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Hernia 315
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External oblique
aponeurosis
External
ring
Ilioinguinal
nerve
Femoral
nerve
Femoral
artery
Femoral
vein
Femoral
canal
Spermatic
cord
(a) (b)
Figure31.2 The anatomy of the inguinal canal: (a) with the external oblique aponeurosis intact; (b) with the external
oblique removed.
Anterior superior
iliac spine
Inguinal
ligament
Internal
ring
Transversalis
fascia
Femoral
nerve
Femoral
artery
Femoral
vein
Internal
oblique
Pubic tubercle
Inferior
epigastric vessels
Conjoint
tendon
Pubic
symphysis
the medial edge of the internal ring; therefore, an
indirect sac will pass lateral, and a direct hernia medial,
to these vessels. Quite often, a direct and an indirect
hernia co-
exist; they bulge on either side of the inferior
epigastric vessels like the legs of a pair of trousers, and
are thus known as a ‘pantaloon’ hernias.
Sixty per cent of inguinal hernias occur on the right
side, 20% on the left and 20% are bilateral. The rightsided preponderance may relate to the right testis
being the last to descend, and possible persistence of
a patent remnant of the processus vaginalis.
Treatment
Investigation is usually unnecessary, since clinical
examination should suffice. However, where the hernia is not apparent, it is worth sending the patient away
to walk around for 5 min before re- examining afterwards. If the hernia is still not visible, ultrasonography
may detect it and ascertain whether direct or indirect,
or identify a lipoma of the cord as the culprit.
Congenital inguinal hernias in infants do not
obliterate spontaneously; the patent processus
vaginalis is ligated and the hernial sac excised at the
age of about one year (herniotomy). In adults, operation is usually advised if the hernia is causing symptoms. This comprises excision of the sac and repair of
the weakened inguinal canal, commonly performed
by reinforcing the posterior wall with a polypropylene mesh (Lichtenstein repair
nique is to place a mesh from within the abdomen
1
). An alternative tech-
laparoscopically, covering the hernial orifice. The
laparoscopic technique has particular advantages in
the treatment of recurrent or bilateral hernias.
A truss is only advised in patients who are in very
poor general condition and are unable to withstand
an operation, although they often have difficulty
keeping a truss correctly in place. Even in such cases,
a painful hernia that threatens strangulation is much
better repaired as an elective procedure, if necessary
under local anaesthesia, rather than as an emergency
when strangulation has supervened.
1
Irving L. Lichtenstein (1920–2000), Surgeon, Cedars- Sinai
Medical Center, Los Angeles, CA, USA.
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Anterior superior
iliac spine
Iliacus
Femoral
nerve
Femoral
artery
Psoas
tendon
Femoral vein
Fascia iliaca
Lateral cutaneous nerve of thigh
Inguinal ligament
Fascia transversalis
Pectineus
Femoral canal
External ring
with emerging
spermatic
cord
Lacunar
part of
inguinal
ligament
Figure31.3 The anatomy of the
femoral canal and its surrounds to show
the relationships of a femoral hernia.
Recurrent inguinal hernias may be caused by, for
example, infection, haematoma or poor surgical technique, and also by a failure to appreciate the underlying
cause of the increased intra-
abdominal pressure that initiated the hernia in the first place (e.g. continuing constipation or bladder neck obstruction by a large prostate).
Femoral hernia
Anatomy
A femoral hernia passes through the femoral canal.
This is a gap normally about 1.5cm in length, which
just admits the tip of the little finger and which lies at
the medial extremity of the femoral sheath containing
the femoral artery and vein. The boundaries of the
femoral canal are as follows (see Figure31.3).
•
Anteriorly: the inguinal ligament.
• Medially: the sharp edge of the lacunar part of the
inguinal ligament (Gimbernat’s ligament
• Laterally: the femoral vein.
2
Manuel Gimbernat (1734–1816), Anatomist and Surgeon to
King Carlos III of Spain.
2
).
• Posteriorly: the pectineal ligament (of Cooper3),
which is the thickened periosteum along the superior pubic ramus.
The canal contains a plug of fat and a lymph node
(the node of Cloquet
4
).
Clinical features
Femoral hernias occur more commonly in women
than in men because of the wider female pelvis (but
note that indirect inguinal hernias are more common than femoral hernias in women). They are
never due to a congenital sac but are invariably
acquired; although cases do rarely occur in children, they are usually seen in the middle- aged and
elderly.
A non- strangulated hernia presents as a globular
swelling below and lateral to the pubic tubercle. It
enlarges on standing and on coughing and may
disappear when the patient lies down. In most cases,
even when the hernia is completely reduced, a swelling
3
Sir Astley Paston Cooper (1768–1841), Surgeon, Guy’s
Hospital, London, UK.
4
Jules Germain Cloquet (1790–1883), Professor of Surgery,
Paris, France.
Iliacus
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Femoral
nerve
Femoral
artery
Femoral
vein
Sac of femoral hernia
Internal inguinal ring
Inferior epigastric vessels
External inguinal
ring
Pubic
tubercle
Sac of indirect inguinal hernia
Hernia 317
Figure31.4 The relationships of
an indirect inguinal and a femoral
hernia compared. The inguinal hernia
emerges above and medial to the
public tubercle; the femoral hernia
lies below and lateral to it.
can still be palpated and this is due to extraperitoneal fat
around the femoral sac.
As the hernia enlarges, it passes through the saphenous
opening in the deep fascia (the site of penetration of
the great saphenous vein to join the femoral vein),
and then turns upwards so that it may project above
the inguinal ligament. There should not, however, be
any difficulty in differentiating between an irreducible femoral and inguinal hernia– the neck of a femoral hernia always lies below and lateral to the pubic
tubercle, whereas the sac of an indirect inguinal hernia extends above and medial to this landmark
(Figure31.4).
The neck of the femoral canal is narrow and has a
particularly sharp medial border. For this reason, irreducibility and strangulation are extremely common
in this type of hernia.
Richter’s hernia
A Richter’s hernia5 is particularly likely to occur in the
femoral sac. In this type of hernia, only part of the wall
of the small intestine herniates through the defect,
5
August Gottlieb Richter (1742–1842), Surgeon, Göttingen,
Germany.
where it is then strangulated. Because the lumen of the
bowel is not completely encroached upon, symptoms
of intestinal obstruction do not occur, although the
knuckle of bowel may become completely necrotic and
indeed perforate into the hernial sac and thence into
the peritoneal cavity, causing acute peritonitis.
Treatment
All femoral hernias should be repaired by excision of
the sac and closure of the femoral canal because of
their great danger of strangulation. This may be
readily accomplished by open or laparoscopic mesh
repair.
Umbilical hernia
Exomphalos
This is a rare condition in which there is failure of all
or part of the midgut to return to the abdominal cavity in foetal life. The bowel is contained within a translucent sac protruding through a defective anterior
abdominal wall. Untreated, this ruptures with fatal
peritonitis, or rupture may occur during delivery.
The condition is commonly associated with other
congenital anomalies.
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Treatment
For small defects less than 4cm (exomphalos minor)
and only containing intestine, immediate surgical
repair is undertaken. When the opening is more than
4 cm (exomphalos major) or the liver is within the
cord, exomphalos a plastic covering (termed a ‘silo’) is
placed over the viscera and the exomphalos closed in
stages over a period of days to weeks, during which the
child grows creating more space inside into which the
viscera are replaced. While most babies make a full
recovery, being very premature or having other physical or genetic conditions are poor prognostic features.
Congenital umbilical
hernia
This results from failure of complete closure of the
umbilical cicatrix. It is especially common in premature children. The vast majority close spontaneously
during the first year of life.
Treatment
Surgical repair should not be carried out unless the
hernia persists after the child is 2 years old. The parents of an infant with a congenital umbilical hernia
should be reassured that the majority disappear
spontaneously. Strapping the hernia or providing a
rubber truss are generally not indicated.
Paraumbilical incisional hernias are also commonly seen where the hernia has protruded through a
defect in the fascia made during laparoscopic surgery, and present in a similar way.
Treatment
The sac is isolated, excised and the edges of the
rectus sheath may be opposed or overlapped above
and below the hernia (Mayo’s operation
defects over 1cm in size, a polypropylene mesh can
be incorporated into the repair via an open or laparoscopic approach.
6
), or, for
Divarication ofthe recti
Divarication of the recti (diastasis recti) is where the
fascia between the two rectus sheaths is stretched,
leaving a gap between the two rectus abdominis
muscles. The result is a midline ridge, predominantly in the upper abdomen between xiphoid and
umbilicus, most marked on coughing or raising
both legs while lying. It is associated with pregnancy
and other causes of abdominal distension. It is not a
true hernia, and in the majority of cases requires no
treatment.
Paraumbilical hernia
This is an acquired hernia that occurs just above or
below the umbilicus. Although not strictly an umbilical hernia, that term is often used to describe a
paraumbilical hernia. It is associated with obesity and
is more common in multiparous women. The neck is
narrow and, like a femoral hernia, it is particularly
prone to become irreducible or strangulated. The
contents are nearly always pre- peritoneal fat or
omentum; large hernias may contain transverse
colon and/or small intestine.
In patients with ascites, a paraumbilical hernia often
progresses to one characterized by complete eversion
of the cicatrix and appearing as a true umbilical hernia.
Repair of such hernias needs careful consideration of
the underlying medical condition that caused it.
Epigastric hernia
A particular variety of ventral hernia is the epigastric
hernia, which consists of one or more small protrusions through defects in the linea alba above the
umbilicus. These usually contain only extraperitoneal
fat, but are often surprisingly painful.
Treatment
Simply suturing of the defect is all that is required if it
is small. Larger defects are likely to need a mesh
repair, and this can be considered via an open or
laparoscopic approach.
6
William Mayo (1861–1939), Surgeon, Rochester, MN, USA.
He rst described this technique in a presentation to the
American Academy of Railway Surgeons in 1895.
Incisional hernia
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An incisional hernia occurs through a defect in the
scar of a previous abdominal operation. The causes,
which are the same as those of a burst abdomen, are
given in Chapter5.
There is usually a wide neck, and strangulation is,
in consequence, uncommon.
Treatment
If the general condition of the patient is good and the
hernia symptomatic, the hernia is repaired by dissecting out the defect and reducing the sac. Defects are
closed with a sheet of mesh, ideally avoiding direct contact of the mesh with bowel which, if it occurs, can result
in fistula formation. Surgery can be performed via an
open or laparoscopic approach. If operation is considered inadvisable, an abdominal binder may be advised.
Differential diagnosis
ofmidline hernia
Hernia 319
the obturator nerve and vessels traverse the membrane
covering the obturator foramen. Pressure of a strangulated obturator hernia upon the nerve may cause
referred pain in its area of cutaneous distribution, so
that intestinal obstruction associated with pain along
the medial side of the thigh in a thin, elderly woman
should suggest this diagnosis. The hernia is often of the
Richter type. CT will confirm the diagnosis.
Spigelian hernia
A Spigelian hernia7 passes upwards through a defect in
the transversus abdominis aponeurosis (Spigelian
fascia) at the lateral margin of the rectus sheath, usually adjacent to the arcuate (semilunar) line, caudal to
which the posterior wall of the rectus sheath is
deficient. Typically, it passes laterally through the
transversus abdominis fascia and internal oblique, but
beneath the external oblique aponeurosis (as such, it is
an example of an interparietal hernia, one that passes
between the layers of the abdominal wall). It presents
as a tender mass to one side of the lower abdominal
wall, but can be surprisingly difficult to identify clinically. Ultrasound or CT will confirm the diagnosis if
doubt exists. Spigelian hernias usually have a narrow
neck and thus are prone to obstruct so repair is advised.
Endometrioma ofthe abdominal wall
Although not a hernia as such, midline endometriomas
are often mistaken for hernias. After a Caesarean section through either a Pfannenstiel or lower midline incision, endometrium seeds into the linea alba where it
has been divided to allow access to the gravid uterus,
where it slowly grows, presenting many months or years
after the pregnancy. There may be associated cyclical
pain, but this is not common. Examination reveals a
non-
reducible, midline lump attached deeply. The
solid soft tissue mass can be confirmed on ultrasound
or computed tomography (CT) scan. Needle core
biopsy often reveals fibrotic tissue, but may contain
endometrial fragments. Treatment is simple excision.
Unusual hernias
Obturator hernia
These are found particularly in thin, elderly women
and usually present with acute intestinal obstruction.
The hernia develops through the obturator canal where
Gluteal hernia
Traverses the greater sciatic foramen.
Sciatic hernia
Passes through the lesser sciatic foramen.
Lumbar hernia
A lumbar hernia is most commonly an incisional
hernia following an open operation on the kidney,
but may rarely occur through the inferior lumbar triangle bounded by the crest of the ilium below, the
latissimus dorsi medially and the external oblique on
the lateral side.
Parastomal hernia
Passes through the same defect in the abdominal wall
that was made to bring the bowel out as a stoma.
7
Adriaan van den Spiegel (Spigelius) (1578–1625), Professor
of Anatomy and Surgery, Padua, Italy.
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Diaphragmatic hernias
The diaphragmatic hernias can be classified as
follows.
1
Congenital.
2
Acquired:
a
Traumatic.
Hiatal.
b
Congenital diaphragmatic hernia
Embryology
These hernias can best be understood by reference to
the embryology of the diaphragm (Figure 31.5). The
diaphragm is developed by fusion of the following.
•
The septum transversum, which forms the central
tendon, and which develops from mesoderm
lying in front of the head of the embryo. With the
folding of the head, this mesodermal mass is carried ventrally and caudally to lie in its definitive
position at the anterior part of the diaphragm.
During this migration, the cervical myotomes
and cervical nerves contribute muscle and nerve
supply, respectively (C3, 4, 5), thus accounting
for the long course of the phrenic nerve from the
neck to the diaphragm.
•
The dorsal oesophageal mesentery.
• The pleuroperitoneal membranes, which close the
primitive communication between the pleural
and peritoneal cavities.
•
A peripheral rim derived from the body wall.
In spite of this complex story, congenital abnormalities of the diaphragm are unusual. They may
manifest as hernias through the following defects:
• The foramen of Morgagni,
and costal origins.
• The foramen of Bochdalek,
peritoneal canal.
• A deficiency of the whole central tendon.
• A congenitally large oesophageal hiatus.
8
Giovanni Battista Morgagni (1682–1771), Professor of
Anatomy, Padua, Italy.
9
Vincent Bochdalek (1801–1883), Professor of Anatomy,
Prague, Czech Republic.
8
between the xiphoid
9
a defect in the pleuro-
Clinical features
Hernias through the foramen of Morgagni are usually
small and unimportant. Those through the foramen
of Bochdalek or through the central tendon are large
and present as respiratory distress shortly after birth.
Urgent surgical repair is required.
The congenital hiatal hernias present with regurgitation, vomiting, dysphagia and progressive loss of
weight in small children; they usually respond to
conservative treatment and nursing the child in a sitting
position. If this fails, surgical repair is necessary.
Traumatic diaphragmatic
hernias
These are comparatively rare and follow blunt (crush)
injuries to the chest or abdomen, or penetrating injuries such as stab wounds, which implicate the diaphragm. The left diaphragm is far more often affected
than the right (which is protected by the liver) and is
accompanied by herniation of the stomach and spleen
into the thoracic cavity. The gasthe left chest after a crush injury may be mistaken for a
tension pneumothorax on chest X- ray. Passage of a
nasogastric tube or ingestion of a small amount of contrast material confirms the diagnosis.
Treatment comprises urgent surgical repair,
through either the chest or abdomen.
filled stomach lying in
Acquired hiatal hernias
Classication
These are divided into:
Sliding (90%).
•
• Rolling (10%).
In the sliding variety, the stomach slides through the
hiatus and is covered in its anterior aspect with a peritoneal sac while the posterior part is extraperitoneal. It thus
resembles an inguinal hernia en glissade (Figure 31.6a).
This type of hernia produces both the effects of a spaceoccupying lesion in the chest and disturbances of the
cardio- oesophageal sphincter mechanism.
In the rolling (or paraoesophageal) hernia, the
cardia remains in position but the stomach rolls up
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Contribution
from body
wall
Inferior
vena
cava
Right
pleuroperitoneal
membrane
Vertebra
Aorta
Septum
transversum
Spinal cord
Mesentery of
oesophagus
Oesophagus
Peritoneal sac
Rib
Left
pleuro-
peritoneal
membrane
Figure31.5 The development of the
diaphragm. The drawing shows the
four contributory elements: septum
transversum, dorsal mesentery of
the oesophagus, body wall and
pleuroperitoneal membrane.
Diaphragm
(b)Sliding hernia(a) Rolling hernia
Figure31.6 (a) Sliding hiatus hernia: the stomach and lower oesophagus slide into the chest through a patulous
oesophageal hiatus. (b) Rolling hiatus hernia: the stomach rolls up through the hiatus alongside the lower oesophagus
(paraoesophageal hernia).
anteriorly through the hiatus, producing a partial
volvulus. Because the cardio- oesophageal mechanism is intact, there are no symptoms of regurgitation
(Figure31.6b).
These hernias probably represent a progressive
weakening of the muscles of the hiatus. They occur in
the obese, middle- aged and elderly, and are four
times more common in women than in men.
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Clinical features
Most are symptomless but when they occur, symptoms fall into three groups.
1
Mechanical, produced by the presence of the her-
nia within the thoracic cavity: cough, dyspnoea,
palpitations, hiccough.
Reflux, resulting from incompetence of the cardiac
2
sphincter: burning retrosternal or epigastric pain
aggravated by lying down or stooping, and which may
be referred to the jaw or arms, thus simulating myocardial ischaemia. Alkalis provide relief. In severe cases,
spill over into the trachea may cause pneumonitis.
3
The effects of oesophagitis: stricture formation with
dysphagia and bleeding, which may be acute or
occult.
Treatment
Sliding hiatus hernias are treated symptomatically; if
symptoms of reflux and oesophagitis are troublesome,
laparoscopic repair is performed, otherwise they
may be left. Paraoesophageal (rolling) hernias are
usually asymptomatic, but potentially more serious
with the risk of complete gastric volvulus into the
chest. Should this occur, urgent surgical repair is
indicated.
Reflux oesophagitis
This is discussed in Chapter22.
Additional resources
Case 81: A large swelling in the groin
Case 82: A groin lump in an old woman
Case 83: A lump at the umbilicus
Case 84: A swelling in the abdominal wall
The liver
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Raaj Kumar Praseedom
Learning objectives
✓ To know the common causes of liver enlargement.
✓ To understand the dierent causes of jaundice, and how they may be
diagnosed and treated.
✓ To have knowledge of cirrhosis, its various manifestations and their
management.
Liver enlargement
Physical signs
The normal liver in the adult is impalpable. In contrast, an infant’s liver is normally palpable two finger
breadths below the right costal margin. The enlarged
liver extends downwards below the right costal margin and may fill the subcostal angle or even extend
beneath the left costal margin in gross hepatomegaly.
The liver moves with respiration, is dull to percussion
and the liver dullness may extend above the normal
upper level of the fifth right intercostal space.
Causes ofhepatomegaly
1 Congenital:
a Riedel’s lobe
b Polycystic liver disease (which develops in
adult life).
1
(rare).
32
2 Acquired:
a Marked steatosis (fatty liver disease, poorly
controlled diabetes).
b
Neoplastic – primary or secondary tumour,
lymphoma.
Cirrhosis.
c
d
Hepatic venous outflow limitation– congestive
cardiac failure and Budd–Chiari syndrome.
e Liver infiltration– lymphoma, glycogen storage
diseases (e.g. Gaucher’s disease
Whenever the liver is palpable, the patient must be
examined to detect any accompanying splenomegaly,
lymphadenopathy or abdominal masses. If the spleen
is palpable in addition to the liver, consider cirrhosis,
haematological malignancy, amyloid or unusual infections as possible diagnoses. If, in addition, the lymph
nodes are enlarged, the diagnosis is often lymphoma.
3
), amyloid.
Jaundice
2
1
Bernhard Riedel (1846–1916), Professor of Surgery, Jena,
Germany. Also described Riedel’s thyroiditis.
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
The normal serum bilirubin is below 17 μmol/L
(1 mg/dL). Excess bilirubin becomes clinically
2
George Budd (1808–1882), Professor of Medicine, King’s
College, London, UK. Hans Chiari (1851–1916), Professor of
Pathology, Prague, Czech Republic.
3
Phillipe Gaucher (1854–1918), Physician, Hôpital St Louis,
Paris, France.
324 The liver
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detectable when the serum level rises to over
35μmol/L (2mg/dL), and gives a yellow tinge to the
sclera and skin, termed ‘jaundice’ (or ‘icterus’).
Bilirubin metabolism (Figure32.1)
Knowledge of bile pigment metabolism and excretion
is essential if the pathogenesis, presentation, investigation and treatment of jaundice are to be understood.
When red cells reach the end of their life in the cir-
culation (approximately 120days), they are destroyed
Liver
Bilirubin
Glucuronyl transferase
Bilirubin glucuronide
Bile duct
in the reticuloendothelial system. The porphyrin ring
of the haemoglobin molecule is disrupted and a
bilirubin–iron–globin complex produced. The iron is
released and used for further haemoglobin synthesis.
The bilirubin–globin fraction reaches the liver as a
lipid-
soluble, water- insoluble substance. In the liver,
the bilirubin is conjugated with glucuronic acid in
thehepatocytes and excreted in the bile as the now
water-
soluble bilirubin glucuronide.
In the bowel lumen, bilirubin is reduced by bacte-
rial action to the colourless urobilinogen. Most of the
Spleen
Red-cell
breakdown
Haem
+
Fe
Some
reabsorbed
Urobilinogen
Kidney
Figure32.1 The metabolism of bilirubin.
Urobilinogen
Urobilin
Urobilin in faeces
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