief    
 Hernia control in ~30% of patients

Operative
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)
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..

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