Hernia

A hernia is a protrusion of a structure beyond the normal covering of the cavity in which it is contained. Hernias occur frequently in the inguinal, femoral, and umbilical areas. They can be congenital or acquired. Congenital hernias occur in infancy due to the patent processus vaginalis hence a rise in inguinal hernias. Acquired hernias occur mostly at point of weakness like sites of surgical incisions.

Predisposing factors

        I.            Increased intra-cavity pressure when lifting heavy objects

      II.            Chronic cough

    III.            Abdominal distention due tumors or ascites

    IV.            Straining while passing urine or faeces

Components of a hernia

        I.            Sac- consist of mouth, neck, body and fundus

      II.            Covering- these are layers that the hernia comes out with like aponeurosis, muscle and skin

    III.            Contents-mostly consists of the small intestines or the greater omentum

Classification of hernias

Reducible – contents can be returned back but the sac persists.

Irreducible hernia- contents cannot be reduced due to the narrow neck.

Incarcerated hernia- this is an irreducible hernia but there is maintained blood supply.

Strangulated hernia- contents of the hernia are stuck in the sac with impaired blood supply.

Obstructed hernia- this is where a part of the intestines is obstructed.

Abdominal hernias

Inguinal hernias

Inguinal hernias take up to 80% of all abdominal hernias. They are common in children and elderly. They are also common in males than females.

Indirect inguinal hernias-passes through the internal ring and is lateral to the epigastric artery. It may extend to the scrotum.

Direct inguinal hernias- protrude through the posterior wall of canal and are medial to the epigastric artery.

Pantaloon hernia- consists of both indirect and direct inguinal hernias.

Differences between direct and direct inguinal hernias

	Indirect	Direct
Patients age	Any age though common in the young	older
Cause	Congenital	Acquired
Protrusion on coughing	Oblique	Straight
Reduction	Not immediate	Reduces immediately
Descent to scrotum	Always	Rare
Neck of sac	Narrow	Wide
Rate of strangulation	High	Low
Position to inferior epigastric vessels	Lateral	Medial

 

Investigations

1.       Clinical findings is gold standard

2.       Ultrasound

3.       Ct scan- especially in obese patients

4.       Herniography

Management

Patients with hernias come with a long progressive history. Risks of strangulation increase with time hence it is important to repair them

Surgical technique

Herniotomy- This is the removal of the sac and closure of the neck. Commonly done to infants.

Herniorrhaphy- This aims at restoring the normal anatomy increasing abdominal wall strength and creating a barrier to counter recurrence.

Laparoscopic repair- includes Trans abdominal pre-peritoneal (TAPP) and total extra peritoneal (TEP) approaches.