? 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 bandthat 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 fromabove.
? 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 inferiorepigastric 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 thedeep inguinal ring.
Femoral hernias
--- Content provided by FirstRanker.com ---
Femoral hernias
protrude through the
--- Content provided by FirstRanker.com ---
small and inflexiblefemoral 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 fiberdensity 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 theextent 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 fullyexposed.
? 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. Surgical2. 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 symptomaticpatient 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 deepto 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 HERNIOPLASTYLaparascopic 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 ---