Definition of External Hernia

Hernia Definition of external hernia: protrusion of the viscus or part of it through a defect in the anterior abdominal wall due to weak abnormal or normal opening Signs of Hernia: 1. Swelling at anatomical sites 2. Expansile on cough / cough impulse 3. Reducibility Types of abdominal wall hernias: 1. Inguinal 2. Femoral Differential Diagnosis for swellings in the groin: • Undescended testes • Inguinal hernia • Femoral hernia • Femoral aneurysm • Saphena varix • Lymphadenopathy • Encysted hydrocele • Psoas abscess • Lipoma of the cord • Subcutaneous lipoma • Sebaceous cyst 3. Epigastric (defect in linea alba) 4. Umbilical Differential Diagnosis: • Sister Mary Joseph Nodules (ulcer, abscess, redness) • Umbilical granuloma (occur in neonates, umbilicus is moist and red) • Lymph nodes enlargement • Subcutaneous nodules • Sebaceous cyst • Umbilical abscess • Umbilical sinus 5. Paraumbilical Differential Diagnosis: • Caput medusae (excluded by the absence of dilated veins) • Subcutaneous Lipoma • Sebaceous cyst 6. Incisional hernia (history of a scar or previous operations) (clear with no Differential Diagnosis) 7. Spigelian hernia/interparietal hernia • rare type. • Usually in the males who lift heavy weights (athletics) • It's an interstitial defect in the Spigelian facia between the internal oblique and transversus abdominus muscle in the lateral aspect of rectus sheath and medial aspect of semilunar line\ • Semilunar line is originally a weak area, if it’s a bit widened and the patient lifted heavy objects --> hernia • Patients usually present with pain and not swelling because the hernia is covered by the external oblique muscle (no cough impulse) • History: sudden severe pain in the lateral aspect of the rectus sheath while carrying heavy objects, sneezing or coughing. The pain is relieved by lying down. • Diagnosed by history and confirmed by CT scan Types of groin hernias: 1. Direct 2. Indirect 3. Atypical (sliding): The organ itself forms a part of the sac (the sac of the direct and indirect hernias is formed only of the peritoneum) How to differentiate between direct and indirect hernia? By the internal ring test: I will reduce the swelling completely then put my finger on the deep inguinal ring (mid-way between the anterior superior iliac spine and pubic tubercle, half inch above the inguinal ligament), after that, ask the patient to cough. If the swelling is medial to my finger, it’s direct hernia. If the swelling doesn’t come out with the cough, I will remove my finger and ask the patient to cough again, if the swelling comes out from the site my finger was on, it’s indirect hernia. Internal ring test reducibility Direct Hernia swelling is medial to my finger upward backward direction. After reducing it, it’ll come out immediately Ability to descent never descends to the scrotum to the scrotum Relation to the inferior epigastric Indirect Hernia swelling comes out from the site my finger upward backward laterally. After reducing it, it won’t come out unless the patient strains or coughs can descend to the scrotum or to the neck of the scrotum Medial to the inferior epigastric Lateral to the inferior epigastric vessels vessels vessels (can be seen intraoperatively) *Richter's hernia: usually in umbilical hernia. Part of the intestinal wall is inside the defect and the other part is inside the abdomen. There's no obstruction. * Littre's hernia: hernia sacs containing only Meckel's diverticulum *Maydl's hernia (w shape hernia): the sac contains 2 loops of bowel. causes ischemia to the intraperitoneal part. *Pantaloon hernia (Romberg's hernia saddle bag hernia): presence of ipsilateral direct and indirect inguinal hernias. Complications of the hernia: 1. Irreducible: very tender and painful swelling with mild abdominal distention. no fever, no vomiting, no tachycardia, no leukocytosis, no bowel dilatation by abdominal X-ray, and the patient is passing stool daily. With stethoscope, no bowel sounds. Admit the patient to the hospital and keep him NPO with IV fluid, pain killers, cold compression, and clinical assessment every 1 hour. 2. Incarcerated: long standing, irreducible with increased pain, nausea. Patient is passing stool normally. No fever. No obstruction. no Bowel dilatation by abdominal X-ray. Incarcerated due to edema and congestion of the bowel inside the sac. With stethoscope, no bowel sounds. Emergent case should be taken to OR. 3. Obstructed: vomiting. abdominal pain and distention. Patient can’t pass gasses nor stool. With abdominal X-ray, the bowel is dilated and there’s air inside the obstructed bowel loop. Absolute constipation. Exaugurated bowel sounds with the stethoscope. Emergent case should be taken to OR. 4. Strangulated: cut of blood supply, signs of inflammation and infection. The content of the sac is gangrenous. Patient is febrile with leukocytosis and rigor. Redness over the site of the swelling. Severe pain at the site of the hernia. Edema. Absent bowel sounds with the stethoscope. Abdominal X-ray shows dilated strangulated bowel. CBC shows leukocytosis. Urgent surgery. Diagnosis of the hernia: • Diagnosed mainly clinically. • Investigations that should be done to prepare the patient for surgery: CBS, blood typing, serology, and chemistry • If the patient is above 40 years, ECG and chest X-ray are done • If the patient is below 40 but he’s asthmatic or a smoker, chest X-ray is done • No need for Ultrasound unless: 1. the diagnosis is unclear 2. If I examined the scrotum and didn’t find the testes 3. if I found another pathology with the expansile swelling • 4. If the patient presented with the complications and I wanted to know the content of the sac CT scan is done in one case only, if I already did ultrasound and still didn’t find the diagnosis. Treatment of the hernia: (by surgery, either laparoscopic or open) 1. Herniotomy: for children below 5 years, because their inguinal canal is not developed, and their deep and superficial rings are superimposed) (Dissect the sac and open it, then reduce the contents, excise the sac, closure of the skin) 2. Herniorrhaphy: herniotomy + repair of the weak posterior wall using the patient’s own tissue to make the repair between the conjoint tendon and the inguinal ligament. There’s some sort of tension. 3. Hernioplasty: herniotomy + repair of the weak posterior wall using a mish between the conjoint tendon and the inguinal ligament. Fix the mish by just applying it, no need for suturing. This procedure is tension free While taking the history, you should ask the patient to know the cause: Do you have cough, chest problems, urinary problems, or straining? A patient presented with 2 swellings one in the umbilicus and one above it, what’s the type of the hernia? If the swelling in the umbilicus is reduced deeply just by touch/palpation and the stump of the umbilicus is present, it is Supra paraumbilical hernia with 2 defects, both defects are supra paraumbilical. Examination of the Abdomen Position: supine with his arms beside him, centralized on bed Exposure: from the nipple to midthigh, but for the traditional purposes the patient will be uncovered only to the lower waist Inspection of the abdomen: • • • From the foot of the bed, comment about the contour of the abdomen (flat, distended, scaphoid), symmetry, movement with respiration (is it abdominothoracic or thoracoabdominal?) You can’t comment about what is mentioned above unless the patient is centralized on bed, if he’s not, just say that you can’t decide. From the right side of the bed, normally you should comment about the 1. Swelling (if present, you should comment about it and palpate it first with all the criteria that’s related to it before shifting to number 2) 2. subcostal angle 3. epigastric pulsation 4. Umbilicus (normally inverted and in the midway between the xiphi-sternum and symphysis pubis with no discharge, dilated veins, nor nodules.) 5. dilated veins 6. stretch marks and stria 7. Pigmentations and scars. Palpation and Percussion of the abdomen: • • • • Superficial and deep palpation of the 9 areas Deep palpation of liver and spleen to detect if there’s organomegaly Palpation to detect any pelvic or abdominal mass Percuss to detect if there’s Ascites (ask the patient to empty the bladder first) Do Per Rectal Examination to Exclude Prostatic Hyperplasia in male patients. If there is a swelling: Inspect: 1. 2. 3. 4. 5. 6. 7. Number Site Size (in cm) Shape (round or oval) Surface (regular or irregular) Skin overlying (normal, discoloration, or ulceration.....etc) Positive expansile on cough (ask the patient to cough) Palpate: 1. Temperature (compared to the patient’s abdominal skin) 2. Tenderness (always palpate while looking at the patient’s face) 3. Confirm the size 4. Confirm the shape 5. Confirm the surface 6. Consistency (soft, hard, or firm) 7. Edge (well or ill-defined) 8. Mobility 9. Positive expansile on cough (specific for hernia) 10. Reducible or irreducible (ask the patient to reduce it)