Hernia Types and Treatment

Spigelian Hernia

• It is an interstitial hernia that occurs through the Spigelian fasciitis is a thin strip of fascia that runs parallel to the outer border of the rectus sheath from the tip of the 9th costal cartilage to the pubic tubercle.
• Since it is very wide in the region of the umbilicus/arcuate line, Spigelian hernias occur commonly at this level.
• Spigelian fascia contributes a few fibers to form a rectus sheath.

Rare External Hernias Interparietal Hernia Spigelian belt

• It is a 6 cm horizontal transverse zone located within the umbilicus and the two anterior superior iliac spines.
• Starts as a direct protrusion behind the rectus abdominis.
• They are intramural; the sac penetrates across transverse muscles and lies behind external oblique muscles.

Rare External Hernias Interparietal Hernia Precipitating Factors

Repeated pregnancies, advancing age, obesity, muscular degeneration, sudden strain due to coughing, and weight lifting, give rise to Spigelian hernias.

Rare External Hernias Interparietal Hernia Clinical Features

• Seen in both sexes equally around 50 years of age.
• A round, soft, reducible swelling situated just below and lateral to the umbilicus—located typically at the junction of the arcuate line and lateral border of the rectus abdominis. Sometimes, it is tender.
• The swelling gives rise to an expansile impulse on cough.
• As the hernia enlarges, it insinuates between external and internal oblique muscles. Hence, it is an example of interparietal hernial

Rare External Hernias Interparietal Hernia Investigations

1. An ultrasound can define the defect in the semilunar line.
2. X-ray abdomen, lateral view shows coils of bowel outside the peritoneal cavity.

Rare External Hernias Interparietal Hernia Differential Diagnosis

• Haematoma within the rectus sheath. However, it will not give rise to the impulse to cough. It occurs suddenly and it will be a tender swelling.
• Pyogenic or pyaemic abscess can occur in the abdominal wall, more so, in diabetic patients. Tenderness and high temperature clinch the diagnosis.

Rare External Hernias Interparietal Hernia Complication

Strangulation is common due to the rigid fascial ring surrounding the hernial Richter’s hernia also can occur here.

Rare External Hernias Interparietal Hernia Treatment

• An incision of about 5 to 6 cm is made over the swelling and abdominal wall muscles are split or cut. The sac is excised after reducing the contents and the defect is repaired
• Recurrence occurs in about 5% of the patients.

Lumbar Hernia

Two types of lumbar hernia are well-recogniseThey are as follows:

1. Primary which occurs through an anatomical defect:

• Through the inferior lumbar triangle of Petit. Its boundaries are:
  • Inferiorly: Iliac crest
  • Laterally: External oblique
  • Medially: Latissimus dorsi
• Through the superior lumbar triangle of Grynfeltt.
  • Its boundaries are
  • Above: 12th rib
  • Medially: Sacrospinalis
  • Laterally: Internal oblique

2. Secondary to a renal operation done through a loin incision. It is an example of a lumbar incisional hernia, which occurs due to either infection or weakness of the loin muscles.

• The operation done for tuberculosis of the spine through a loin incision, very often gives rise to a secondary lumbar hernia (it is an incisional hernia).

Lumbar Differential Diagnosis

1. Lipoma is common in the lumbar region (loin). It is soft, lobular, and slips under the palpating fingers.

2. Cold abscess secondary to tuberculosis of the spine gives rise to a non-tender swelling in the paravertebral space.

Tenderness is present over the spine which gives a clue to the diagnosis. Patients may have a deformity of the spine in the form of Gibbs.

Lumbar Hernia Treatment

Small defects can be closed with simple sutures. Large defects need to be closed with or without mesh. Primary lumbar hernias are very rare.

 

Obturator Hernia

• This hernia occurs through the obturator canal which is bounded above by the superior ramus of pubis and below by the sharp edge of the obturator membrane.
• As the hernia is covered by the pectineus muscle, it is often overlooked.

Obturator Hernia Precipitating Factors

• In females, the obturator foramen is wider in the transverse direction (it is triangular in shape in females and oval in males).
• Repeated pregnancies
• Loss of body weight
• Chronic lung diseases

Obturator Hernia Clinical Features

• The most common presentation is acute intestinal obstruction with strangulation (80%). Recurrent attacks of intestinal obstruction which get resolved spontaneously are also common.
• This hernia causes more pain than any other type of hernia in often radiates along the obturator nerve and may even be referred to the knee via its geniculate branch called the Howship-Romberg sign.
• The leg is usually kept in the semi-flexed position and movement of the limb gives rise to pain.
• If the limb is flexed, abducted, and rotated outwards, the hernia becomes prominent. Patients are usually over 60 years of age and women are more frequently affected than men.
• Due to strangulation and blood in the hernial sac, bruising is seen below the medial edge of the inguinal ligament.
• A few patients (20%) complain of palpable hernia mass in the groin. Per vaginal examination can reveal a tender lump on the lateral side of the vault.

Obturator Hernia Treatment

• The constricting agent in case of obstruction is the obturator fascia, which needs to be divided
• Nerves and vessels are posterolateral to the hernial since the majority of the cases present with intestinal obstruction and strangulation, a lower laparotomy is done.
• A grooved director is used to divide the obturator fascia
• The contents are reduced or if there is gangrene, the affected bowel is resecteClosure of the obturator opening is done by stitching the broad ligament over the opening or by using monofilament nylon.

Obturator Hernia

• The most common presentation is not swelling but acute intestinal obstruction
• Can present as only pain in the knee—(HowshipRomberg sign)
• Vaginal examination: Tender mass can be felt on the lateral side
• Very high chance of strangulation

Perineal Hernia

These are very rare hernias that confuse many clinicians and present in different varieties. Hernia protrudes through muscles and fascia of the perineal floor.

1. Anterolateral perineal hernia: This occurs in women and presents as a swelling of the labium majus. Often, the patient is examined by a gynecologist and Bartholin’s cyst is diagnosed.
2. Posterolateral perineal hernia: This type of hernia passes through the levator ani and enters the ischiorectal fossa.
3. Median sliding hernia is nothing but a complete prolapse of the rectum.
4. Postoperative hernia through perineal scar, e.g. after abdominoperineal resection wherein rectum is removed.

Perineal Hernia Clinical Features

They can present as asymptomatic swelling, pain, dysuria, bowel obstruction, or perineal ulceration and bleeding.

Perineal Hernia Diagnosis

• Ultrasound can detect loops of bowel/fluid.
• CT scan/MRI can clearly define the course of the hernia, its relationship with the urinary bladder/ureter, and its descent into the pelvis.

Perineal Hernia Repair

It can be very difficult in large hernias. Often a combined approach, both perineal and abdominal, may be necessary. Mesh repair with adequate fascial and muscular perineal repair is required.

 

Parastomal Hernia

It is an acquired condition/iatrogenic It is a complication of ileostomy/colostomy Herniation occurs from the side of colostomy/ ileostomy and is hence called parastomal hernia.

Devlin’s Classification

1. Subcutaneous: It is the most common variety. It takes more time for obstruction.
2. Interstitial: In this variety, herniation happens through the intermuscular plane—between transversus abdominis and internal oblique muscles, etc.
3. Intrastromal: Here, the herniation occurs between the emerging and everting parts of the stoma.
4. Personal: In this variety, herniation occurs between layers of the prolapsed stoma.

Parastomal Hernia Clinical Features

• The patient complains of swelling on her side of the ostomy, which increases/prolapses on coughing/straining and decreases at rest.
• Pain and irreducibility indicate obstruction.
• Tense and tender abdomen, pain indicates obstruction.

Parastomal Hernia Diagnosis

• CECT abdomen provides an accurate diagnosis of the type of hernia.

Parastomal Hernia Treatment

Contents are reduced, defects identified, broad mesh is placed over the intraperitoneal and parastomal defects and sutured by nonabsorbable sutures, and extraperitoneal meshes are applied.

Internal Hernias

• These hernias occur intra-abdominally wherein the bowel protrudes through peritoneal or mesenteric aperture or foramen.
• They may cause obstruction. Examples are hiatus hernia and Petersen’s hernia (occurs in space posterior to gastrojejunostomy).