Section: Abdominal wall and retroperitoneum Sub-section: Hernias Curriculum: Curriculum, page 4

Definition

Incidence

Usually present as small bowel obstruction
Many present with acute pain
1/3 have had similar Sx in the past
Difficult to diagnose pre-op
Hernia is rarely palpable in the groin
- Sits deep to pectineus/adductors
A mass may be felt on PV or PR examination
Often is a Richter’s type hernia
Howship-Romberg sign (present in ≈ 25-50%):
- Pain extending down the medial thigh with extension, internal rotation & adduction of the hip
- Causes compression of cutaneous branch of Obturator Nerve
Hannington-Kiff Sign:
- Intact Patellar Reflex but concurrent loss of Thigh Adductor Reflex
- Due to compression of Obturator Nerve causing weakness of adductor muscles
- Bruising below the med pt of ing lig can occur due to a strangulated hernia

Hernia follows Obturator Canal
Courses
- Between the Superior Pubic Ramus & Obturator Membrane
- Sac spreads out deep to Pectineus
- Sac travels between Adductor longus and Adductor Brevis
  - Or Adductor Brevis and Adductor Magnus
Often contains small bowel as a Richter’s hernia

See Obturator Hernia repair
Abdominal approach
- Ideally, in Trendelenburg position
- Rarely, it may be necessary to enlarge the canal, by incising posteromedially to the neck of the hernia (so avoiding damage to obturator nerve)
- Repair
  - Primary stitch
  - Overlay of mesh
  - Close primarily + overlay bladder or uterus
Retropubic approach (Cheatle-Henry approach)
- Median or Pfannenstiel incision, the Retzius’ space is dissected
- Repair similar to a McEvedy femoral hernia repair
Laparoscopic approach
- TAPP or TEP