Medical Articles
Abdominal Wall & Diaphragmatic Hernias
Abdominal Wall Hernias
Definition: Protrusion of intra-abdominal tissue through a fascial defect in the abdominal wall External hernia typically consist of:
- Neck ⇒ the opening in the abdominal wall fascia
- Sac ⇒ of peritoneum
- Contents ⇒ Organs (bowel, ovaria, bladder) or other tissue (omentum)
- Covering ⇒ (skin, subcutaneous tissue)
Important terminology
- Reducible hernia ⇒ contents of the sac can return to the abdominal cavity.
- Irreducible (incarcerated) hernia ⇒ contents of the sac cannot return to abdominal cavity (narrow neck)
- Obstructed hernia ⇒ obstruction of flow of bowel contents.
- Strangulated hernia ⇒ compromise to blood supply of contents
- Richter’s hernia ⇒ only part of the circumference of the bowel is incarcerated or strangulated.
- Littre hernia ⇒ a Meckel’s diverticulum forms part of contents.
- Sliding hernias ⇒ wall of a viscus forms part of the hernia sac (i.e. Bladder, ovary, sigmoid, cecum)
- Rolling hernia ⇒ sac consists only of peritoneum.
Inguinal Hernia
Most common external hernia (±75%) Adults: 10-15% - M:V 12:1 Inguinal (direct + indirect) Femoral – more common in females
Inguinal Canal
- Tube ± 5cm long from internal opening to external opening
- Internal opening – hole in fascia transversalis, midway between SIAS and pubic tubercle, above inguinal ligament.
- External opening – hole in external oblique aponeurosis superolateral to pubic tubercle.

Anatomic Relationships:
Fascia transversalis ⇒ Posterior
External oblique ⇒ Anterior
Inguinal ligament ⇒ Inferior
Falx ingenialis/Conjoined tendon is anterior laterally, superior in the middle and posterior medially (Conjoined tendon – fusion of the internal oblique and transversus abdominus muscle)
Hernia sac of an indirect inguinal hernia – patent processus vaginalis. Found Antero-medial to spermatic cord.

Hesselbach’s triangle
- Inferior epigastric vessels lateral
- Lateral edge rectus abdominus muscle medial
- Inguinal ligament inferior
Area of weakness – direct hernia originates.
Direct hernia situated medial to indirect hernia.
Combination = pantaloon hernia


Femoral Canal
- Lacunar (Gimbernat) ligament medial
- Inguinal (Poupart) ligament superior
- Ileopectined ligament (Cooper) inferior
- Femoral vein lateral
Origin of femoral hernia (and form the narrow unyielding neck ⇒ high incidence of strangulation)

Clinical Presentation
Mass in the groin
Occours or increases in size with increased abdominal pressure May present with complications
Irredusable
Bowel obstruction
Strangulated
Indirect lnguinal Hernia
- Congenital (processus vaginalis not obliterated), presents later in life
- Travels obliquely in inguinal canal to scrotum
- Reduces obliquely upwards to internal opening
- Internal opening is the neck and pressure here keeps the hernia reduced.
Direct inguinal hernia
Acquired
- Weakness in transversalis fascia in Hesselbach’s triangle
- Increased intra-abdominal pressure
- COPD, prostatic hyperplasia
- Colon carcinoma, ascites
Protrudes directly through Hesselbach’s triangle Reduces directly (straight), cannot be controlled by pressure at internal opening.
Femoral hernia
- Acquired
- More common in females
- Often asymptomatic until it strangulates
- Prone to strangullatiion
Differential diagnosis of a groin mass
- Hernia
- Indirect
- Direct
- Femoral
- Testicle ⇒ undecended, retractile, torsion of the testis
- Lymph nodes
- Lipoma
- Varices of the sapheno-femoral junction
- Aneurysm (femoral)
- Abscess
Complications
- Irreducible
- Bowel obstruction
- Strangulation
Management of groin hernias
1) Surgical repair
- All hernias should be surgically repaired unless there are specific contra-indications.
- Preferably elective repair
- Emergency repair if presents with complication
- Many surgical options
- open and laparoscopic
- various techniques
- Pure tissue repair
- Pure prosthetic repair
- Combination
Surgical repair (continued)
Aim:
Remove or reduce the hernia sac Repair/strengthen normal anatomy (mesh or permanent suture material) Strangulation – resect infarcted tissue
Local or general anaesthesia
Complications:
Hematoma
Wound sepsis
Damage to cord structures
cutaneous nerve damage
Recurrence
Mortality
Management (continued)
- Truss
Prefferably avoided Old,, chronically ill patient, direct hernia which easily reduces or patient refuses surgery
Other abdominal wall hernias
Umbilicall Hernia
- Congenital
- Through umbilical ring
Para-umbilical hernia
Acquired
- Outside umbilical ring
- Female
- Increased intra-abdominal pressure
- Narrow elliptical neck ⇒ strangulation
Epigastric Hernia
- Linea alba (in epigastrium) - foramina where cutaneous nerves and blood vessels penetrate
- Young men
- Preperitoneal fat (Not peritoneal sac)
- Neck narrow ⇒ strangulate
Incisional Hernia
- Previous surgical scar
- Etiology
- Poor wound healing
- Increased wound tension
- Poor technique
- Problems
- Cosmetic
- Functional
- Pain
- Strangulation
- Recurrence
Special hernia’s
- Rare
- Littre’s hernia
- Spigelian herna
- Lumbar hernia (Grynfeltt, Petit)
- Obturator hernia
- Perineal hernia
- Siatic hernia
Diaphragmatic hernias
Definition: Herniation of abdominal content through
a defect in the diaphragm into the thoracic cavity.
Classification:
Congenital - Bochdalek
Morgagni
Acquired - Traumatic
Hiatal ~ Sliding
Para-esophageal (Rolling)

- Bochdalek hernia – neonatal emergency see Ped. Surg.Notes.
- Morgagni hernia (parasternal or anterior diaphragmatic hernia).
- Failure of fusion of sternal and costal elements of diaphragm.
- Presents later in life:
- Incidental finding on CXR (asymptomatic)
- Vague upper abdominal complaints/retro-sternal pain
- Emergency – bowel obstruction/strangulation
- Surgical repair once diagnosed.
Traumatic diphragmatic hernia
Penetrating or blunt trauma ⇒ Chronic established hernia – Stab
⇒ Hernias due to blunt trauma or due to GSW are usually found at early surgery
⇒ 95% left - Right handed assailants - Liver protects the right diaphragm
⇒ Presents months to years after initial injury with bowel obstruction/strangulation of contents
⇒ Mortality 50% in cases of strangulated colon in the chest
Traumatic diaphragmtic hernia
Diagnosis: CXR
- Bowel gas and fluid levels in chest
- Stomach as content of hernia ⇒ nasogastric tube in chest
- barium meal
- barium enema
Treatment Prevention
- Urgent surgical repair
- High index of suspicion in wounds between the nipple line and the costal margin especially on the left
Hiatus Hernia
- Herniation of part of the stomach through the oesophageal hiatus into the thorax
- Classification
- Sliding-type
- Rolling-type (para-oesophageal)
- Combination
Anatomy of a hiatus hernia

Rolling hernia ⇒ EGjunction under diaphragm

Sliding-hernia ⇒ EGjunction above diaphragm
Hiatus hernia
Sliding Hernia
- Most common (95%)
- GERD
Rolling Hernia
- rare (5%)
- reflux not a problem
- Mechanical problems ⇒
Incarceration/stasis/ulceration/perforation ⇒ Symptoms – asymptomatic to vague left upper quadrant discomfort, dysphagia, chest pain
Para-esophageal hernia
- Diagnosis – CXR: air fluid level behind cardiac shadow
- Management Surgical repair: open or laparoscopic
- Reduction of hernia
- Closure of esophageal hiatus ± fundoplication