View Full Version : Rare Hernias

Medical Videos
06-08-2008, 08:28 AM
1- Spigelian H.:
ÄDefinition. Through a defect in the linea semilunaris (lateral border of the rectus sheath) at the level of arcuate line.
ÄPathology. The sac may lie beneath the internal oblique muscle where it is usually impalpable. Moe often it advances between the external and internal oblique muscle and give rise to more evident swelling.
ÄDiagnosis. The patient is usually obese and usually over 50 years of age, men and women being equally affected. Typically soft reducible mass can be felt lateral to the rectus sheath and just below the umbilicus. Diagnosis is confirmed by (CT) or ultrasound scanning. Ultrasound scanning having the advantage of being able to stand the patient while doing scanning.
ÄTreatment. If a defect is palpable muscle splitting approach is used. If no sac is palpable paramedian incision is needed . The sac is dissected, excised and anatomical repair of the three muscles of anterior abdominal wall is done.
2- Lumbar H:
· Mostly through inferior and less commonly through superior lumbar triangles.
· Boundaries of the triangles (see figure19). Primary lumbar hernias are very rare.
· More commonly it occurs after lumbar incision (incisional lumbar hernia)

ÄDifferintial diagnosis:
1. Lipoma.
2. A cold abscess pointing to this point.
3. Phantom hernia due to local muscular paralysis due to interference with the nerve supply of the affected muscles (e.g. poliomyelitis).
ÄTreatment. Small defects can be easily closed. Large defects need mesh support.
3- Obturator H:
ÄDefinition. It is the hernia which passes through obturator canal.
ÄIncidence. It affects females six times more common than males. Most patients are usually over 60 years of age.
ÄDiagnosis. The swelling is liable to be overlooked as the sac passes below pectineus muscle. Rarely it gives swelling in the femoral (Scarpa’s) triangle. If the limb is flexed abducted and externally rotated the swelling becomes more apparent.
The hernia usually presente after strangulation. It is usually of Richter variety giving only local symptoms. 50% of cases presents with pain in the femoral trangle increases with movement and causing semiflexion of the thigh. The pain radiate to the knee through the geniculate branch of the obturator nerve.
On vaginal or rectal examination the hernia can be felt as a tender swelling in the region of the obturator foramen.
ÄTreatment. Lower laparotomy is needed. The sac is delivered after incising the fascia surrounding its neck. Excision of the sac is done.

The contents are dealt with and closure of the defect, usually with stitching broad ligament over it, can prevent recurrence.
4- Gluteal And Sciatic Hernias:
· A gluteal hernia passes through greater sciatic foramen either above or below the piriformis. A sciatic hernia passes through the lesser sciatic foramen.
· Differential diagnosis must be made between the conditions and:
1. Lipoma or fibrosarcoma of the gluteal region:
2. A tuberculous abscess.
3. A gluteal aneurysm.
5- Perineal H:.
This type of hernia is very rare. Varieties include:
1. Postoperative hernia through perineal scar after excision of the rectum.
2. Median sliding perineal hernia which is a complete prolapse of the rectum.
3. Anterolateral perineal hernia occurs in women and presents with swelling at the labium majus.
4. Posterolateral perineal hernia, which passes through the levator ani to enter the ischiorectal fossa.
F What are the ventral hernias?
A: They are the hernias protruding from abdominal wall rather than the common hernias. e.g. Incisional hernia, Spigelian hernia and Epigastric fatty hernia.
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