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HerniaSurgerySimplied

allowsperforationoftheaponeurosisastheherniasac coursesoverthefemoralcanal.eretrovascularhernia sacdescendsintheposteriorsheathofthefemoralvein.

Epigastric Hernia

Anepigastric hernia isa typeof hernia whichmay developintheepigastrium.Epigastricherniasaremost commonininfantsbutmayoccurinhumansofanyage. eytypically resultfroma minordefectof thelinea albabetweentherectusabdominismuscles.isallows tissuefrominside theabdomen to herniateanteriorly. Oninfants,this maymanifestas anapparent‘bubble’ undertheskinofthebellybetweentheumbilicusand xiphisternum.

Umbilical Hernia

Umbilicalherniaisacongenitalmalformation,especially commonininfantsofAfricandescent,andmorefrequent ingirls. An acquiredumbilical hernia directlyresults fromincreasedintraabdominalpressureandaremost commonlyseeninobeseindividuals.

Presentation

Ahernia ispresentat thesiteof theumbilicus inthe newborn;althoughsometimesquitelarge,thesehernias tendtoresolvewithoutanytreatmentbyaroundtheage of5years.Obstructionandstrangulationofthehernia israrebecausetheunderlyingdefectintheabdominal wallislargerthaninaninguinalherniaofthenewborn. esizeof the baseoftheherniatedtissueisinversely correlatedwithriskofstrangulation(i.e.narrowbaseis morelikelytostrangulate).Anumbilicalherniapresents asacentral,midabdominalbulge.  Babiesare pronetothis malformationbecauseof theprocessduring fetaldevelopmentby whichthe abdominalorgansform outsidethe abdominalcavity, laterreturninginto itthroughan openingwhich will becometheumbilicus.

Paraumbilical Hernia

enameparaumbilicalherniaapplieswhenthisdefect isadjacenttotheumbilicus.

Hiatus Hernia

Ahiatus hernia orhiatal herniaisthe protrusion(or herniation)of theupperpart ofthe stomachintothe thoraxthroughatearorweaknessinthediaphragm.

Symptoms

esymptomsincludeacidreuxand pain,similar to heartburn,inthechest,andupperstomach.  Inmostpatients,hiatusherniascausenosymptoms. Sometimes patients experience heartburn and regurgitation,whenstomachacidreuxesbackintothe esophagus.

Diagnosis

ediagnosisofahiatusherniaistypicallymadethrough anuppergastrointestinal(GI)seriesorendoscopy(Fig.7.2).

Incisional Hernia

Anincisionalherniaoccursinanareaofweaknesscaused byanincompletelyhealedsurgicalwound.Sincemedian

Dierential Diagnosis

Importantlythis typeofhernia mustbe distinguished fromaparaumbilicalherniawhichoccursinadultsand involvesa defectinthemidlinenear to theumbilicus,

and from omphalocele.

Fig. 7.2: Upper gastrointestinal (GI) endoscopy

depicting hiatus hernia

Diagnosis of Hernia

incisionsin theabdomenare frequentforabdominal exploratorysurgery,ventralincisionalherniasaretermed ventralhernias.  Clinically, incisionalherniaspresent as abulge or protrusionat or nearthe areaofa surgicalincision. Virtuallyany priorabdominal operation candevelop anincisionalherniaatthescararea(providedadequate healingdoesnotoccur),fromlargeabdominalprocedures (intestinalsurgery,vascularsurgery),tosmallincisions (appendixremoval,orabdominalexploratorysurgery). Whiletheseherniascanoccuratanyincision,theytend tooccurmorecommonlyalongastraightlinefromthe xiphoidprocessofthesternumstraightdowntothepubic bone,andaremorecomplexintheseregions.

Obturator Hernia

Anobturatorhernia isa raretype ofabdominal wall herniainwhich abdominalcontentprotrudesthrough theobturatorforamen. Becauseofdifferences in anatomy,it ismuch more common infemales thanin males,especiallymultiparous and olderwomen who haverecentlylostalotofweight.ediagnosisisoften madeintraoperativelyafter presentingwithbowel obstruction.Agynecologistmaycomeacrossthistype ofherniasasasecondaryndingduringgynecological opensurgery orlaparoscopy.e HowshipRomberg signis suggestiveofan obturatorhernia,exacerbated bythighextension,medialrotationandadduction.Itis characterizedbylancilating paininthe medialthigh/ obturatordistribution,extendingtotheknee;causedby herniacompressionoftheobturatornerve.  Obturatorhernias have intermittent,acute, and severehyperesthesiaor paininthe medialthighor in

the region of the greater trochanter. e symptoms are

usuallyrelievedbyexionofthethighandareworsened bymedialrotation,adduction,orextensionatthehip. Rarely,thereisapalpablemassinthemedialupperthigh.

Perineal Hernia

Perinealherniaisaherniainvolvingtheperineum.e herniamaycontain fat,anypart ofthe intestine, the rectum,orthebladder.Itappearsasasuddenswelling tooneside(sometimesbothsides)oftheanus.

muscle,behindby latissimusdorsiand belowbyiliac crest.Theneck islarge,so chances ofstrangulating aresmall. Occursmoreofteninmalesontheleftside. Protrudeswhenthechildcries.

Grynfeltt-Lesshaft Hernia

GrynfelttLesshaftherniais aherniation ofabdominal contentsthroughthe back,specificallythroughthe superiorlumbar triangle,which isdefined bythe quadratuslumborummuscle,twelfthrib,andinternal obliquemuscle.

Sciatic Hernia

Atendermassintheglutealareathatisincreasinginsize issuggestiveofasciatichernia.Sciaticneuropathyand symptomsofintestinalorureteralobstructioncanalso occur.Perineal herniasgenerally present as aperineal masswithdiscomforton sitting and occasionallyhave obstructivesymptomswithincarceration.

Diastasis Recti

Diastasisrecti or awidened lineaalba hasnoclinical significanceand doesnotrequire operativerepair. However,theremaybesmallopeningsinthelineaalba throughwhichpreperitonealfatcanprotrude.

Interparietal Hernia

eterm “interparietalhernia”isused collectivelyto designatea groupofratherunusualherniaswhichare locatedintheinguinalregionbetweenthevariouslayers oftheabdominalparietes.Anatomically,thesehernias maybeclassiedasfollows:  1. Properitonealhernia,thattypeinwhichthehernial

sacliesbetweentheperitoneumandthetransversalis

fascia.

 2. Interstitialhernia,inwhichthesacliesbetweenthe

transversalisfascia and thetransversalis,internal oblique,orexternalobliquemuscles.

 3. Superficialhernia, inwhichthe sacis situated

betweenthe aponeurosisofthe externaloblique muscleandtheintegument.

Petit’s Hernia

Petit’sherniaistheonethatprotrudesthroughlumbar

triangle. is triangle lies in the posterolateral abdominal

wallboundedinfrontbyfreemarginofexternaloblique

Monolocular Properitoneal Hernia

Properitonealhernia (Figs 7.3to7.8), inboth the monolocularandthebilocularforms,maybeclassied asfollows:

HerniaSurgerySimplied

Symptoms

ereisno pathognomonicsignor symptomthatwill leadtothediagnosisofproperitonealhernia.Fully90% ofthepatientswillpresentthemselveswiththeclinical syndromeof acute intestinalobstruction. Theymay havehadareducibleinguinalorfemoralherniaoflong standing.Followinganapparentreduction,thepatient becomesnauseatedandvomits,theabdomenbecomes distended,andthebowelsconstipated.Onexamination, anirreducibleinguinalorfemoralherniamaybefound, withsome tendernessoverthe regionofthe internal inguinalring, but asa ruleno swellingoccursabove Poupart’sligament.

Interstitial Hernia

Supercial Hernia

Insupercialherniathesacliesbetweentheskinandthe aponeurosisoftheexternalobliquemuscle.

Fig. 7.3: Bilocular properitoneal hernia

Diaphragmatic Hernia

Fig. 7.4: Monolocular properitoneal hernia

 1. Inguinoproperitonealhernia, which occursas a

diverticulumfromapreexistinginguinalhernia.

 2. Cruroproperitoneal hernia,whichoccurs asan

outpouchingofafemoralhernia.

 3. Simpleproperitonealherniawhichisindependent

oftheinguinalorfemoralcanals.

Adiaphragmatichernia isabirth defect,which isan abnormalitythatoccursbeforebirthasafetusisforming

Fig. 7.5: Bilocular interstitial hernia

Diagnosis of Hernia

Fig. 7.6: Monolocular interstitial hernia

Fig. 7.7: Bilocular

Fig. 7.8: Monolocular

erearetwotypesofdiaphragmatichernia:  1. Bochdalek hernia: ABochdalek herniainvolves

an opening on the left side of the diaphragm. e

stomachand intestinesusuallymove up intothe chestcavity.

2. Morgagni hernia: AMorgagnihernia involvesan openingontherightsideofthediaphragm.eliver andintestinesusuallymoveupintothechestcavity.

Congenital Abdominal Wall Defects

Maternalserumalphafetoprotein screeningcanhelp identifyventralwall defectsin thefetusduring the secondtrimester.Prenatalultrasonographycandene thelocationoftheabdominalwalldefect,thestatusofthe viscera,itsinvolvementwithassociatedstructures,and thepresenceofadditionalmalformations.Recognition ofa smallomphaloceleor herniaof theumbilical cordstalkmaynotoccur until afterdelivery.ismay resultin compromiseof the smallbowelordamageto anomphalomesenteric ductasthe cordisclamped. erefore,thecordshouldbeclampedwellawayfrom theabdomeninaninfantwithanunusualcordbaseor widenedumbilicalcordbasetopreventiatrogenicinjury totheintestine(Fig.7.9).

inthe mother’s uterus.Anopening ispresentin the diaphragm.Withthistype ofbirth defect, someof the organsthatarenormally foundintheabdomen move upintothechestcavitythroughthisabnormalopening.

Radiology in Hernia Diagnosis

Sometimesherniamaynotbeobviousasitmaybeon manyoccasions.Forthecompletediagnosisofherniathe

HerniaSurgerySimplied

Fig. 7.9: Congenital diaphragmatic hernia

surgeonhastoundertakesomeinvestigationstoprove thediagnosisofhernia.Someherniasarewellhiddenin theabdomenorpelvislikeobturatorhernia.Itbecomes diculttodiagnosetheseherniasclinically.Forinstance

epigastric hernia may also be misleading to diagnosis

oflipoma.Astheswellingissoftinepigastrichernia;it confusesthesurgeon.Heresomespecialinvestigations arehelpfultothesurgeonlikeCTscan,ultrasonography, bariumswallow,herniography,etc.

Peritoneography/Herniography

Peritoneography is highly reliable for detecting clinically

occultinguinalherniaandhasalowcomplicationrate. Peritoneographyinvolvestheintraperitoneal injection ofnonionic contrastfor evaluationof the abdominal parietes.When usedselectively forevaluationof the inguinalregionandpelvicoor,itistermedherniography.

Indications

 1. Inguinalpain(Inguinodynia).  2. Clinicallyabsent inguinalherniaon physical

examination.

Herniography Technique

etechniqueofherniographyisperformedasfollows: Aninitialphysicalexaminationof theinguinalregions isperformed standingand then supineto exclude herniaandtoevaluateforothercausesofinguinalpain relatedtothe symphysispubis,adductormusculature,

andhipjoints.Withthe patientin thesupineposition onthe radiographictilt table,thepatient is asked toelevate head andshoulders offthetable, andthe

tensed abdomen is examined. e midline region of the

supraumbilicallinea albaandthe linea semilunarisat thelateralmargin of therectussheath adjacentto the umbilicusareidentied andmarkedwherepossible, dependingonoperatorpreference.Anintravenousline isinstituted thatcanbe usedfor conscioussedation (rarelyneeded)ortreatmentof vagal reactions (again, rarelyneeded), reactionsto the localanesthetic orthe contrastmedium.The chosenareais preparedand drapedinsterilefashion,andtheskinandsubcutaneous tissuesdowntotheperitoneumareinltratedwith1% xylocaine.A small dermatotomyismade andthe 7 or 12cm 21gauge micropunctureneedle (dependingon bodyhabitus)froma10or15cmmicropuncturesetis insertedinanobliquefashion(notvertically)untilthe patient’s faceregistersthe characteristicgrimaceand thecharacteristicpop isfelt,indicating passageofthe needletipthroughtheperitoneum.Atthistime,asmall amountofcontrastisinjectedbyhandunderuoroscopy. Ifnecessary,theneedleisrepositioneduntiltheinjected contrastshowsthecharacteristicinterloopappearance onuoroscopy,indicating theneedle tip iswithin the peritonealcavityandnotwithintheparietes,thegreater omentum,andthesmallbowelmesenteryorwithinthe bowellumen.e0.018inchdiameterguidewirefrom themicropuncturesetispassedthroughtheneedleand theneedle isremoved.e4F micropuncturesheath/ dilatorispassedoverthewireintotheperitonealcavity,

Diagnosis of Hernia

thewire and dilatorareremoved, and then150 ml nonioniccontrastmedium(Omnipaque300),isinjected byhandthroughthesheathintotheperitonealcavity.e sheath is capped o and left in situ,coveredbyasterile occlusivedressing.epatientisturnedintotheprone positionandtheheadofthetableiselevated20°to25° tooptimallypool theintraperitonealcontrastoverthe inguinalregions.Radiographsare then obtainedwith thepatientinproneandproneobliquepositionsatrest andduring provocativemaneuvers such ascoughing, sning,Muellermaneuver(forced inspirationagainst aclosed glottis),andstraining orValsalvamaneuver (forcedexpirationagainstaclosedglottis).Inaddition, thepatientisoccasionallyaskedtoelevateuponknees andelbowstorelievecompressionfromobesityonthe inguinalregions(acauseoffalsenegativeresults).Cross tablelateralradiographsareoccasionallyusedaswell. Asanimportantadjuncttotheexamination,thepatient isaskedtopointwithasingleindexngerortoplacea radiographicmarkeratthesiteofhisorherpain,anda radiographisobtainedforcorrelation.Inmalepatients, standingimagesaresometimesuseful.Inmalepatients, thescrotumshouldbebrieyevaluatedwithuoroscopy afteralltheprovocativemaneuverstoseewhetherany contrasthasentered the scrotum.Thiscan indicate herniawhentheneckisnotapparentorcompressed.If thereisateatappearanceinthesupravesicalormedialor lateralinguinalfossae,thepatientcanbeturnedsupine

andthe feetelevated20° to25° and airor CO2 can be injectedthroughtheindwellingsheath.isoccasionally detectsahernia,thesacllingwithnegativecontrast.is usuallyrequiresabdominaldistentionwithgas.  e entire proceduretakes approximately20 to30 minutes.Whentheprocedureiscomplete,the4Fsheath isremovedandasteriledressingisapplied.  Herniography has greatvaluein excludinginguinal herniainpatientswithchronicsymptomsinthegroin. Itisa usefuldiagnostic tool forthe identificationof clinicallyoccult herniaeandthis investigationcan preventneedless surgeryand reexplorationin those caseswith previousherniarepair.Its principalroleis toestablishthediagnosisofoccultherniaasacauseof obscurepaininthegroin.

Ultrasonography

Sonographyhasbeenusedinthediagnosisofabdominal wallherniationsaswellaspathologicconditionsaecting theinguinalandfemoralregions.Itprovidesarapidand noninvasivemethodof imagingthe scrotal contents andhas enabled differentiationof testicularfrom extratesticularpathologyinmostcases.

Ultrasonography can also aid in prenatal diagnosis of

herniainfetus,e.g.hiatushernia.

Criteria for prenatal hiatus hernia diagnosis: The

ultrasoundcriterion for prenataldiagnosisis the

presence of a herniated stomach in the posterior

mediastinum,sometimes having adynamicposition duringexamination,withnomediastinalshiftassociated withnormal diaphragmappearance onparasagittal

sections of the thorax.

Fig. 7.10: X-ray showing right inguinal hernia (arrow)

Inguinal Hernia (Fig. 7.10)

Inthe obese,distortion of anatomy,thepresence of pannus,andthesoundattenuatingpropertiesofadipose tissue maymakeidentifyingtheanatomymoredicult. Initially,examination ofthe inguinalregionisdone withthepatientsupine.Itisessential toaskthepatient toincrease abdominal pressure(Valsalvamaneuver)

at each of the sonographic steps to identify transient hernias.

 TheValsalvamaneuveris a criticalcomponent of theexamination, becausein manypatientsthe hernia maybe completely reduced atrest.In addition,the characteristicmovementofthe herniatingtissues

often clinches the diagnosis. is dynamic capability of

sonographyisanadvantagewhencomparedwithother

HerniaSurgerySimplied

crosssectional imagingtechniques.Reexamination withthepatientstanding isalsorecommendedifsupine evaluationdoesnotrevealherniation.Herniated bowel contentsmayshow peristalsis,and herniatedfat will appearhyperechoic.Itisalsoimportanttoevaluatefor reducibility ormucosalblood ow.

Indirect Inguinal Hernia (Fig. 7.11)

andbowelviabilityidentiedbyperistalsis

Foran indirect inguinalhernia,once the transduceris

positioned

wheretheinferiorepigastricarteryoriginates

from the external iliacartery,itisrotatedobliquelysothat the medial aspect isinferior,alongthelong axisofthe

inguinalligament. Inmen, the healthyspermaticcord canbeseenin longitudinaland heterogeneoushyperechoicstructurewith

transverseplanesasa

hypoechoic

tubulesand vascularity,originatingfrom theinternal inguinalring.isstructureshouldbedierentiated from theinguinalligament,whichhasamorecompact brillar appearance,istautextendingfromtheiliumtothe

pubis, andis justinferiorin relationtothe internalinguinal ring.With the transducerpositioned longitudinalto theinguinal canalandvisualizingtheinferiorepigastric

artery at its origin,an indirectinguinalhernia canbe

seenprotrudinganteriorly towardthetransducerfrom

its origin lateral to the inferior epigastric artery. e

herniatedtissue then turnsmedially anterior to the

inferior epigastric artery and extends inferomedially as

ittraversesandoftendistendstheinguinalcanalparallel totheskinsurface.Anindirectinguinalhernia may reach thepubictubercleandexitthesupercialringand may enterthescrotuminaman.

Fig. 7.11: Indirect inguinal hernia-right

Direct Inguinal Hernia

Similartoindirectinguinalherniaevaluation,foradirect inguinalherniathetransducerisplacedlongitudinalto

the inguinalcanalandanteriortotheinferiorepigastric artery origin.However,thetransducerismovedmedially

because directinguinalherniasoriginatemedialtothe

inferior epigastric arteryinHesselbach’striangle.Imaging

superiortotheinguinal canalaswellasintheorthogonal planewill ensurecompleteevaluation ofHesselbach’s triangle.Withthe Valsalva maneuver, thishernia will protrudedirectlyanteriorlytowardthetransducer.

Femoral Hernia (Fig. 7.12)

Havingevaluated theinguinalregion superiorto the inguinal

ligament,thetransducer ismovedinferior to

Fig. 7.12: Femoral hernia

theinguinalligament,

and the area medial to the femoral

veinisevaluatedforfemoral hernia.DuringtheValsalva maneuver, the femoralvein willnormally dilateand shouldbedierentiatedfrom a femoral hernia.

Spigelian Hernia (Fig. 7.13)

The sonography examination for a spigelian hernia

shouldbegin atthelateralmarginoftherectusabdominis

Fig. 7.13: Spigelian hernia

Fig. 7.14: Scrotal hernia with bowel loops

(thelinea semilunaris) inthe transverseplane from thelevel oftheumbilicus.

Asthe transducerismoved

inferiorly,theinferiorepigastric arterycanbeidentied

as it passes deep in relation to the lateral border of the

rectusabdominismuscle.Justsuperior

tothislocation, alongthelineasemilunaris,isthesitewherea spigelian herniamayoccur.einferior epigastricartery

is then

followedinferiorlytothe external iliac artery,dening thelateralboundaryofHesselbach’striangle.

Scrotal Hernias (Fig. 7.14)

Sonographyhasbeenusedinthediagnosisofabdominal wallherniations as wellas pathologicconditions aectingthe inguinalandfemoral regions.It provides arapidandnoninvasivemethodofimagingthescrotal contentsandhas enableddierentiationoftesticular fromextratesticularpathology inmostcases. Scrotal herniaconstitutesasecondaryextratesticularmasswith

Diagnosis of Hernia

its origin in the abdomen. e contents of the hernia sac

includessmallbowelorcolonand/oromentuminmost cases.Ifthe scrotumalone is scanned,the diagnosis ofscrotal hernia containingbowel isbased on the recognitionofvalvulaeconniventesonhaustrationsand onthedetectionofpenistalsisonrealtimesonography. Intheabsenceofthesefeatures,thediagnosisofscrotal herniaisdicult.Evenwhenthesefeaturesarepresent, extratesticularpathology,such asmultiloculated hydroceleandhematocele containing fibroussepta, cansimulateuidlled loopsof bowel.Inaddition, fattytissue and fatcontainingmasses canproduce highamplitudeechoessimilar to a primary scrotal mass containingfat.Duetosimilarityintheirechoamplitude,

these masses may be impossible to dierentiate from a

scrotalherniacontainingomentum.Forthesereasons, scanningalongtheplaneoftheinguinalcanalandthe regionof the Hesselbach’striangle shouldalwaysbe performedwhenevaluatingascrotalmass.

e inferior epigastric artery at its origin is a critical

anatomiclandmark in differentiating indirect from directinguinalhernias;a hernia originating lateral to the

inferior epigastric artery isindirect,whereasonethatis medial is direct.

 Femoralhernias characteristicallyoccurmediallyto thefemoralveinandinferiorly inrelationtotheinguinal

ligament.

 Spigelianhernias occur at the lateral margin of the rectusabdominissuperiortothe inferior epigastric artery whereitcrossesthelineasemilunaris.  Withanunderstandingofinguinalregionanatomyand knowledge ofthevarietyofherniasfoundintheinguinal region,sonographic diagnosiscanassistthesurgeonin

managing this common clinical condition.

 istechniquehassensitivityof100%andspecicity of97.9%.

Dynamic Ultrasound Versus a CT or MRI Scan for Diagnosing Hernias

Adynamic ultrasound maybeorderedto diagnosea herniaor tocharacterizethe contentsofa herniaand determineitsreducibility.eultrasoundexamination isdynamicbecauseitisperformedinrealtime,showing motionlive,andbecauseitcanbeperformedwhilethe patientislying onhis/herback orstandingupright.It canalso beperformed whenthepatient is breathing quietlyorstrainingvigorously.Finally,ultrasound can

HerniaSurgerySimplied

beperformedwhiletheherniaisbeingcompressedwith theultrasoundtransducer.Computedtomography(CT) andmagneticresonance(MR)scans,ontheotherhand, canonlybedonewiththepatientlyingonhis/herback andgenerallywithoutstraining.Becauseoftheabilityof ultrasoundtoshowmotionduringdynamicmaneuvers, ultrasoundhasseveraladvantagesovermoreexpensive CTand MRscansin evaluatingforgroin andanterior abdominalwallhernias.  1. CTandMRcanshowonlynonreduciblehernias—

thosehernias thatare“outall thetime”.Only a minorityofherniasarenonreducible.Mosthernias arereducibleand willfall back intothe abdomen whenthepatientisquietlylyingonhis/herbackon aCTorMRtable.

 2. Ultrasound, likeCTand MR,can show larger

nonreduciblehernias,but canalsosmaller show reduciblehernias that CTand MR cannotshow. Becauseultrasoundimagesshowrealtimemotion, wecan seereduciblehernias movingin and out duringdynamicmaneuvers.

 3. Duringtheultrasoundexamination,anyherniathatis

foundcanbecompressedwiththeultrasoundprobe todetermineiftheherniaisreducibleortender.CT andMR,ontheotherhand,even when theyshow ahernia, cannotdeterminewhether thehernia is tender. Tenderness isimportant,because hernias areso common, thatwe often find“incidental” smallherniasthatarenotthecauseofthepatient’s pain.If aherniais tenderwhencompressed by theultrasound probe,it isfar morelikelythat the herniais,indeed,thecauseofpain,andnotmerely acommonincidentalnding.

 4. Ultrasoundcanidentifyherniasthatarecompletely

reduciblewhenthepatientislyingdown,butbecome nonreducibleandmoretenderwhenthepatientis standing.CTandMRIcannot.

inthefascia helpssurgeontoascertain themethodof repairandplansurgeryaccordingly.

Obturator Hernia (Fig. 7.15)

Obturatorhernia,althoughrare,isawelldocumented problem.Inmanyelderly,emaciated,debilitatedandill women,symptomsandsignsofsmallbowelobstruction withoutpreviousabdominal surgeryhistory andpain alongtheipsilateralthighandknee(HowshipRomberg’s sign)probablyindicated anincarceratedobturator hernia.CTscanisusefulintheearlydiagnosis.Prompt diagnosisandearlysurgerycanreducethemortalityrate andproducegoodclinicalresult.  Plain radiographs oftenshownonspecic ndings ofsmall bowelobstruction and seldomhelpful in diagnosingobturatorhernia.Noticinggasshadowinthe obturatorforamenareamaybehelpful.Bariumenema orsmallbowel seriescanbe helpful ifabowel loopis inthe obturatorcanal, butbarium studyismore time consumingin diagnosing caseof acute abdomenand retainedbariuminbowelloopmayincreasetheriskof subsequentoperation.  Ultrasonographyis usefuland reliablein diagnosis ofobturatorhernia,butitisoftenlimitedbytherelative inaccessibilityofthisdeepregionandoperatordependent. euseofCTscanindetectingobturatorherniawasrst reportedbyMezianeetalin1983.ecommonCTscan ndingislowdensitymassbetweenobturatorexternus andpectineusmuscle.elowdensitymassmaycontain

air density in some cases and apparently dierent from

Computed Tomography

Inthe modernera,computed tomography(CT)scans cometo helpsurgeonsdiagnose hidden,difficult to diagnosehernias.Alsooccultherniasarewellvisualized withthehelpofCTscanmodality. Aim: Unlikeother diagnosticmodalities; theaim of computedtomography(CT) scanningfordiagnosis

of hernia is to identify the fascial defect rather than

visualizationofherniacontents.eassessmentofdefect

Fig. 7.15: Herniated bowel (arrow head) between superior and middle fasciculi of right obturator externus muscle (arrows). Mild wall thickening of herniated bowel with blurring of adjacent fat plane can be found

Diagnosis of Hernia

theopposite side.Associatedbowel loopdilatationin theabdomeniscommon.SincetheuseofCTscan,pre operativediagnosisratewasimprovedfrom43to90%.CT scancanaccuratelydiagnosenotonlyobturatorhernia butalsootherconditionofbowelobstruction.

Incisional Hernia

Computedtomography(CT)scanninginincisionalhelps todiagnose thefascialdefect, massofrectus muscles

prior to repair.

 Italsorendersinformationaboutcontentsofthesac ofhernia,incarcerationofbowel/omentuminsac.  • Scan showingtransversecolon incarceratedin

ventralabdominalwallhernia(incisional).

 • Soft tissuestrandingin subcutaneousfataround

incarcerated hernia.

 • Absenceofentericcontrastpastareaofincarceration

withcollapseofleftcolonconsistentwithcomplete largebowelobstruction(Fig.7.16).

Barium Swallow for Hiatus Hernia (Fig. 7.17)

Bariumswallowisconsideredessentialinthepreoperative assessmentofgastroesophagealreuxdiseaseandhiatal

hernias.

Endoscopy for Hiatus Hernia (Fig. 7.18)

 • Hiatalhernia isdiagnosed easily usingupper

gastrointestinal endoscopy.

 • ediagnosisofahiatalherniaactuallyisincidental,

andendoscopy is usedto diagnosecomplications suchas erosiveesophagitis, ulcers inthe hiatal hernia,Barrettesophagusortumor.

Fig. 7.16: Scan showing transverse colon incarcerated

in ventral abdominal wall hernia (incisional)

Fig. 7.17: X-ray contrast lled in hiatus hernia

Fig. 7.18: Endoscopic view of hiatus hernia

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