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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1060_Библиотеки_им_академика_М_И_Перельмана
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Examination of Hernia
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Note: Size of the defect is important to decide the
type of surgical closure in incisional hernia. Midline
hernia expels the content more outwards due to
contraction of rectus muscles on both sides.
Preoperative Preparations for Incisional
Hernia Surgery
Reduction in weight and control of obesity; Nutritional
supplementation, control of anaemia; Treatment for
diabetes, hypertension, cardiac diseases, respiratory
problems; Treating the precipitating causes; Chest
X-ray, US abdomen to be done; Massive incisional
hernia after reduction might cause IVC compression,
paralytic ileus and diaphragmatic elevation with
respiratory embarrassment (abdominal compartment
syndrome). It is prevented by prior increasing the
capacity of peritoneal cavity by creating the pneumoperitoneum using CO
so as to increase the peritoneal
2
pressure by 12-15 cm of H2O, daily for 3-6 weeks.
Later definitive surgery is done. Lordosis and back
pain may be presenting features. Sac and contents may
get adherent to the thin skin over the summit of the
hernia leading to skin ulceration and occasionally
fistula formation. Often might need resection of the
adherent bowel segment.
421
A
Epigastric Hernia
It is fatty hernia of linea alba; initially it is sacless
(protrusion of extraperitoneal fat) but later develops
true epigastric hernia with sac containing contents.
It occurs through decussation of the linea alba above
the umbilicus. It is 10% common; 20% are multiple
Swiss cheese pattern. It is often symptomless but later
can cause pain, obstruction and strangulation. It is
better seen and palpated in standing position as a firm
nodule which is relatively non-mobile. Abdominal wall
lipoma which mimics epigastric hernia is freely mobile.
Often it is associated with peptic ulcer and so pain
may be due to peptic ulcer, hence gastroscopy should
be done in doubtful patients (Figs 17.43A to C).
Paraumbilical Hernia
It is midline herniation above or below the umbilicus
through a defect adjacent to umbilicus. It is common
above the umbilicus. It often attains large size and
sags downwards. Neck may be narrow with omentum/
B
C
Fig. 17.41:Incisional hernia showing visible intestine
under thinned out skin.
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Fig. 17.42: Laparoscopic view of incisional hernia.
SRB’s Clinical Surgery
small bowel as contents. Obstruction/strangulation
tend to occur. It is commonly associated with obesity
and multiple pregnancies. It is common in females;
obese; middle or old aged. Swelling, impulse on
coughing, dragging pain and reducibility are usual
presentations. After reduction firm ring-like fibrous
edge is felt (Fig. 17.44).
Figs 17.43A to C: Epigastric hernia.
Umbilical Hernia
It is herniation through a weak umbilical cicatrix. It
is common in infants and children. It is common in
Negroes. It is hemispherical in shape with defect felt
during crying. Commonest content is small intestine.
It can cause obstruction and strangulation. 95% of
umbilical hernias disappear in 2 years. If it persists
beyond 2 years, and if the defect is more than 2 cm
in size or if associated with complications surgery is
indicated. It is operated through an infraumbilical
incision; defect is closed with interrupted sutures after
ligating the sac. Acquired umbilical hernia occurs in
adult life but it is very rare (Figs 17.45 and 17.46A
and B).
Ventral Hernia
Any protrusion through abdominal wall with the
exception of hernia through the inguinofemoral region
is defined as ventral hernia. Incisional hernia (80%)
A
B
Fig. 17.44: Paraumbilical hernia.
Examination of Hernia
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Fig. 17.45: Umbilical hernia
and primary defects in abdominal fascia which can
cause umbilical hernia, epigastric hernia, paraumbilical
hernia or Spigelian hernia are grouped under ventral
hernia. V entral hernia can be – Reducible; irreducible;
obstructed; strangulated; single; multiple small defects
(Swiss cheese hernia) (Fig. 17.47). Causes: Congenital
defect; obesity; smoking; chronic cough.
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Richter’s Hernia
It is herniation of a portion of circumference of intestine
usually small bowel leading into gangrenous change.
But patient presents with features mimicking gastroenteritis without any signs of intestinal obstruction.
Eventually it leads to perforation and peritonitis. It
is common in femoral hernia. It is treated by resection
and anastomosis and repair (Figs 17.48 and 17.49).
Sliding Hernia
Posterior wall of the sac is formed by parietal peritoneum and also by sigmoid colon/caecum/urinary
bladder. It occurs exclusively in males and common
Fig. 17.47: Large ventral hernias.
on left side. It attains large size and its content is usually
small bowel. Posterior wall should not be separated
from the sac. Sac is excised only partially and then
is pushed into peritoneal cavity. Mesh repair is done
afterwards (Fig. 17.50).
Figs 17.46A and B: Umbilical hernia strangulated
(rreducible, tense, tender) showing also gangrenous bowel
on table.
Fig. 17.48: Richter’s hernia.
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Pantaloon Hernia
SRB’s Clinical Surgery
Inguinal hernia containing both direct and indirect sacs
is called as pantaloon hernia but it presents as direct
hernia. It is also called as double hernia, saddle hernia
or Romberg hernia. So in all cases of direct hernia
indirect sac should be looked for. Condition is one
of the causes for recurrence.
Strangulated Hernia
It is due to compromised blood supply of the contents
of the hernia like bowel/omentum causing toxicity,
tenderness at the site. There is no impulse on coughing,
and is irreducible and tense. Features of intestinal
obstruction are present if the content is bowel. Narrow
neck and adhesions are the causes of strangulation.
It is treated by emergency surgery.
Clinical features of strangulated hernia: Presents
with sudden severe pain, initially over a pre-existing
hernia which later becomes generalised over the abdomen; persistent vomiting, constipation and distension
of the abdomen; hernia is tense, severely tender,
irreducible , without any expansile impulse on coughing. Rebound tenderness is diagnostic.Features of
toxicity and dehydration; electrolyte imbalance; abdominal distension with guarding and rigidity oliguria
are other features.
Fig. 17.49: Richter’s hernia with gangrene of part of the
circumference of the bowel with perforation in a case of
femoral hernia.
Strangulation during infancy: Incidence is 4%.
Female to male ratio is 5:1. In female infants, the
content may be ovary with or without fallopian tube.
Taxis may be dangerous as during taxis, contusion
and rupture of the intestinal wall can occur. Reduction
en masse may mask the gangrenous bowel existing
in the sac. Inner gangrenous loop of Maydl’s hernia
may be missed. Rupture of the sac extraperitoneally
can also be the possibility. Taxis have no role in
femoral hernia and strangulated hernia. If tried,
contusion, reduction en masse and rupture of the sac
can occur. In strangulated omentum features of obstruction are not present. Omentum becomes congested,
oedematous and black in colour which secretes toxic
fluid with secondary bacterial infection. But here, the
sepsis is slower initially than that of strangulated
intestinal obstruction. Eventually the infection spreads
causing diffuse peritonitis. Downward spread of
infection can cause scrotal abscess (Figs 17.51 to
17.53).
A
B
Fig. 17.50: Sliding hernia.
Examination of Hernia
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Fig. 17.51: In strangulated hernia if the content is strangulated omentum, then omentum is excised and repair is done.
Mesh is usually not used in strangulated hernia.
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of Cloquet. It is 1.25 cm long and 1.25 cm wide at
the base. Below it is closed by cribriform fascia.
Femoral ring is bounded anteriorly by inguinal ligament; posteriorly by iliopectineal ligament of Cooper,
pubic bone and fascia covering the pectineus muscle;
medially by concave, sharp lacunar (Gimbernat’s)
ligament; laterally by a thin septum separating from
femoral vein (Figs 17.55A and B and 17.56).
Figs 17.52A and B: Strangulated enterocele with irreducibility, absence of impulse on coughing, signs of acute inflammation, tense and tender mass with features of intestinal
Maydl’s Hernia
obstruction. Bowel strangulation is obvious during surgery.
Here bowel loop in the form of ‘W’ lies in the hernial
sac and center of the portion of the W is strangulated.
It may get reduced ‘en-masse’. Strangulation of center
part is common (Fig. 17.54).
Femoral Hernia
It is common in females. It occurs in medial most
part of the femoral canal.
Surgical Anatomy of Femoral Canal
It is the most medial compartment of the femoral sheath
which extends from femoral ring above, to saphenous
opening below . It contains fat, lymphatics, lymph node
A
B
Fig. 17.53: Diagram showing the strangulated hernia
with toxic fluid and site of obstruction.
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Fig. 17.54: Maydl’s ‘W’ hernia.
SRB’s Clinical Surgery
Pathology in femoral hernia: Through femoral canal,
hernial sac descends down vertically upto saphenous
opening and then escapes out into the loose areolar
tissue to expand out like a retort. Because of its irregular
pathway and narrow neck, it is more prone for obstruction and strangulation. During surgery , precaution
should be taken about the femoral vein and pubic
branch of obturator artery (or accessory obturator
artery) which often may get injured leading to torrential
haemorrhage.
Clinical features: Common in females (2:1), common
in multiparae; Rare before puberty; 20% occurs
bilateral, however more common on right side; presents
as a swelling in the groin below and lateral to the
pubic tubercle (Inguinal hernia is above and medial
to the pubic tubercle); swelling, impulse on coughing,
reducibility, gur gling sound during reduction, dragging
pain, are the usual features. When obstruction and
strangulation occurs which is more common (due to
rigid opening of femoral canal), presents with features
of obstruction—pain, tender, inflamed, irreducible
swelling without any impulse. They also present with
abdominal distension, vomiting, and feature of toxicity.
Often femoral hernia can be associated with inguinal
hernia also. Gaur (Surgeon Bombay Hospital, India)
Figs 17.55A and B: Femoral hernia is common in females.
It occurs below and lateral to pubic tubercle. Herniation
occurs through femoral ring—medial most part of the femoral
canal. ASIS—Anterior Superior Iliac Spine; IL—Inguinal
Ligament; FN—Femoral Nerve; FA—Femoral Artery;
FV—Femoral Vein.
dilatation of one or both veins (Fig. 17.57). Rememberpresentations may be – No lump/expansile impulse
on coughing in saphenous opening/visible impulse
which get reduced and more prominent on coughing/
irreducible tender, tense swelling in femoral region
often extend into inguinal region from below upwards.
In congenital dislocation of hip, femoral hernia
occurs behind the femoral vessels—Narath’ s femoral
hernia. If sac lies under the pectineal fascia, is called
as Cloquet’s hernia. S trangulation and Richter’s hernia
are common in femoral hernia. Often on medial side,
a portion of bladder forms the wall of the femoral
hernial sac—sliding femoral hernia.
Differential Diagnosis for Femoral Hernia
Inguinal hernia: It is confirmed by its location above
and medial to pubic tubercle and invagination test is
positive and full whereas in femoral hernia invagination
Examination of Hernia
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test is negative and empty. Impulse will be felt in
saphenous opening and Zieman’s test will demonstrate
impulse in ring finger.
Prevascular type of femoral hernia: It is in front of
femoral vessels. It bulges just underneath the inguinal
ligament; shows wider neck; impulse on coughing is
easily felt; easily reducible; strangulation is rare;
difficult to repair.
Saphena varix: It is saccular dilatation of the great
saphenous vein near saphenofemoral junction. It
apparently shows impulse on coughing which is
actually tremor imparted on the feeling fingers like
a jet of water entering and filling the pouch –
Cruveilhier’s sign of saphena varix . There will be
associated long saphenous vein varicosity. Blue
discolouration of the skin over it is often obvious.
Saphena varix is softer.
Enlarged Cloquet’ s inguinal lymph node: It mimics
irreducible femoral hernia. One has to look for focus
like infection or neoplastic.
Psoas abscess: It is usually a cold abscess due to
tuberculosis of thoracolumbar spine (Pott’s disease).
It is painless reducible swelling below the inguinal
ligament lateral to the femoral artery pulsation; often
there is swelling above in iliac region which is then
cross fluctuant across inguinal ligament. Spine should
be examined. US abdomen and groin confirms pus.
CT pelvis is confirmative.
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absence of impulse, firm swelling with testicular
sensation on pressure is typical.
Lipoma in femoral region: It is soft, freely mobile,
smooth, lobulated with positive slip sign.
Femoral hernia—medial to femoral vein.
Narath’s hernia—in front of femoral artery.
Hesselbach’s hernia—lateral to femoral artery.
Cloquet’s hernia— behind femoral vessels.
Laugier’s hernia—through lacunar ligament.
Rare Hernias
Obturator hernia is herniation through obturator canal.
Mainly presents as intestinal obstruction; often pain
in knee joint (referred); rarely as a swelling in the
medial side of the thigh (Fig. 17.58).
Enlarged psoas bursa: Psoas bursa gets enlarged in
osteoarthritis of hip joint as this bursa which is located
in front of the hip joint and behind psoas major
communicates with joint cavity. Clinically it produces
a tense, cystic swelling in front of the hip joint below
the inguinal ligament which diminishes in size when
joint is flexed.
Femoral aneurysm: It is pulsatile (expansile), mobile
only side-to-side; compressible swelling. But if
thrombosed, pulsation may not be evident and mimic
irreducible femoral hernia.
Hydrocele of femoral hernial sac: It presents as soft,
fluctuant swelling which is transilluminant.
Ectopic testis: When ectopic testis is located in femoral
triangle it mimics femoral hernia. Empty scrotum,
Fig. 17.56: Anatomical locations of femoral and inguinal
hernia. Inguinal hernia is above and medial to pubic tubercle.
Femoral hernia is below and lateral to pubic tubercle. Also
note the location of the obturator hernia below in Scarpa’s
triangle.
Funicular hernia: It is prevesical direct hernia which
is prone for strangulation, is herniation of prevesical
fat, bladder, or intestine through a small defect in the
medial part of the conjoint tendon just above the pubic
tubercle.
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Spigelian hernia: It is an interparietal hernia occurring
at the level of arcuate line through spigelian point
with sac lying deep to internal oblique or between
internal oblique or external oblique muscles (Fig.
17.59).
Lumbar hernia: It is herniation through either superior
lumbar triangle bounded by sacrospinalis, 12th rib,
posterior border of internal oblique–(Grynfeltt-
Lesshaft’ s triangle) or inferior lumbar triangle bounded
by latissimus dorsi, external oblique and iliac crest
(Petit’s triangle). It is common through inferior
triangle. It should be differentiated from lipoma, cold
abscess, lumbar phantom hernia.
Phantom hernia is a muscular bulge as a result of
local muscular paralysis due to interference with nerve
supply of the affected muscles like in poliomyelitis.
It is common in lumbar region. It is often seen in lower
abdomen.
SRB’s Clinical Surgery
Fig. 17.57: Gaur sign (dilated superficial epigastric vein)
in a patient with femoral hernia (Gaur, Mumbai, India).
Infantile hernia: It is clinically difficult to diagnose;
often it is diagnosed on table. Processus vaginalis is
closed at internal ring and hernial sac either invaginates
processus vaginalis as ‘inverted umbrella’ or comes
behind processus vaginalis.
Examination of Inguinoscrotal and Scrotal Swelling
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Examination of
Inguinoscrotal and
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18
In this chapter inguinoscrotal and scrotal swellings
other than inguinal and femoral hernias are discussed.
Hydrocele and other differential diagnosis of groin
swellings are discussed here.
History taking begins with:
Name:
Age:
Address:
Occupation:
Funiculitis occurs in young age. T esticular tumour
occurs in early adult age (seminoma) but can occur
in young (teratoma). V aricocele presents in adolescents
and young. Filarial funiculitis, orchitis, lymph varix
are common in Orissa, West Bengal, coastal regions.
Carcinoma of scrotal skin is seen in elderly. Torsion
testis is seen in adolescents. Hydrocele is common
in adult. Epididymal cyst, spermatocele are seen in
adult. Tuberculous orchitis is seen in young individuals.
Carcinoma of scrotal skin is often occupation related
those who come in contact with soot (Chimney sweep’ s
Inguinoscrotal and scrotal swellings Femoral swellings
Encysted hydrocele of the cord Inguinal lymph nodes
Varicocele Saphena varix
Lymph varix Psoas abscess
Funiculitis Psoas bursa enlargement
Diffuse lipoma of the cord Lipoma in femoral triangle
Ectopic testis Femoral artery aneurysm
Undescended testis Hydrocele of femoral hernia
Retractile testis Ectopic testis
Torsion testis
Testicular tumour
Inguinal or iliac lymphadenopathy
Abscess in the groin – inguinal region
External iliac artery aneurysm
Scrotal oedema
Epididymal cyst
Spermatocele
Extravasation of urine
Scrotal Swelling
cancer); tar or oil (Mule spinner’ s disease). Prolonged
standing may cause varicocele.
History
History of Present Illness
Swelling: Like any other swelling detailed history
should be asked – mode of onset, progress, regress,
history of trauma, whether swelling disappears on lying
down (reducible hernia will disappear on lying down,
hydrocele will not disappear). Rapid increase in size
occurs in testicular tumours. T rauma may precipitate
haematocele or hydrocele. Sudden pain and swelling
in scrotum is probably due to acute epididymoorchitis
or pyocele. Inguinal hernia begins in groin; hydrocele,
testicular tumour begins in scrotum; varicocele begins
in root of the scrotum. Lipoma of cord, encysted
hydrocele of the cord appears in groin or near root
of the scrotum. Undescended testis presents with
swelling in the groin with empty scrotum. In bilateral
swellings the side on which it appeared first and after
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SRB’s Clinical Surgery
how long has it appeared on opposite side should be
asked. Hydrocele can be bilateral; varicocele is more
common on left side but can be bilateral; bilateral
impalpable undescended testes are called as cryptor-
chidism. Other swellings in epigastric region in the
abdomen (due to palpable enlarged paraaortic lymph
nodes)/in the supraclavicular region due to enlarged
lymph nodes may be elicited in history often. Scrotal
oedema may be due to filariasis or part of generalised
anasarca. Trauma on bulb of urethra may cause urinary
extravasation and swelling in the scrotum. Gonococcal
urethritis with stricture also can cause extravasation
and scrotal swelling – watering can perineum.
Swelling with heaviness in the scrotum may be
initial presentation of testicular tumour.
Pain: Epididymoorchitis, funiculitis presents with pain
and often fever. History of severity of pain, onset,
progress, whether initially painless later became
painful (in testicular tumour) should be asked. Haematocele, pyocele can be severely painful. T orsion testis
presents with pain often precipitated by straining due
to sudden violent contraction of the cremaster. Severe
pain in scrotum and groin with fever, redness and
swelling may be features of acute epididymoorchitis.
Periodic mild fever with pain, discomfort and swelling
in the scrotum and spermatic cord are the features
of filarial epididymoorchitis.
Presence of fever: Fever often with chills should be
asked for. Fever is due to infection, filarial orchitis,
pyocele, etc. Evening rise of temperature may be
feature of tuberculous epididymitis or funiculitis.
History of cough and haemoptysis suggests associated
pulmonary tuberculosis.
Trauma: History of trauma is important as scrotum
being entirely outside is prone for it. Haematocele,
urinary extravasation in urethral injury, haematoma
scrotum in perineal injury – are important conditions
to be remembered. Existing disease may be obvious
after trauma.
Infertility: It may be the presenting complaint in
varicocele or cryptorchidism.
Past History
History of tuberculosis; old trauma; sexual exposure
(in gonococcal uethritis or syphilitic orchitis) are earlier
important signs should be asked for. Patient might
have undergone surgery for inguinal hernia (postherniorrhaphy hydrocele) or hydrocele surgery.
Personal History
History of sexual contact earlier should be elicited.
Swellings which reduce on lying down in the groin
Reducible inguinal hernia – reduces rapidly
Varicocele – reduces spontaneously with elevation of
scrotum
Lymph varix reduces slowly.
General Examination
Pallor, nutrition, oedema, jaundice should be checked;
pulse and blood pressure should be recorded. Anaemia
and malnutrition may be features in tuberculosis or
advanced malignancy.
Local Examination
First always patient should be examined in standing
position later in lying down position.
Inspection
Swelling: Swelling in the scrotum may be due to
hydrocele, epididymal cyst, spermatocele, scrotal
oedema, and varicocele. Hydrocele causes obvious
swelling often very large. In encysted hydrocele of
the cord, lipoma of the cord swelling may be in the
groin or root of the scrotum. Swelling in the groin
or superficial inguinal pouch may be due to undescended testis or ectopic testis (Figs 18.1A and B).
Here empty scrotum is obvious on inspection. Scrotal
oedema may be associated with penile oedema. It may
be due to scrotal cellulitis, cardiac/renal/hepatic causes,
filariasis, advanced secondaries in the inguinal lymph
nodes blocking cutaneous lymphatic drainage, and
extravasation of urine. Extravasation may be due to
urethritis or urethral trauma. Penis may be buried in
large hydrocele, large inguinoscrotal hernia, and scrotal
oedema.
Skin over the scrotum/swelling/groin should be
inspected. It is red and oedematous in funiculitis, and
orchitis. Acutely inflamed skin with redness is also
often a feature of torsion testis (Fig. 18.2). Strangulated
hernia also shows signs of inflammation over the skin.
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