Groin Hernia 1

GROIN HERNIAS

4.1 Development of Inguinal Canal

The   descent   of   the  testis   from   its   intra   abdominal

retroperitoneal  position  into the scrotum is via  the  inguinal

canal.

A  diverticulum  of  the  perietal  peritoneuum,  the   Processus

vaginalis  accompanies  the  testicle, its  connection  with  the

abdominal peritoneium is obliterated in utero or in early infancy

Fig. above

The  spermatic cord passes obliquely downward through an  opening

in  the  transversalis  fascia  (the  inner  most  layer  of  the

abdominal wall) into the inguinal canal at the internal  inguinal

ring,  here the fascia continues into the inguinal canal  as  the

internal spermatic fascia.

The cord running obliquely downward, emerges through the external

inguinal  ring;  an opening in the aponeurosis  of  the  external

oblique, just above the scrontum.  The entire canal is 4 cm  long

and  is  2-4  cm above and parallel  to  the  inguinal  ligament.

Weakness at the internal ring or the posterior wall can result in

injunal hernias.

4.2 An indirect inguinal hernia with its sac leaves the abdominal

cavity at the internal ring and passes medial to the stuctures of

the  permatic  cord  either  remaining  in  the  inguinal   canal

(bubobnocele)  or  descends all the way into  the  scrotum.   The

indirect hernia lies within the fibres of the cremaster muscle.

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Incisional & Ventral hernia

Incisional hernias

This  is  a  diffuse hernia through a poorly healed  scar  of  an

earlier  incision.  The factors responsible for the poor  healing

are  post-operative haematoma and sepsis, bad closure  technique,

drains  in  wound, the age of patient, obesity and  diabetes  can

also.

The  treatment  is surgical repair using either  layer  by  layer

closure  or keel repair. In some cases a mesh graft needs  to  be

used  to strengthen the repair or bridge a large tissue loss  gap

in abdominal wall.

Ventral Hernia

These are usually hernias in old incision wounds

Incision is over the old wound and excision of the old scar.

Wide dissection around the bulge will expose the rectus sheath on both side of the bulge

Relaxing incision on rectus sheath will permit easy approximation of edges of sheath

It is also possible to reinforce sheath by interposing a cut out of synthetic marlex mesh.

Close the wound

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Umbilical Hernia & other hernia Adult

3.1 Umbilical hernia (Fig 24.8b)

Childhood  umbilical hernia appear in newborn infants and  should

be treated conservatively for they can undergo reduction in  size

as  the  child  grows  some may  require  repair  if  the  defect

persists.

Adult  unbilical hernia appears after 40 years and  results  from

increased  intrabdominal  pressure  due  to  repeated  pregnancy,

malignancy  or obesity.  Acute abdominal pain and back  ache  are

common  complaints.  Mayo's operation is  recommended  treatement 

and aims to close and reinforce the defect in the abdominal wall.

3.2  Epigastric  hernias, is another hernia  frequently  presents

through  a  defect in the linea alba above  the  umbilicus.  (Fig

24.8c)

3.3  Diverication (separation) of recti below the  umbilicus  may

show as a hernia in the midline.

3.4  There is a potential weakness at the lateral border  of  the

rectus  muscle,  where it joins the linea semilunaris,  a  hernia

which  protrudes at this site and is called a  Spegelian  hernia. 

Fig.24.8a  They  occur more frequently in women but do  occur  in

men.   There  is a diffuse lump that aches, the  lump  disappears

when  the  patient  lies  down.   Treatment  is  by  Mayo's  type

operation.

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UMBLICAL DEFECTS 3

UMBILICAL DEFECTS

During  the  embryonic period at about the tenth  week  of  fetal

life; the viscera normally return to the abdominal cavity and the

abdominal wall closes slowly during subsequent fetal development.

At birth, many infants will show a small umbilical hernia because

this  process has not been completed (Fig. 24.8b).  In most  cases

spontaneous closure occurs within the first three years of life.

Rarely,  the  process  of  abdominal  wall  closure  is   totally

incomplete  at birth and omphalocele is present.  The  defect  at

the umbilicus is covered only by a peritoneal sac.

In a few cases, the embyrologic duct from small bowel to the yolk

sac (vitillo-intestinal duct) remains patent and attached to  the

umbilical cord at birth.

This  duct  is  likely  to be included  in  the  tie.   When  the

umbilical remanent sloughs later; a fistula into the small gut is

created.

In  other cases; the tract from the bladder; the  urachus  enters

the  umbilical arteries.  The remnant of the cephalic portion  of

the  embryonic  urinary  bladder is  usually  obliterated  before

birth;  if  it  remains patent, it may  become  involved  in  the

umbilical  cord  ligature  and a  draining  umbilical  sinus  may

present.

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