Introduction
Abnormal protrusion of viscus or a part of it
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through a weak point in the abdominal wall
Anatomy of inguinal region
? Superficial inguinal ring-
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? triangular aperture in the aponeurosis of the ext oblique
muscle .
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? Lies 1.25 cm above the pubic tubercle .? Normally it doesn't admit the tip of the little finger.
? Deep inguinal ring ?
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? U shaped condensation of the fascia trasversalis? Lies 1.25cm above the mid inguinal point.
Inguinal canal
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? Oblique passage in the lower part of the anteriorabdominal wal .
? Extends from deep inguinal ring to superficial inguinal ring.
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? Directed downwards forwards and medial y? About 4cm long
Boundaries
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? Anterior ? Ext. oblique aponeurosis & conjoined
muscle lateral y.
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? Posterior ? Fascia transversalis & the conjoinedtendon.
? Superiorly ? conjoined muscle.
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? Inferiorly ? inguinal ligament.
Contents
? Spermatic cord
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? Ilioinguinal nerve
? Genital branch of genitofemoral nerve
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? Females ? Round ligament is present instead of spermatic cord.Spermatic cord constitutes- vas deferens, testicular & cremastic
arteries , pampiniform plexus of veins, lymphatics
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Defence mechanism of inguinal canal
? Obliquity of the inguinal canal.
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? Shutter mechanism-due to conjoined tendoncontraction
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Anatomical classification? Indirect hernia ? more common about 2/3 of
inguinal hernia .
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? It is more common in young
? Direct hernia- more common in old
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? Indirect hernia ? the abdominal contents herniation occursthrough the deep ring into the inguinal canal.
? Comes out through the superficial ring.
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? It may extend into the scrotum.
? Depending upon extent it may be complete or incomplete.
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? Direct hernia ? contents herniate directly through
the posterior wall of the inguinal canal through the
Hesselbach's triangle
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? It is a weakness in posterior wall of the inguinal
canal
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? It is bounded laterally -inferior epigastric artery,medially ? lateral border of rectus abdominus muscle
inferiorly ? inguinal ligament
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Male inguinal hernia
Female inguinal hernia
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Clinical types? Reducible ?contents can be returned into the abdominal
cavity.
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? Irreducible ? contents cannot be returned into the abdominal
cavity.
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? Obstructed ? irreducibilty + intestinal obstruction, but theblood supply is not impaired.
? Strangulated- irreducibilty + intestinal obstruction+ arrest of
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the blood supply.
? Inflammed- rare condition. Occurs when contents eg.
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Appendix,meckel's diverticulum is inflamedEpidemiology
?Approximately 7% of all surgical outpatient.
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?Accounts for 96% groin hernias (other 4% are femoral)?Bilateral in 20% of cases
?Lifetime risk of inguinal hernia: 10%
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?M:F 9:1
? Affects 1-3% of young children
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? 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
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requiring surgical intervention in the paediatric age group
? Much more common in boys (90% of cases) than girls
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? 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.
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Risk factorsIn infants:
prematurity
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maleIn adults:
male
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Obesity
Constipation
chronic cough
Heavy lifting
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SmokingUrinary obstructive symptoms
Presentation
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? Pain? Localized pain
? Referred pain
? Generalized pain
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? Nausea and vomiting
? Constipation
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? Urinary symptomsPresentation
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? At first appearance, it is easily reducible.? With time it can no longer be reduced, it is irreducible or
incarcerated.
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? Strangulation: when visceral contents of the hernia become
twisted or entrapped by the narrow opening.
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Strangulation usually leads to bowel obstruction with sudden,severe pain in the hernia, vomiting and irreducibility.
Nyhus Classification System
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Diagnosis- Inspection
? Inguinal hernias are best examined with the patient
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standing.
? Coughing may increase the size of the hernia.
? Site and shape of the hernia:
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? those appearing above and medial to the pubic tubercle
are inguinal hernias
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? those appearing below and lateral to the pubic tubercleare femoral hernias
? whether the lump extends down into the scrotum
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? any other scrotal swel ings? any swel ings on the 'normal' side
? scar from previous surgery or trauma
Digital examination of the inguinal canal
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Palpation? Confirm inspectory findings
? Examine the scrotum- Getting above the swelling is not
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possible? Consistency, temperature, tenderness and fluctuance.
? One should attempt to reduce the hernia:Ask the patient to
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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
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? Expansile cough impulse
? Deep ring occlusion test- reduce the swel ing
? Locate the deep ring 1/2 " above the midpoint of the
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inguinal ligament and occlude it asking the patient to cough.
? Impulse seen- direct, not seen- indirect
? Leg raising test- Malgaigne's bulgings seen
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? Zieman's method? Swel ing gurgles- enterocoele, firm/granular- omentocoele.
? Always palpate the other inguino-femoral region as herniae
are often bilateral
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PercussionThe characteristics of hernias depend on their contents:
? bowel is hyper-resonant and has bowel sounds unless it is
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strangulated
? omentum and fat is dull and does not have bowel sounds
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InvestigationsUltrasound
? High Test Sensitivity (>90%)
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? High Test Specificity? Distinguish Incarcerated Hernia from firm mass
Herniography
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? Suspected hernia, but clinical dx unclear
? Procedure done under flouroscopy fol owing injection of
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contrast medium? Frontal and oblique radiographs are taken with and without
increased intra-abdominal pressure
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Systemic examination? Examine respiratory system
? Per rectal examination
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? Abdominal
? Ext genitalia
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ComplicationsBowel incarc?ration ( acute, chronic ): The trapping of abdominal
contents within the Hernia itself
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Strangulation: pressure on the hernial contents may compromise
blood supply (especially veins, with their low pressure, are
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sensitive, and venous congestion often results) and causeischemia, and later necrosis and gangrene, which may become
fatal.
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Smal Bowel Obstruction
Management
Non operative Treatment
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? Watchful waiting: for asymptomatic or minimallysymptomatic
Truss is a mechanical appliance ,belt with a pad applied to
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groin after spontaneous or manual reduction of hernia
The purpose is twofold: to maintain reduction and to
prevent enlargement.
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Surgery
Mesh repairs
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Open repair (Lichtenstein, Shouldice, Bassini)Most commonly performed: Lichtenstein repair
It's "tension-free" repair
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Tension-free repairs
? Desarda
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? GuarnieriBassini technique,first suture:
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? Aponeurosis musculi obliq. ext.
? Musculus obliquus internus
? Musculus transversalis
? Fascia transversalis
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? Peritoneum? Ligamentum inguinale.
Laparoscopic repair
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? transabdominal preperitoneal (TAPP)? totally extra-peritoneal (TEP) repair
Intraoperative view by TEP
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Operation.1. Genital ramus of genitofemoral nerve.
2. Preperitoneal lipom and spermatic
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cord.
Laparoscopic mesh surgery, as compared to open mesh surgery
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AdvantagesDisadvantages
?Quicker recovery
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?Needs surgeon highly
experienced
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?Less pain during first daysLonger operating time
?Fewer postoperative
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Increased recurrence of
complications
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primary hernias ifsuch as infections, bleeding and surgeon not experienced
seromas
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enough
?Less risk of chronic pain
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Meshes
? Permanent mesh
? Commercial mesh
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? Mosquito-net mesh
Complications are frequent (>10%).
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? Foreign-body sensation? Chronic pain
? Ejaculation disorders
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? Mesh migration
? Mesh folding (meshoma)
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? Infection? Adhesion formation
? Erosion into intraperitoneal organs
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? In the long term, polypropylene meshes face degradation due
to heat effects.
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? obstructive azoospermiaBiomeshes
? they can be used for repair in infected
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environment,an incarcerated hernia? reduce the risk of inguinodynia