Abdominal Wall Hernias neuralgia

							              Hernias

     Gregory P. McLennan II, MS3
St. Louis University School of Medicine
                      Definitions
• Hernia
       • A general term referring to a protrusion of a tissue
         through the wall of the cavity in which it is normally
         contained
• Incarceration
       • the contents of the hernia cannot be returned to the
         cavity from which they came
• Strangulation
       • The blood supply to the herniated tissue is disrupted
         causing ischemia and tissue death
            Groin Hernias
• 96% Inguinal – 9:1 M:F

• 4% Femoral – 4:1 F:M

• Lifetime risk approximately 25% in males
  and <5% in females

• 700,000 repairs each year
                      Case 1
• 14 y/o male with no significant PMHx presents to the
  ED with “scrotal swelling” that he noticed after
  helping his father carry a couch. He has never
  noticed this swelling before, but it now causes him
  some discomfort when he stands from a sitting
  position. The patient states that it seems to mainly be
  on the right side of the scrotum. He denies severe
  pain, N/V, fevers, and says that the bulge does not
  seem to go away when he is supine.
         Differential Diagnosis
• Acute Conditions
  – Testicluar Torsion
  – Epididymitis
• Nonacute Conditions
  – Hydrocele
  – Varicocele
  – Spermatocele
  – Epdidiymal Cyst
  – Testicular Tumor
          Important Anatomical Relationships

• Inguinal Ligament
• Hesselbach’s Triangle
• Inferior Epigastric Vessels




         http://feedbus.com/wikis/wikipedia.php?title=Inferior_epigastric_artery
             Testicular Descent
• Ventromedial aspect of urogenital
  ridge
• Descend through coelomic cavity
  pulled by gubernaculum testis
• Processus vaginalis forms at
  internal ring and precedes testicles
  into scrotum
• Processus Vaginalis obliterates


                http://caltest.vet.upenn.edu/repropath/MReview/normdiag/picture.htm#Testicular%20Descent
  Indirect Inguinal Hernia Track
• Lateral to inferior epigastric
  vessels

• Through deep inguinal ring
  and canal

• Through external inguinal ring
   – Often into scrotum

• Hernial sac formed by
  processus vaginalis

• Hernia is w/in the coverings of
  the spermatic cord
                                   http://www.aafp.org/afp/990101ap/143.html
         Indirect Inguinal Hernia
• Most common groin hernias in men and women
• 20x more common in males
• Most are congenital due to defective obliteration of the
  processus vaginalis and lack of closure of internal
  inguinal ring

• Sx
   – Bulge medial to pubic tubercle and into the scrotum
   – Heaviness or dull discomfort more pronounced with lifting or
     straining
   – Pain with straining or standing
   – Severe pain and/or peritoneal signs with strangulation, fevers,
     N/V

• PE
   – Reducible versus non-reducible
   – Can be mildly tender to exquisitely tender (strangulated)
              Hernia Complications
• Incarceration
      •   14 to 31% of inguinal hernias, usually in infants < 1y/o
      •   Swelling due to decreased venous and arterial flow
      •   Outright pain, irritability and crying in children
      •   Bowel obstruction (N/V/colicky abdominal pain/distention)
      •   Tender, edematous, erythematous


• Strangulation
      •   Severe pain secondary to bowel ischemia
      •   Bowel obstruction
      •   Swelling, erythema, tenderness, peritoneal signs, fever, N/V
      •   Study of 439 patients showed probability of strangulation was 2.8%
          at three months, 4.5% at two years for groin hernias
               Direct Inguinal Hernia
• Common in older males, rare in women
• Occur as a result of weakness in the floor of the abdominal
  wall medial to the inferior epigastric arteries
   –   Inborn Defect
   –   Smoking
   –   Chronic steroid use
   –   Collagen disorders
   –   Some studies have shown a correlation with heavy lifting

• Sx
   – Similar to Indirect hernias without extension of the hernia into the
     scrotum

• PE
   – Symptoms similar to indirect inguinal hernias
   – Often more easily reducible than indirect hernias
   Hernia Track
• Bulges through
  Hesselbach’s Triangle in
  hernial sac formed by
  transversalis fascia

• Traverses the medial
  portion of the inguinal canal

• Emerges around conjoint
  tendon to reach the
  superficial inguinal ring

• Gains an outer covering of
  external spermatic fascia
                        http://www.hernia.net.au/hernia_inguinal.html
      Inguinal Hernia Treatment
• Medical Management

  – Watchful Waiting Trial with 720 men >18 y/o and
    asymp/minimal sx; easily reducible
     • Open tension free repair versus Waitful Watching
         – 23% and 31% of WW group had surgery at 2 and 4 years
  – Truss use is not supported in the literature


• Incarceration/Strangulation
  – Only true indications for repair
  – Emergent reduction
  – Bowel can be saved in most patients if operation
    occurs within four to six hours
                       Tx Cont’d
• Operative Repair
  – Only definitive repair
  – Recurrence in .5 to 15% depending on type of repair

  – Open Repair versus Laparoscopic repair
     • Lap with less post op pain and faster return to work
     • Increase risk of complications with longer surgery, higher risk
       of nerve, vascular, bowel, and bladder injury

  – Mesh versus suture repair
     • Mesh repair creates less tension but very few studies to
       compare the techniques
     • One meta-analysis of 26000 hernia repairs found mesh
       repairs with a lower reoperation rate

  – Complications include recurrence, infection, seromas,
    pain and neuralgia
                    Case 2
• 57 y/o G5P5 female with PMHx of HTN presents
  to clinic with a two hour history of a non-
  reducible bulge on her upper thigh. She reports
  severe pain, some fevers, N/V. She reports that
  she has had this same bulge intermittently for
  about a month. However, it has never hurt like it
  does at the time of presentation.
• Physical exam shows an exquisitely tender,
  erythematous bulge on the upper anterior thigh
  below the inguinal ligament. It is non-reducible.
                 Femoral Hernia
• 40% present with emergencies
  (incarceration/strangulation)

• Most commonly in females, especially
  older women
  – Less bulky musculature
  – Weakness of pelvic floor muscles 2/2
    childbirth
  – Pelvic floor muscle atrophy 2/2 age
  – Prior inguinal hernia repair is a RF



                     http://herniaplasty.med.nyu.edu/strangulatedhernia.html
                  Hernia Track
• Hernia protrudes through
  medial aspect of femoral
  canal/sheath

• Below the inguinal ligament
  medial to the femoral vein

• Below and lateral to the pubic
  tubercle through the femoral
  ring

• Becomes more pronounced
  when it passes through the
  saphenous opening
                             http://www.aafp.org/afp/990101ap/143.html
               Incisional Hernia
• Due to failure of fascial tissues to heal and close

• Promoted by inhibition of wound healing

• 10-15% of abdominal incisions

• Highest incidence with midline incisions

• RCT with vertical versus transverse incisions for
  AAA
   – Incisional hernia more likely with vertical incision (37
     pt)
                Incisional Hernia
• Sx
  – Bulge of abdominal wall deep to skin scar
  – Cosmetic concern versus discomfort
  – Worsened with coughing or straining
  – Incarceration
       • <1cm, >7-8 cm unlikely to incarcerate
• Tx
  – Most should be repaired (unlike groin hernias)
  – Suture versus mesh repair
       • Suture repair in one European study showed 60%
         recurrence with mesh recurrence at 30%
                    Umbilical Hernia
• Congenital
  – Opening in linea alba when umbilical scar fails to heal
    at birth
  – More common in AA children
  – Most close in first 12-18 months of life
  – Repair rarely recommended prior to 3 y/o
• Acquired
  – 3:1 F:M – Men more likely have incarceration
  – Associated with increased
    intra-abdominal pressure
     •   Obesity
     •   Ascites
     •   Abdominal distention
     •   Pregnancy
                                http://medicine.ucsd.edu/clinicalimg/abdomen-incarcerated-umbo.html
                          Spigelian         Hernias
• Lateral ventral hernia
   – Junction of vertical semilunar line and
     horizontal semicircular line (arcuate
     line)

• 90% located 0 - 6 cm above anterior
  superior iliac spine
   –   Sharp pain, swelling, easily reducible
   –   20% present with incarceration
   –   median age = 50 years
   –   more common in males and on (R)
   –   Rare

• PE
   – Difficult to diagnose
   – Below EAO
   – U/S or CT can aid in diagnosis


                                  http://herniaplasty.med.nyu.edu/spigelianhernia.html
                         Richter’s


- Hernia where only a portion of the bowel wall circumference incarcerates
   or strangulates
                 Littre’s
• Any groin hernia that involves a Meckel’s
  Diverticulum
• Usually incarcerated or strangulated
               Armand’s
• Any hernia that contains the appendix
• Can cause symptoms of Appendicitis
          Pantaloon Hernia
• Simultaneous Direct and Indirect Inguinal
  Hernias
• Two bulges straddle the inferior epigastric
  vessels
                   Take Home Points
• Hernias can involve the small bowel, appendix, a Meckel’s
  diverticulum, ureter

• Incarceration with frank pain or strangulation are operative
  emergencies and bowel can be saved if done within 4-6 hours

• An attempt at reduction should be made with a hernia, but operative
  reduction is the only definitive treatment

• Femoral hernias have a high rate of incarceration and should be
  repaired, but other inguinal hernias may be watched if asymptomatic

• With abdominal incisions, try not to put excessive tension or damage
  the suture in any way as it can promote incisional hernias