hernia and herniorrhaphy
TRANSCRIPT
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PRESENTED BY:INUSAH ADAMS
(Ternopil State Medical Univ.)Nov, 2013
HERNIA HERNIORRHAPHY
PLAN OF PRESENTATION DEFINITION EPIDEMIOLOGY TYPES ANATOMY ETIOLOGY PATHOGENESIS SIGNS &SYMPTOMS DIAGNOSIS/INVESTIGATIONS DIFFERENTIALS TREATMENT COMPLICATIONS HERNIORRHAPHY PROGNOSIS
What is hernia?
It is the outlet of the visceral organs from their physiological placement through natural channels or defects of the abdominal and pelvic wall.
Epidemiology
Hernias comprise approximately 7% of all surgical outpatient visits.
Male: female ratio is 8:1.They affect 1-3% of young children.In men, the incidence rises from 11
per 10,000 person-years, aged 16-24 years,
200 per 10,000 person-years, aged 75 years or above.[1]
Classification of abdominal Hernias?Etiology: Congenital and acquired herniasAnatomical location1. Inguinal hernia2. Femoral hernia3. Umbilical hernia4. Epigastric hernia5. Diaphragmatic hernia6. Incisional/recurrent hernia• clinical presentations: incarcerated hernia
(complete and incomplete), reducible and nonreducible, complicated and noncomplicated.
• External (through wall of abdomen) and internal (through the peritoneum) hernias
What is the etiology of hernia?Risk factors are:Malformation of abdominal wallsex age hereditaryObesityAscites weight losspostoperative scar improper weight liftingChronic Constipationchronic coughpregnancy
What is the pathogenesis of hernia?1. incomplete closure of the
abdominal wall in case of congenital hernia
2. increased abdominal pressure 3. increasing dehiscence of fascial
structure with accompanying loss of abdominal wall strength
Where are the most common sites of hernias?
Describe the inguinal canalSite: is situated just above the medial half of
the inguinal ligament. Content: It transmits the spermatic cord
(male) and the round ligament (female); the ilioinguinal nerve.
Length: approx.. 3.75 to 4 cm (4-5cm)Direction: It is obliquely directed
anteroinferiorly and mediallyBoundaries/walls: Superior wall: fasciae of internal oblique and transversal abdominal musclesInferior wall: inguinal ligamentAnterior wall: fascia of a external oblique abdominal musclePosterior wall: fascia of transverse abdominal muscle
What is inguinal hernia?hernia in which a loop of intestine
enters the inguinal canalThey make up 75% of all abdominal
wall hernias
Types of inguinal hernia Direct and indirect-Reducible vs. irreducible-Strangulated hernias -unilateral or bilateral
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Indirect inguinal hernia: protrusion of parts of the intestines into the inguinal canal via the internal/deep inguinal ring.
Its sac is lateral to the inferior epigastric artery
Direct inguinal canal: protrusion of parts of the intestines into the inguinal canal through a weak point in the fascia of the abdominal wall.
Its sac is medial to the inferior epigastric artery.
Differences b/n indirect & direct inguinal hernias?
Indirect inguinal hernia Direct inguinal hernia
Hernia gate is deep inguinal ring
Hernia gate is in Inguinal space
Hernia sac is lateral to the spermatic cord or inferior epigastric vessel
Hernia sac is medial to the spermatic cord or inferior epigastric vessel
Shape: oval Shape: round
It can be acquired or congenital
It can Only be acquired
3 elements of herniaHernia gate
Hernia sac (3 parts; neck, body and fundus)
Hernia content
Signs and symptoms?swelling/protrusion
Weakness or pressure in the groin
Pain or discomfort in the groin, especially when bending over, coughing or lifting
Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum
Severe pain in strangulated hernia
Physical examination of patient?Examine the patient (inspection and
palpation) both standing and lying positions
Place your finger on the swelling and instruct patient to cough or strain
positive symptom of "cough push“ is elicited in case of hernia
Assessment of inguinal hernia (Symptom of the "cough push"
what can be done to diagnose hernia?
Anamnesis (weight lifting, chronic cough or constipation, previous abdominal surgeries etc.)
physical examination.(Digital investigation of the hernia channel)
Sonography of the hernia pouch. herniography with injection of X-ray contrast
agent into the peritoneum Common blood analysis. Bacteriological examinations Common urine analysis.
Ultrasound of right inguinal hernia
Differential diagnosis of inguinal hernia?
DISEASE FINDINGS
1. Abscess of groin region Hyperemia of skin, fluctuation, intoxication syndrome, constant pain, leukocytosis, bacterieia
2. Femoral hernia Protrusion below inguinal canal
3. Undescended testes Empty scrotum, negative’’ cough push’’ symptom, ultrasound shows testes in abdomen
4. Varicocele Feeling of heaviness in the testicleMild to Moderate painVisible or palpable enlarged vein
5. Testicular torsion Acute onset, severe pain, testicle is positioned high than normal, ultrasound shows decrease testicular blood flow
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Left-sided varicocele
How can diagnosis of hernia be formulated?
LocationType Reducible vs. irreducibleComplication (s)
Dx: Indirect Right inguinal hernia, irreducible with strangulation
What are the treatment options of inguinal hernia?
Treatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated.
◦ Reducible hernia Can be treated with surgery but does not have to
be.
◦ Irreducible hernia Urgent surgical treatment because of the risk of
strangulation. An attempt to push the hernia back can be made
◦Strangulated hernia Emergency operation
What are the possible complications of hernia?
Incarcerated (irreducible hernia)
Strangulated herniaSigns and symptoms of strangulated hernia:Nausea, vomiting or bothFeverRapid heart rateSudden pain that quickly intensifiesA hernia bulge that turns red, purple or
darkAbsent bowel sounds on auscultation
Herniotomy & Herniorrhaphy
Open method and
Laparoscopic method
Anterior abdominal wall layers
Preoperative careHistory, physical findings, Lab. Works:
blood test, grouping and cross-matching, urinalysis, ultrasound, etc.
signed informed consent form anesthesiologist examination and
recommendationNPO, urinary catheter if necessary correction of hemodynamics; IV access for
fluids, drugs (sedatives, antibiotics etc.)Explanation of the procedure to patient and
Reassurance
Steps of Herniotomy Skin incision (3-5cm) above and parallel to
inguinal ligament, then subcutaneous tissueLigation of superficial epigastric veinOpening of scarpa’s fasciaOpening of external oblique aponeurosis (follow
fiber direction and avoid nerve damage; ilioinguinal, genitofemoral, iliohypogastric nerves,)
Identify inguinal ligament (poupart’s ligament) Isolate spermatic cord (using a Penrose drain for
convenient retraction)Dissect the spermatic cord (using the index finger
in a sweeping and medially encircling fashion) to the internal ring
Identify and isolate hernia sac (peritoneum)Reposition hernia into abdominal cavityClose the defect
Steps of Herniorrhaphy(Lichtenstein technique)
Identify the conjoint tendon (lateral rectus border)First suture on lateral rectus border (not on pubic
tubercle) to the mesh and tie securely but not too tight
Then over (not through) pubic tubercleSuture to lower part of inguinal ligamentProceed until just beyond the internal inguinal ringCreate a new internal ring and attach upper part of
mesh to inguinal ligamentSize the mesh and secure upper part with single
suturesClose external oblique aponeurosis, then scarpa’s
fasciaSuture skin, infiltrate local anesthetic and apply
sterile dressing
Video (Lichtenstein technique)
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Herniorrhapy (Bassini Repair)tension method
A technique in which the surgeon sutures the conjoined tendon to the inguinal ligament, which slides the patient’s own muscles together to cover the hole in the abdominal wall and repair the hernia.
Conjoint tendon (falx inguinalis)Common tendon of insertion of the transversus
and obliquus internus muscles into the crest and spine of the pubis and iliopectineal line
Postoperative carePatient is discharged the same
day of operation once anesthesia wears off, but some may need to stay in the hospital overnight.
Drugs: only analgesic is necessary
Diet: start with sips of water, if patient can take it then semi-liquid foods until he can tolerate solid foods
Wound dressing until removal of sutures
Possible complications after herniorrhapy
chronic painejaculation disordersHemorrhage infectionadhesionsImpotencyRecurrent hernias
Prognosis?
The outcome of this surgery is usually very good. In a few persons, the hernia returns.