Download MBBS General Surgery PPT 6 Inguinal Hernia Lecture Notes

--- Content provided by FirstRanker.com ---

? 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.

--- Content provided by⁠ FirstRanker.com ---

? Before the first year of age
? After age 40

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

--- Content provided by​ FirstRanker.com ---

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

--- Content provided by⁠ FirstRanker.com ---

Anatomy
? 4- to 6 cm-long

? Anterior portion of the pelvic

--- Content provided by⁠ FirstRanker.com ---

basin

? Spermatic cord:
? Three arteries
? Three veins

--- Content provided by⁠ FirstRanker.com ---

? Two nerves
? Pampiniform venous plexus
? Va s deferens

Anatomy

--- Content provided by FirstRanker.com ---

? Anterior

? External oblique aponeurosis

--- Content provided by‍ FirstRanker.com ---

? Lateral

? Internal oblique muscle

? Posterior

--- Content provided by‌ FirstRanker.com ---

? Transversalis fascia and transversus

abdominus muscle

--- Content provided by⁠ FirstRanker.com ---

? Superior

? Internal oblique muscle

? Inferior

--- Content provided by FirstRanker.com ---

? Inguinal ligament
Anatomy

? Anterior

--- Content provided by‍ FirstRanker.com ---

? External oblique aponeurosis

? Lateral

--- Content provided by​ FirstRanker.com ---

? Internal oblique muscle

? Posterior

? Transversalis fascia and transversus

--- Content provided by‌ FirstRanker.com ---

abdominus muscle

? Superior

--- Content provided by‌ FirstRanker.com ---

? Internal oblique muscle

? Inferior

? inguinal ligament

--- Content provided by‌ FirstRanker.com ---

Anatomy
Other structure :
? Iliopubic tract:

--- Content provided by‍ FirstRanker.com ---

? An aponeurotic band

that begins at the

anterior superior iliac

--- Content provided by‌ FirstRanker.com ---

spine and inserts into

Cooper's ligament from

--- Content provided by​ FirstRanker.com ---

above.

? lacunar ligament (ligament of

Gimbernat)

--- Content provided by​ FirstRanker.com ---

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

--- Content provided by‍ FirstRanker.com ---

? Iliopubic tract:

An aponeurotic band

that begins at the

--- Content provided by‌ FirstRanker.com ---

anterior superior iliac

spine and inserts into

--- Content provided by​ FirstRanker.com ---

Cooper's ligament from

above.

? lacunar ligament (ligament of

--- Content provided by‌ FirstRanker.com ---

Gimbernat)

? Cooper's ligament (pectineal)
? Conjoined tendon

--- Content provided by⁠ FirstRanker.com ---

HESSELBACH'S

TRIANGLE
? Medial aspect of Rectus

--- Content provided by‍ FirstRanker.com ---

abdominis muscle

? Inferior epigastric vessels
? Inguinal ligament

--- Content provided by FirstRanker.com ---

Subtypes

? Direct hernia
? Indirect hernia
? Femoral hernia

--- Content provided by FirstRanker.com ---

Direct hernia

Direct hernias protrude

--- Content provided by⁠ FirstRanker.com ---

medial to the inferior

epigastric vessels,

within Hesselbach's

--- Content provided by​ FirstRanker.com ---

triangle.
Indirect hernias

Indirect hernias

--- Content provided by FirstRanker.com ---

protrude lateral to the

inferior epigastric

--- Content provided by​ FirstRanker.com ---

vessels, through the

deep inguinal ring.

Femoral hernias

--- Content provided by⁠ FirstRanker.com ---

Femoral hernias

protrude through the

--- Content provided by FirstRanker.com ---

small and inflexible

femoral ring.
Etiology
? Acquired:

--- Content provided by‍ FirstRanker.com ---

the best-characterized risk

factor is weakness in the

--- Content provided by​ FirstRanker.com ---

abdominal wal musculature

? Chronic obstructive

pulmonary disease: direct

--- Content provided by​ FirstRanker.com ---

? increase intra-abdominal

pressure

--- Content provided by‌ FirstRanker.com ---

? decreased col agen fiber

density in hernia patients

Congenital

--- Content provided by​ FirstRanker.com ---

? The majority of pediatric hernias
? Patent processus vaginalis

(PPV)

--- Content provided by FirstRanker.com ---

? The high incidence of indirect

inguinal hernias in preterm

--- Content provided by​ FirstRanker.com ---

babies.
DIAGNOSIS

? History:

--- Content provided by‍ FirstRanker.com ---

? 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

--- Content provided by​ FirstRanker.com ---

? 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.

--- Content provided by​ FirstRanker.com ---

? 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.

--- Content provided by‌ FirstRanker.com ---

Physical Examination

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

--- Content provided by FirstRanker.com ---

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

exposed.

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

--- Content provided by‌ FirstRanker.com ---

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

external inguinal ring.

--- Content provided by FirstRanker.com ---

? Femoral hernias should be palpable below the inguinal ligament,

lateral to the pubic tubercle.
Imaging
? US:

--- Content provided by‌ FirstRanker.com ---

? sensitivity of 86% and specificity of

77%

--- Content provided by​ FirstRanker.com ---

? CT :

? sensitivity of 80% and specificity of

65%

--- Content provided by‌ FirstRanker.com ---

? MRI:

? Sensitivity of 95% and specificity of

--- Content provided by‌ FirstRanker.com ---

96%
TREATMENT

? Surgical repair is the definitive treatment of inguinal hernias

--- Content provided by​ FirstRanker.com ---

1. Surgical

2. Conservative

Conservative Treatment

--- Content provided by‌ FirstRanker.com ---

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

operative risk, elective surgery should be deferred until the condition

--- Content provided by​ FirstRanker.com ---

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

--- Content provided by⁠ FirstRanker.com ---

complications.
Conservative Treatment

? Nonoperative inguinal hernia

--- Content provided by FirstRanker.com ---

treatment targets pain, pressure,

and protrusion of abdominal

--- Content provided by​ FirstRanker.com ---

contents in the symptomatic

patient population.

? Trusses externally

--- Content provided by FirstRanker.com ---

? not prevent complications

? Femoral inguinal hernia

SURGICAL REPAIR

--- Content provided by FirstRanker.com ---

? Al surgical repairs follow the same basic principles:

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

--- Content provided by​ FirstRanker.com ---

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

--- Content provided by‌ FirstRanker.com ---

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

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

--- Content provided by‍ FirstRanker.com ---

LICHENSTEIN REPAIR i.e. MESH HERNIOPLASTY

Laparascopic hernia repair
1. Trans abdominal Preperitoneal Procedure (TAPP)
2. Totally Extraperitoneal (TEP) Repair

--- Content provided by‍ FirstRanker.com ---

COMPLICATIONS
? Hernia Recurrence
? Pain
? Cord and Testes Injury
? Wound infection

--- Content provided by FirstRanker.com ---

? Seroma
? Hematoma
? Bladder injury
? Osteitis pubis
? Urinary retention

--- Content provided by‍ FirstRanker.com ---