Download MBBS Surgery Presentations 26 Hernia Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 26 Hernia PPT-Powerpoint Presentations and lecture notes


Hernia: Inguinal ? Surgical anatomy,

presentation, treatment,

complications

Introduction

Abnormal protrusion of viscus or a part of it

through a weak point in the abdominal wall
Anatomy of inguinal region

? Superficial inguinal ring-

? triangular aperture in the aponeurosis of the ext oblique

muscle .

? Lies 1.25 cm above the pubic tubercle .
? Normally it doesn't admit the tip of the little finger.

? Deep inguinal ring ?

? U shaped condensation of the fascia trasversalis
? Lies 1.25cm above the mid inguinal point.

Inguinal canal

? Oblique passage in the lower part of the anterior

abdominal wal .

? Extends from deep inguinal ring to superficial inguinal ring.
? Directed downwards forwards and medial y
? About 4cm long


Boundaries

? Anterior ? Ext. oblique aponeurosis & conjoined

muscle lateral y.

? Posterior ? Fascia transversalis & the conjoined

tendon.

? Superiorly ? conjoined muscle.

? Inferiorly ? inguinal ligament.
Contents

? Spermatic cord

? Ilioinguinal nerve

? Genital branch of genitofemoral nerve

? Females ? Round ligament is present instead of spermatic cord.

Spermatic cord constitutes- vas deferens, testicular & cremastic

arteries , pampiniform plexus of veins, lymphatics

Defence mechanism of inguinal canal

? Obliquity of the inguinal canal.

? Shutter mechanism-due to conjoined tendon

contraction


Anatomical classification

? Indirect hernia ? more common about 2/3 of

inguinal hernia .

? It is more common in young

? Direct hernia- more common in old

? Indirect hernia ? the abdominal contents herniation occurs

through the deep ring into the inguinal canal.

? Comes out through the superficial ring.

? It may extend into the scrotum.

? Depending upon extent it may be complete or incomplete.


? Direct hernia ? contents herniate directly through

the posterior wall of the inguinal canal through the
Hesselbach's triangle

? It is a weakness in posterior wall of the inguinal

canal

? It is bounded laterally -inferior epigastric artery,
medially ? lateral border of rectus abdominus muscle

inferiorly ? inguinal ligament


Male inguinal hernia

Female inguinal hernia

Clinical types

? Reducible ?contents can be returned into the abdominal

cavity.

? Irreducible ? contents cannot be returned into the abdominal

cavity.

? Obstructed ? irreducibilty + intestinal obstruction, but the

blood supply is not impaired.

? Strangulated- irreducibilty + intestinal obstruction+ arrest of

the blood supply.

? Inflammed- rare condition. Occurs when contents eg.

Appendix,meckel's diverticulum is inflamed
Epidemiology

?Approximately 7% of all surgical outpatient.

?Accounts for 96% groin hernias (other 4% are femoral)

?Bilateral in 20% of cases

?Lifetime risk of inguinal hernia: 10%

?M:F 9:1

? Affects 1-3% of young children

? In men the incidence rises from 11 per 10,000 person years aged 16

-24 years to 200 per 10,000 person years aged 75 years or above.

? Extremely common; represents the most frequent problem

requiring surgical intervention in the paediatric age group

? Much more common in boys (90% of cases) than girls

? Definite familial tendency,

? more frequent on the right side as a result of later descent of the

right testis and delayed obliteration of the right processus vaginalis.
Risk factors

In infants:

prematurity
male

In adults:

male

Obesity
Constipation
chronic cough
Heavy lifting
Smoking
Urinary obstructive symptoms

Presentation

? Pain

? Localized pain
? Referred pain
? Generalized pain

? Nausea and vomiting

? Constipation

? Urinary symptoms


Presentation

? At first appearance, it is easily reducible.

? With time it can no longer be reduced, it is irreducible or

incarcerated.

? Strangulation: when visceral contents of the hernia become

twisted or entrapped by the narrow opening.

Strangulation usually leads to bowel obstruction with sudden,

severe pain in the hernia, vomiting and irreducibility.

Nyhus Classification System


Diagnosis- Inspection

? Inguinal hernias are best examined with the patient

standing.

? Coughing may increase the size of the hernia.
? Site and shape of the hernia:

? those appearing above and medial to the pubic tubercle

are inguinal hernias

? those appearing below and lateral to the pubic tubercle

are femoral hernias

? whether the lump extends down into the scrotum
? any other scrotal swel ings
? any swel ings on the 'normal' side
? scar from previous surgery or trauma

Digital examination of the inguinal canal
Palpation

? Confirm inspectory findings
? Examine the scrotum- Getting above the swelling is not

possible

? Consistency, temperature, tenderness and fluctuance.
? One should attempt to reduce the hernia:Ask the patient to

reduce. Otherwise flex and medially rotate the hip and reduce

? If the hernia cannot be reduced the probable identity of the

hernia is: femoral > indirect inguinal > direct inguinal

? Expansile cough impulse

? Deep ring occlusion test- reduce the swel ing
? Locate the deep ring 1/2 " above the midpoint of the

inguinal ligament and occlude it asking the patient to cough.

? Impulse seen- direct, not seen- indirect
? Leg raising test- Malgaigne's bulgings seen
? Zieman's method
? Swel ing gurgles- enterocoele, firm/granular- omentocoele.
? Always palpate the other inguino-femoral region as herniae

are often bilateral
Percussion

The characteristics of hernias depend on their contents:

? bowel is hyper-resonant and has bowel sounds unless it is

strangulated

? omentum and fat is dull and does not have bowel sounds

Investigations

Ultrasound

? High Test Sensitivity (>90%)
? High Test Specificity

? Distinguish Incarcerated Hernia from firm mass

Herniography

? Suspected hernia, but clinical dx unclear

? Procedure done under flouroscopy fol owing injection of

contrast medium

? Frontal and oblique radiographs are taken with and without

increased intra-abdominal pressure
Systemic examination

? Examine respiratory system

? Per rectal examination

? Abdominal

? Ext genitalia

Complications

Bowel incarc?ration ( acute, chronic ): The trapping of abdominal

contents within the Hernia itself

Strangulation: pressure on the hernial contents may compromise

blood supply (especially veins, with their low pressure, are

sensitive, and venous congestion often results) and cause

ischemia, and later necrosis and gangrene, which may become

fatal.

Smal Bowel Obstruction
Management

Non operative Treatment
? Watchful waiting: for asymptomatic or minimally

symptomatic

Truss is a mechanical appliance ,belt with a pad applied to

groin after spontaneous or manual reduction of hernia
The purpose is twofold: to maintain reduction and to

prevent enlargement.

Surgery

Mesh repairs

Open repair (Lichtenstein, Shouldice, Bassini)

Most commonly performed: Lichtenstein repair

It's "tension-free" repair

Tension-free repairs

? Desarda

? Guarnieri


Bassini technique,first suture:


? Aponeurosis musculi obliq. ext.
? Musculus obliquus internus
? Musculus transversalis
? Fascia transversalis
? Peritoneum
? Ligamentum inguinale.

Laparoscopic repair

? transabdominal preperitoneal (TAPP)

? totally extra-peritoneal (TEP) repair
Intraoperative view by TEP

Operation.

1. Genital ramus of genitofemoral nerve.

2. Preperitoneal lipom and spermatic

cord.

Laparoscopic mesh surgery, as compared to open mesh surgery

Advantages

Disadvantages

?Quicker recovery

?Needs surgeon highly

experienced

?Less pain during first days

Longer operating time

?Fewer postoperative

Increased recurrence of

complications

primary hernias if

such as infections, bleeding and surgeon not experienced

seromas

enough

?Less risk of chronic pain


Meshes

? Permanent mesh
? Commercial mesh

? Mosquito-net mesh

Complications are frequent (>10%).

? Foreign-body sensation

? Chronic pain

? Ejaculation disorders

? Mesh migration

? Mesh folding (meshoma)

? Infection

? Adhesion formation

? Erosion into intraperitoneal organs

? In the long term, polypropylene meshes face degradation due

to heat effects.

? obstructive azoospermia
Biomeshes

? they can be used for repair in infected

environment,an incarcerated hernia

? reduce the risk of inguinodynia

This post was last modified on 08 April 2022