Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Surgery Final Year Case Presentation Hernia Discussion Clinical Examination Discussion and Treatment
? Q.1: What is Hernia ?
? A : Hernia means to bud,
to protrude ,
off shoot in Greek ,
rupture in latin
? Q.2: Define abdominal Hernia .
? A : A bulge of the whole or part of the contents of the
abdominal cavity through a weakness in the abdominal
wal .
? Q.3 : What is groin?
? A : The area between the abdomen and the upper thigh
on either side of the body.
ANATOMY
? Q: What is Inguinal Canal ?
? A:The inguinal canal is a oblique passage in the lower part of the
abdominal wal 3.75cm long which lies above the medial half of the
inguinal ligament. It commences at the deep inguinal ring and ends at
the superficial inguinal ring.
? Q:What is the length of inguinal canal ?
? A: The inguinal canal is about 3.75 cm (1 '/2 inch) long and is directed
downwards and medial y from the deep to the superficial inguinal ring.It
is also cal ed as HOUSE OF BASSINI.
ANATOMY
? Q: What is Deep Inguinal ring ?
? A: It is an `U' shaped condensation in the fascia transversalis 1.25 cm above the mid
-inguinal point i.e. midpoint between the symphysis pubis and the anterior
superior iliac spine. It transmits the spermatic cord in the male and the round
ligament of the uterus in the female
? Q : What is superficial Inguinal ring ?
? A: It is a triangular opening in the aponeurosis of the external oblique muscle. It is
situated 1.25cm above pubic tubercle. The superficial inguinal ring gives passage to
the spermatic cord and ilio-inguinal nerve in the male and to the round ligament of
the uterus and the ilio-inguinal nerve in case of females.It is bounded by
superomedial and inferolateral crus.Normal y it just admits the tip of the little
finger.
?
ANATOMY
? Q : What is Canal of Nuck ?
? A : Inguinal canal in females.
? Q: What are the Boundaries of Inguinal canal ?
? Anteriorly --skin, the superficial fascia and the external oblique aponeurosis
? Posteriorly - Transversalis Fascia and Conjoint tendon
? Above - arched fibres of the internal oblique and transversus abdominis fuse to
form the conjoined tendon
? Below or floor -- by the grooved upper surface of the inguinal ligament
? Q : What are the contents of Inguinal canal ?
? A : Contents of the inguinal canal.--
1. Ilioinguinal nerve
2. In case of male the spermatic cord
3. In case of female the round ligament of the uterus
?
ANATOMY
? Q : What are the contents of Spermatic cord ?
? A : (i) The main constituent is the vas deferens.
(i ) Arteries of the spermatic cord are -- testicular artery, artery of the vas
deferens and artery to the cremaster.
(i i) Pampiniform plexus of testicular veins.
(iv) Lymph vessels of the testis.
(v) Nerves -- testicular plexus of sympathetic nerves which accompany the
testicular artery and the artery of the ductus deferens and the genital branch
of the genitofemoral nerve
? Q : What is Hesselbach's Triangle ?
? A : It is a triangle which is bounded --
(i) Medial y -- by the outer border of the rectus abdominis muscle.
(i ) Lateral y -- by the inferior epigastric vessels.
(i i) Below -- by the medial part of the inguinal ligament
Through this Hesselbach's triangle direct inguinal hemia comes out.
ANATOMY
? Q : What are the protective mechanisms ?
? A : Obliquity of the inguinal canal , Shutter mechanism , Bal -
valve action of the cremaster
? What is the importance of Hesselbach's triangle ?
? A : neck of the direct hernia lies medial to the inferior epigastric
vessels, whereas the neck of the indirect hernia lies lateral to the
inferior epigastric vessels.
? Q : What are the coverings if Indirect inguinal hernia ?
? A : (i)Peritoneum; (i ) Extraperitoneal fat (i i) Internal spermatic
fascia (iv) Cremasteric fascia and muscles, the muscular fasciculae
being separated by areolar tissue;(v) External spermatic fascia
ANATOMY
? Q : What is Myopectineal Orifice of Fruchaud?
? A : It is an osseo ? myo- aponeurotic tunnel.It is
through this tunnel , al the groin hernias occur.
? Q : What are the boundaries of Myopectineal
Orifice of Fruchaud ?
? A : Superior ? Arched fibres of internal oblique
? Lateral : Iliopsoas muscle
? Medial : Lateral border of Rectus abdominis
? Inferior : Cooper's ligament
ANATOMY
? Q : What is Triangle of Pain ?
? A : Triangle of pain is bounded spermatic vessel medial y,
the iliopubic tract lateral y and inferiorly the inferior edge
of skin incision. This triangle contains lateral femoral
cutaneous nerve (commonly injured) and anterior
femoral cutaneous nerve of thigh. Nerve injury /
entrapment occurs if anchorage of the mesh is performed
here.
? Q : What is Triangle of Doom ?
? A :The Triangle of Doom is an anatomical triangle defined
by the vas deferens medial y, spermatic vessels lateral y
and external iliac vessels inferiorly. This triangle
contains external iliac vessels, the deep circumflex iliac
vein, the genital branch of genitofemoral nerve and
hidden by fascia, the femoral nerve. Injury to the external
iliac vessels wil occur if dissection is done in this triangle.
INCIDENCE
? Q : What is the incidence of Inguinal hernia ?
? A : 90% of external abdominal hernias.
? Q : What is the sex ratio ?
? A : Male : Female = 20:1
? Q : What is the incidence of Bilateral inguinal hernias
?
? A :10% of all hernias is bilateral
20% occult contralateral on Laparascopic
evaluation
33% life time risk to develop hernia in the other
side
CLINICAL
? Q :What is taxis ?
? A : The fundus of the sac is gently held with one hand and even pressure
is applied to squeeze the contents into the abdomen while the other
hand wil guide the contents through the superficial inguinal ring
? Q : What is Zieman's technique ?
? A : Clinician puts his index finger over the deep inguinal ring (1/2) inch
above the midinguinal point and the middle finger over the superficial
inguinal ring. The patient is asked to cough or to hold the nose and blow.
? Q: What is ring occlusion test ?
? A : The hemia must be reduced first. A thumb is pressed on the deep
inguinal ring. The patient is asked to cough. A direct hemia wil show a
bulge medial to the occluding finger but an indirect hernia wil not find
access, so no bulge.
DIFFERENCE BETWEEN DIRECT AND INDIRECT
HERNIA
FEATURE
DIRECT
INDIRECT
EXTENT INTO SCROTUM
DOES NOT GO INTO SCROTUM
CAN DESCEND INTO THE SCROTUM
DIRECTION OF REDUCTION
REDUCE UPWARDS AND STRAIGHT
REDUCE UPWARDS, LATERALLY AND
BACKWARDS
STRAIGHT BACKWARDS
CONTROLLED BY INTERNAL RING
NOT CONTROLLED BY PRESSURE
CONTROLLED AFTER REDUCTION
PRESSURE
DIRECTION OF REAPPEARANCE
BULGE REAPPEARS
THE BULGE REAPPEARS IN THE
MIDDLE OF THE INGUINAL REGION
AND FLOWS MEDIALLY TO THE NECK
OF SCROTUM
PALPABLE DEFECT
DEFECT MAY BE PALPABLE
NOT PALPABLE
RELATIONSHIP OF CORD TO SAC
SAC APPEARS MEDIAL TO THE
SAC INSIDE SPERMATIC CORD
INFERIOR EPIGASTRIC ARTERY AND
OUTSIDE THE SPERMATIC CORD
CLASSIFICATION ANATOMICAL
? DIRECT (MEDIAL) ? ACQUIRED
CONGENITAL (OGILVIE)
? INDIRECT(LATERAL) ? CONGENITAL
-COMPLETE
-FUNICULAR
-BUBONOCELE
? PANTALOON(BOTH)
CLASSIFICATIONS - CLINICAL
? Q : How is Inguinal hernia classified clinical y ?
? A : Reducible , Irreducible , Obstructed , Strangulated.
? Q : What is European Hernia Society Classification ?
? A : P = primary hernia ; R = recurrent hernia ; 0 = no hernia
detectable
1 = < 1.5 cm (one finger) 2 = < 3 cm ( two fingers) 3 = > 3
cm (more than two fingers) ; x = not investigated
L = lateral/ indirect hernia ; M = medial/ direct hernia ;
F = Femoral
CLASSIFICATIONS
? Q :What is NYHUS classification ?
? A : Type 1 - indirect inguinal hernia with normal internal ring
(congenital, as seen in infants and children).
Type 2 - indirect hernia with dilated internal ring but
normal posterior inguinal wall (usually seen in children and
young adults).
Type 3 - posterior wall (inguinal floor) defects:
3A: Direct hernia.
3B: Indirect hernia with dilated internal ring
associated with or caused by weakness of posterior wall;
includes sliding hernia. Type 3B hernias are acquired, not
congenital.
3C: Femoral hernia.
Type 4 - Recurrent inguinal hernia.
TREATMENT
? Q : What are the investigations ?
? A : Investigations
Plain x-ray ? of little value
Ultrasound scan ? low cost, operator dependent
CT scan ? incisional hernia
MRI scan ? good in sportsman's groin with pain
Contrast radiology ? especial y for inguinal hernia
Laparoscopy ? useful to identify occult contra lateral
inguinal hernia
What are the treatment options ?
? Management
Not all hernias require surgical repair
Small hernias can be more dangerous than
large
Pain, tenderness and skin colour changes
imply high risk of
strangulation
Femoral hernia should always be repaired
TREATMENT
? Operative approaches to hernia
All surgical repairs follow the same basic principles:
1) reduction of the hernia content into the abdominal cavity
with removal of any non-viable tissue and bowel repair if
necessary;
2) excision and closure of a peritoneal sac if present or
replacing it deep to the muscles;
3) reapproximation of the walls of the neck of the hernia if
possible;
4) permanent reinforcement of the abdominal wall defect
with sutures or mesh
TREATMENT
? Operations for inguinal hernia
Herniotomy
Open suture repair
Bassini
Shouldice
Desarda
Open flat mesh repair
Lichtenstein
Open complex mesh repair
Plugs
Hernia systems
Open preperitoneal repair
Stoppa
Laparoscopic repair
TEP
TAPP
DIFFERENTIAL DIAGNOSIS ? INGUINO
SCROTAL SWELLINGS
Inguinoscrotal swellings (except inguinal hernia).--
? (i) Encysted hydrocele of the cord;
? (ii)Varicocele;
? (iii) Lymph varix or lymphangiectasis;
? (iv) Funiculitis;
? (v) Diffuse lipoma of the cord;
(vi) Inflammatory thickening of the cord extending upwards from the testis
and epididymis;
? (vii)Malignant extension from the testis;
? (viii) Ectopic testis;
? (ix) Undescended testis;
? (x) Torsion of
the testis;
? (xi) Retractile testis;
? (xii) Enlarged lymph nodes (external iliac and inguinal groups)
? (xiii) Abscess in the inguinal region;
? (xiv) Aneurysm of the external iliac artery
COMPLICATIONS
Complications
Early ? pain, bleeding, urinary retention,
anaesthetic related
Medium ? seroma, wound infection
Late ? chronic pain, testicular atrophy
RECURRENCE RATES
? Herniotomy
Open suture repair
Bassini ? 8%
Shouldice ? less than 1%
Desarda -
Open flat mesh repair
Lichtenstein ? 1%
Open complex mesh repair
Plugs
Hernia systems
Open preperitoneal repair
Stoppa
Laparoscopic repair
TEP ? 2.5%
TAPP
This post was last modified on 08 August 2021