Specific Hernia Types

INDIRECT INGUINAL HERNIA The inguinal canal is the tract in the abdominal wall through which pass the gubernaculum, testis, and spermatic cord in males or the round ligament in females. The canal is defined by an internal ring defect in the transversalis fascia and transversus abdominis aponeurosis, lateral to the inferior epigastric vessels, and a more medial external ring defect in the external oblique aponeurosis ( Fig 7,6,-1 and Fig 7,6-2.).

Normal passage through the inguinal canal is accompanied by peritoneal evagination known as the processus vaginalis. Normal obliteration of the processus occurs in infancy. Passage of contents through a persistent patent processus vaginalis along the inguinal canal leads to an indirect inguinal hernia. Congenital failure of obliteration is the etiology for all indirect inguinal hernias. Acquired myoaponeurotic defects may additionally contribute to indirect inguinal hernia in adults.

Passage of the testis is thought to enlarge the canal and increase the likelihood of inguinal hernia in males. It is more common on the right side due to later passage of the right testis. Indirect inguinal hernias infrequently incarcerate and strangulate, particularly in the first year of life and in females. 1

DIRECT INGUINAL HERNIA These are protrusions through the transversalis fascia and the external ring, medial to the inferior epigastric vessels. ( Fig,, 7,6.-1 and Fig

76-3). Direct inguinal hernias are acquired defects that do not involve passage through the inguinal canal and occur predominantly in adults; they rarely incarcerate and strangulate. A hernia with ipsilateral direct and indirect inguinal components may be called a pantaloon hernia.

FEMORAL HERNIA A femoral hernia is a protrusion below the inguinal ligament and adjacent to the femoral vessels in the femoral canal ( Fig, 7.6,-1). Femoral hernias are more common in women due to the different anatomic structure of the pelvis. Femoral hernias are far less common than inguinal hernias. They do frequently incarcerate and strangulate.2

UMBILICAL HERNIA In utero contraction of the umbilical cord insertion forms the fibromuscular umbilical ring. Incomplete development or weakness in the ring allows herniation of abdominal contents (Fig 7,6:4).

Congenital umbilical hernias affect 10 to 30 percent of white infants and a higher percentage of children of African descent. They are more common in females. Incarceration and strangulation of childhood umbilical hernias are very rare. 13

Umbilical hernias may also develop in adults. This acquired defect is more common in women and is associated with obesity, pregnancy, and ascites. Incarceration and strangulation frequently occur.

EPIGASTRIC HERNIA An epigastric hernia involves herniation through the linea alba of the rectus sheath, above the umbilicus ( Fig 76-.4).

SPIGELIAN HERNIA Herniation at the site of the semilunar or arcuate line, just lateral to the rectus muscle, through the combined aponeurosis of the transversus abdominis and internal oblique muscles is known as a Spigelian or lateral ventral hernia. This hernia is frequently interparietal, making diagnosis difficult ( Fig i7.6.i-4).

PELVIC HERNIA Pelvic hernias are rare. There are sciatic hernias, passing through sciatic foramen; perineal hernias, passing between perineal muscles; and obturator hernias, passing through the obturator canal with the obturator vessels. Obturator hernias frequently incarcerate. 4

LUMBAR HERNIA Herniation rarely may occur through the inferior or superior lumbar triangles.

INCISIONAL HERNIA Herniation may occur through an incisional area. Infection and obesity contribute to poor wound healing, which increases the likelihood of development of incisional hernia.

TRAUMATIC HERNIA Traumatic herniation involving a variety of organs and locations may be observed. These usually occur without true hernia sacs. 5 EPIDEMIOLOGY

The incidence of abdominal hernia is estimated to be from 10 to 20 per 1000 births and is greater among premature infants. 6 In the screening of otherwise healthy young adult military recruits, approximately 3 percent are determined to have groin hernias. 7 Currently, approximately 700,000 herniorrhaphies are performed annually in the United States for inguinal hernias alone. 8

Virtually all groin hernias are more commonly seen in males than in females, whereas hernias of the anterior abdominal wall are of similar incidence ( T.a.b.!e...Z.6.-1). Consequently, the distribution of hernia types by sex is markedly different ( Fig 7,6,15 and Fig. . . . 76-6).

TABLE 76-1 Hernias in Males and Females, Henry Ford Hospital (1965 and 1967)

FIG. 76-5. The relative distribution of common hernias seen in 1655 men in 1965 and 1967. The high proportion of indirect and direct inguinal hernias is striking.(From Ponka JL: Hernias of the Abdominal Wall. Philadelphia, Saunders, 1980, p 85. With permission.)

FIG. 76-6. The distribution of common hernias in 325 females in 1965 and 1967. Note the relatively greater frequency of incisional, umbilical, hiatal, and femoral hernias in the female.(From Ponka JL: Hernias of the Abdominal Wall. Philadelphia, Saunders, 1980, p 85. With permission.)

Indirect inguinal hernias have a bimodal preponderance, with peaks in the first year of life and after the age of 40 years. 9 Direct inguinal hernias are characteristically seen in adults, with a large male preponderance after 40 years of age. Femoral hernias have roughly equal incidence by sex and also tend to occur predominantly after age 40.

Epigastric hernia is of approximately equal incidence by sex. Most occur between the ages of 30 and 70 years. Congenital umbilical hernias are seen in the newborn population and in early childhood. Acquired umbilical hernias in adults increase gradually in incidence from age 20 and are rarely seen beyond age 70. They are slightly more common in women and constitute a larger percentage of the hernias in the female population.

There is no difference in the incidence of incisional hernia in males versus females. As in the case of many other hernias, the vast majority of patients diagnosed with incisional hernia are over 40 years of age. The incidence and distribution of other uncommon hernias is less clear.

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