Download MBBS General Surgery PPT 6 Inguinal Hernia Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Surgery PPT 6 Inguinal Hernia Lecture Notes


Inguinal hernia

Epidemiology
? Inguinal hernia repair is one of the most commonly performed operation.

? Approximately 75% of abdominal wall hernias occur in the groin.
? Of inguinal hernia repairs, 90% are performed in men and 10% in women.
? The incidence of inguinal hernias in males has a bimodal distribution.

? Before the first year of age
? After age 40

? Approximately 70% of femoral hernia repairs are performed in women;

however, inguinal hernias are five times more common than femoral hernias.

? The most common subtype of groin hernia in men and women is the indirect

inguinal hernia
Anatomy
? 4- to 6 cm-long

? Anterior portion of the pelvic

basin

? Spermatic cord:
? Three arteries
? Three veins
? Two nerves
? Pampiniform venous plexus
? Va s deferens

Anatomy

? Anterior

? External oblique aponeurosis

? Lateral

? Internal oblique muscle

? Posterior

? Transversalis fascia and transversus

abdominus muscle

? Superior

? Internal oblique muscle

? Inferior

? Inguinal ligament
Anatomy

? Anterior

? External oblique aponeurosis

? Lateral

? Internal oblique muscle

? Posterior

? Transversalis fascia and transversus

abdominus muscle

? Superior

? Internal oblique muscle

? Inferior

? inguinal ligament

Anatomy
Other structure :
? Iliopubic tract:

? An aponeurotic band

that begins at the

anterior superior iliac

spine and inserts into

Cooper's ligament from

above.

? lacunar ligament (ligament of

Gimbernat)

? Cooper's ligament (pectineal)
? Conjoined tendon
Anatomy
Other structure :
? Iliopubic tract:

An aponeurotic band

that begins at the

anterior superior iliac

spine and inserts into

Cooper's ligament from

above.

? lacunar ligament (ligament of

Gimbernat)

? Cooper's ligament (pectineal)
? Conjoined tendon

HESSELBACH'S

TRIANGLE
? Medial aspect of Rectus

abdominis muscle

? Inferior epigastric vessels
? Inguinal ligament
Subtypes

? Direct hernia
? Indirect hernia
? Femoral hernia

Direct hernia

Direct hernias protrude

medial to the inferior

epigastric vessels,

within Hesselbach's

triangle.
Indirect hernias

Indirect hernias

protrude lateral to the

inferior epigastric

vessels, through the

deep inguinal ring.

Femoral hernias

Femoral hernias

protrude through the

small and inflexible

femoral ring.
Etiology
? Acquired:

the best-characterized risk

factor is weakness in the

abdominal wal musculature

? Chronic obstructive

pulmonary disease: direct

? increase intra-abdominal

pressure

? decreased col agen fiber

density in hernia patients

Congenital

? The majority of pediatric hernias
? Patent processus vaginalis

(PPV)

? The high incidence of indirect

inguinal hernias in preterm

babies.
DIAGNOSIS

? History:

? Groin pain
? Extrainguinal symptoms such as a change in bowel habits or urinary symptoms
? Generalized pressure, localized sharp pain, and referred pain
? Pressure or heaviness in the groin , following prolonged activity

? Sharp pain tends to indicate an impinged nerve and may not be related to the

extent of physical activity performed by the patient.

? Neurogenic pain may be referred to the scrotum,testicle, or inner thigh.
? Hernias wil often increase in size and content over a protracted time.

? Patients wil often reduce the hernia by pushing the contents back into the

abdomen, thereby providing temporary relief.

Physical Examination

? Ideally, the patient should be examined in a standing position to

increase intra-abdominal pressure, with the groin and scrotum fully

exposed.

? Inspection: an abnormal bulge along the groin or within the scrotum

? Palpation: advancing the index finger through the scrotum toward the

external inguinal ring.

? Femoral hernias should be palpable below the inguinal ligament,

lateral to the pubic tubercle.
Imaging
? US:

? sensitivity of 86% and specificity of

77%

? CT :

? sensitivity of 80% and specificity of

65%

? MRI:

? Sensitivity of 95% and specificity of

96%
TREATMENT

? Surgical repair is the definitive treatment of inguinal hernias

1. Surgical

2. Conservative

Conservative Treatment

? When the patient's medical condition confers an unacceptable level of

operative risk, elective surgery should be deferred until the condition

resolves, and operations reserved for lifethreatening emergencies.

? A nonoperative strategy is safe for minimally symptomatic inguinal

hernia patients, and it does not increase the risk of developing hernia

complications.
Conservative Treatment

? Nonoperative inguinal hernia

treatment targets pain, pressure,

and protrusion of abdominal

contents in the symptomatic

patient population.

? Trusses externally
? not prevent complications

? Femoral inguinal hernia

SURGICAL REPAIR

? Al surgical repairs follow the same basic principles:

1. Reduction of the hernia content into the abdominal cavity.

2. Excision and closure of a peritoneal sac if present or replacing it deep

to the muscles

3. Re-approximation of the walls of the neck of the hernia if possible

4. Permanent reinforcement of the abdominal wall defect with sutures or

mesh.(i.e. Anatomical vs Prosthetic repair)
SHOULDICE REPAIR
LICHENSTEIN REPAIR i.e. MESH HERNIOPLASTY

Laparascopic hernia repair
1. Trans abdominal Preperitoneal Procedure (TAPP)
2. Totally Extraperitoneal (TEP) Repair
COMPLICATIONS
? Hernia Recurrence
? Pain
? Cord and Testes Injury
? Wound infection
? Seroma
? Hematoma
? Bladder injury
? Osteitis pubis
? Urinary retention

This post was last modified on 07 April 2022