Inguinal Hernia


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This presentation is made by Dr Ashok Jaisingani

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Inguinal Hernia

  1. 1. Dr. Ashok Jaisingani
  2. 2.  Superficial Inguinal Ring: It is triangular aperture in the aponeurosis of the external oblique muscle and lie 1.25 cm above the pubic tubercle. Normally the ring will not admit the tip of little finger. Deep Inguinal Ring: It is U shape condensation of transversalis fascia and it lies 1.25 cm above inguinal (Poupart’s) ligament. The transversalis fascia is the fascial envelope of abdomen and competency of deep inguinal ring depends on the integrity of this fascia.
  3. 3.  Infants: In infants the superficial and deep ring is almost superimposed and the obliquity of the canal is slight. Adult: In adult the inguinal canal is 3.75 cm is long is directed downward and medially from the deep to superficial inguinal ring. In male inguinal canal transmit the spermatic cord, ilioinguinal nerve & genital branch of genitofemoral nerve. In female round ligament replace the spermatic cord.
  4. 4.  Indirect Inguinal hernia is most common hernia of all especially in young. Direct inguinal hernia become more common in the elderly. An indirect hernia travels down the canal on the outer (Lateral & anterior) side of spermatic cord. A direct inguinal hernia comes out directly forward through posterior wall of inguinal canal. The neck of indirect inguinal hernia lateral to inferior epigastric vessels The neck of direct inguinal hernia usually emerge medial to the inferior epigastric vessels except in saddle – bag or pantaloon type (have both lateral & medial component)
  5. 5.  An inguinal hernia can be differentiate from the femoral by ascertaining the relation of the neck of the sac to the medial end of the inguinal ligament & pubic tubercle. Inguinal Hernia: The neck lie above and medial to the medial end of inguinal ligament & pubic tubercle. Femoral Hernia: The neck lie below and lateral to the medial end of the inguinal ligament & pubic tubercle.
  6. 6.  Indirect inguinal hernia is most common in young In first decade of life inguinal hernia is more common on right side in male, this is associated with later descent of right testis & higher incidences of failure of closure of procesus vaginalis. In adult male 65% of inguinal hernias are indirect and 55% are right – sided The hernia is bilateral 12% of the cases
  7. 7.  There are three types of indirect inguinal hernia; 1- Bubonocele: (hernia is limited to inguinal canal) 2- Funicular: (The processus vaginalis closed just above the epididymis), the content of sac can be left separately from the testis (lie below the hernia) 3- Complete (scrotal): Rarely present at birth commonly encounter in infancy. The testis appear to lie within the lower part of hernia.
  8. 8.  The patient is instructed to look at the ceiling and cough, if the hernia will comes down, the examiner look and feel for impulse and address following question. Is the hernia right, left or bilateral? Is it an inguinal or femoral hernia? Is it a direct or indirect inguinal hernia? Is it reducible or irreducible hernia? Is the inguinal hernia is complete or incomplete? Looks for contents.
  9. 9.  Indirect inguinal hernia is 20 times more common in males than females. The patient complain the pain in groin or pain refer to testis when perform the work or strenuous exercise. On coughing a small transitient bulging is seen and feel together with expansile impulse. When the sac is limited to inguinal canal, the bulge may be better seen by observing the inguinal region from side or looking down to abdominal wall. An indirect inguinal hernia on coughing comes down and persist until it is reduced In large hernias there is sensation of the dragging & weight on mesentery, may produce epigastric pain. The indirect inguinal hernia is “translucent” in infancy and early childhood but never in adult hood
  10. 10.  Vaginal Hydrocele Encysted hydrocele of cord Spermatocele Femoral hernia Incomplete descended testis in inguinal canal Lipoma of the cord
  11. 11.  Hydrocele of the canal of Nuck Femoral Hernia
  12. 12.  Surgery is the treatment of the choice Surgery is either open or laparoscopic Truss is used when the operation is contraindicated or when operation is refused.
  13. 13.  It is consist of 1- Excision of hernial sac 2- Repair of transversalis fascia and internal ring 3- Further reinforcement of posterior wall of inguinal canal.
  14. 14.  In adult male 35% of inguinal hernias are direct At presentation 12% of patients will have contralateral hernia, and there is four fold increase in risk of contra-lateral hernia. A direct inguinal hernia is always acquired, the sac passes through a weakness or defect of transversalis fascia in posterior wall of inguinal canal. Women practically never develop direct inguinal hernia (Brown).
  15. 15.  Smoking Occupation that involve straining and heavy lifting Damage to illioinguinal nerve (Previous appendicectomy) is another cause
  16. 16.  Direct hernia do not often attain a large size or descend into scrotum In contrast to indirect inguinal hernia, direct inguinal hernia lies behind the spermatic cord The sac is often smaller than mass, the protruding mass consist of the extra-peritoneal fat. As the neck of sac is wide, the direct inguinal hernias do not strangulate or strangulate rarely.
  17. 17.  This is narrow necked hernia with prevesical fat and portion of bladder that occur through a small oval defect in the medial part of conjoined tendon just above the pubic tubercle. It occurs principally in elderly Occasionally it become strangulated Operation should always be advised until there is definite contraindication.
  18. 18.  This type of hernia consist of two sac that straddle the inferior epigastric artery, One sac being medial and other one lateral to this vessel. This condition is not rare & is cause of recurrence
  19. 19.  Strangulation of inguinal hernia occurs at any time during life, occurs in both sex equally. Indirect inguinal hernia strangulate more commonly, but not so often direct variety because of wide neck of sac. More often the strangulation occurs in pts who have worn truss for long time & those with partially reducible or irreducible hernias.
  20. 20.  The Neck Of Sac The External Inguinal Ring In Children Adhesion Within Sac
  21. 21.  Usually the small intestine is involved in strangulation with next most common that involved in strangulation is omentum. It is rare the large intestine to become strangulated, even when the hernia is of sliding type.
  22. 22.  The incidences of strangulation during infancy is 4% (Gross). The ratio of girls to boy is 5:1 More frequently the hernia is irreducible but not strangulated. Most cases of strangulated inguinal hernias occurs in females infants and contents will be ovary or ovary plus fallopian tube.
  23. 23.  Resuscitation with adequate fluids Empty stomach with nasogastric tube Give antibiotic to contain infection Catheterize to monitor hemodynamic state Operation: Inguinal herniotomy for strangulation
  24. 24.  These are indicated only in infants, the child is given analgesics & placed in gallow’s traction. In 75% of the cases the reduction is effected and there appear to be no danger of gangrenous intestine Forcible reduction must be avoided & should not be attempted.
  25. 25.  It is rare type of the hernia. The strangulated loop of W within abdomen, so local tenderness over the hernia is not marked. At operation two – comparatively normal looking loop of intestine are present in the sac. The strangulated loop will become apparent if traction is exerted on the middle of the loops occupying the sac.
  26. 26.  It result from slipping of posterior parietal peritoneum on the underlying retroperitoneal structure. The posterior wall of the sac formed by sigmoid colon, mesentery on left, caecum on right & some time by either side portion of bladder. Mostly sac consist of caecum, appendix or the portion of the colon. A small bowl sliding hernia occurs approx. 1 in 2000 cases The sac-less hernia occurs 1 in 8000 cases
  27. 27.  A sliding hernia occurs almost exclusively in men Five out of six sliding hernias are situated on the left sides Bilateral sliding hernias are rare The patient is nearly over the 40 year of age It should be suspected in very large globular inguinal hernia descending well into the scrotum. Occasionally the large intestine strangulated in sliding hernia, more often non – strangulated large intestine large intestine is present behind the sac