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Hernia examination by Dr Min Oo
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Hernia examination by Dr Min Oo



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  • 1. Examination of Hernia DR MIN OO Surgery
  • 2. Outline• Definition• Types• Predisposing factors• Basic features of a hernia• Inguinal hernia• Applied anatomy• Examination of inguinal hernia• Differences b/t direct and indirect inguinal hernia• Some definitions• Video click for inguinal hernia examination 7/31/2012 2
  • 3. Learning out come• To understand the basic principle for examination of hernia.• To know the various types of herniae.• Able to understand the applied anatomy for the inguinal region.• Able to demonstrate the examination of inguinal hernia.• Comprehend the differences between direct and indirect inguinal hernia.• To appreciate the some confused definitions.• To be able to develop the skill for the examination of a herniae7/31/2012 3
  • 4. What is hernia?7/31/2012 4
  • 5. Hernia – protrusion of a viscous or part of viscous through an abnormal opening in the walls of its containing activity. 25th edition,Bailey`s & Love`s Short practice of surgery7/31/2012 5
  • 6. WHY HERNIA OCCUR?7/31/2012 6
  • 7. Predisposing factors ??? Obesity Straining Smoking Abdominal Coughing Causes distension7/31/2012 7
  • 8. Composition of hernia Sac Covering Contents • Derived • Omentum- omentocele from the • Intestine- enterocoele• Sac is a layers of diverticulum of abd wall • Portion of circumference of peritoneum through intestine- Richter’s Hernia which the • Portion of bladder (or a• Consist of sac passes diverticulum) mouth,neck, • Ovary with or w/o body and corresponding Fallopian fundus tube • Meckel’s diverticulum- Littre’s hernia • Fluid 7/31/2012 8
  • 9. Classification7/31/2012 9
  • 10. Irrreducible Hernia- Reducible Hernia- contents cannot be contents can be returned to the returned to abdomen abdomen but there is no other complication Obstructed Hernia- irreducible hernia Strangulated Hernia- containing intestine blood supply is that is obstructed with obstructed good blood supply Inflammed Hernia- contents of the sac become inflammed7/31/2012 10
  • 11. Basic features of hernia???• Occur at weak point (Congenital or acquired)• Reducible on lying down or with direct pressure• Have an expansile cough impulse (Visible & palpable) Note: last 2 signs may be absent if constricted at the neck7/31/2012 11
  • 12. Causes of abdominal HerniaeAnatomical weakness Acquired weakness• Structures passing through • Trauma • High intra-abdominal the abdominal wall pressure• Muscle fail to develop • Coughing • Straining• Scar tissue • Abdominal distension 7/31/2012 12
  • 13. Various types of Herniae?(common) • Inguinal • Umblical • Incisional • Femoral • Epigastric7/31/2012 13
  • 14. Other rare herniae • Spigelian • Obturator • Lumbar • Gluteal7/31/2012 14
  • 15. Inguinal Hernia7/31/2012 15
  • 16. Surface anatomy ?????7/31/2012 16
  • 17. 7/31/2012 17
  • 18. Relation to the surrounding structures 1.Anterior wall Medially-external obliqueaponeurosis Lateral- internal oblique muscle 2.Posterior wall Medially – strong conjoint tendon Lateral- fascia transversalis 3.Floor Medial- Lacunar ligament Lateral- inguinal ligament 4.Roof Arching of fibers of int oblique and transverse muscles.7/31/2012 18
  • 19. 7/31/2012 19
  • 20. 7/31/2012 20
  • 21. Examination of the hernia • Ask permission • Exposure • Position • Third party • Privacy • Manner7/31/2012 21
  • 22. Ask the patient to stand up • Lying position …..why not? Not possible to see the true size. proper examination even not detect at all. • If suspect since early,start with standing position • If found during routine abdominal exam, complete abd exam first and ask the patient to stand up to examine properly. NOTE: examine both inguinal regions7/31/2012 22
  • 23. Look at the swelling from the front • Exact size and shape • Visible expansile cough impulse • Distinguish from femoral hernia • Extend of lump…down into the scrotum ?? • Other scrotal swelling …. • Any other swelling on the “normal side”7/31/2012 23
  • 24. Feel from the front • Exam the scrotum and content • First whether inguino-scrotal or true scrotal by getting above the upper edge ( get above ) • Don’t exam the external ring or canal as it is painful7/31/2012 24
  • 25. Feel from the side • Having exam the scrotal content & can’t get above the lump – assuming the inguinal hernia – proceed to examination of the lump…….??? Inguinal Hernia examination • Stand at the side of the patient –same side of hernia • Place on hand at the back of to support the patient • Examinating hand and fingers parallel to the inguinal ligament.7/31/2012 25
  • 26. Expansile cough impulse• Firmly compress the lump with fingers• Ask the patient to turn head toward to opposite side & to cough• If Tense and expansile = cough impulse (+)Note:• Localized swelling in the spermatic cord and undescended testis come out during cough but not bigger nor tense .• (+) is diagnostic for hernia• (-) can not exclude diagnosis (e.g adhesion …)7/31/2012 26
  • 27. Is the swelling is reducible? • Position???? • Can control at internal ring =indirect • Can not control = direct Note: • Reduction point to pubic tubercle • above and medial … inguinal • Below and lateral …….femoral Only for reducible one7/31/2012 27
  • 28. Remove the finger and watch the reappearance• Direction and the way reappearance help to deduct the origin of hernia• Obliquely downward = indirect• Directly project forward = directNOTE:Difficult in obese patient7/31/2012 28
  • 29. Percuss and auscultate • Intestine = resonant and audible bowel sound7/31/2012 29
  • 30. Feel the other side • Move the other side and exam the inguinal region • Commonly bilateral particularly in direct inguinal hernia • Ask the patient to cough to make obvious small bulge7/31/2012 30
  • 31. Examine the abdomen • Any possible increased intra-abdominal pressure e.g ..????7/31/2012 31
  • 32. Cardiovascular & respiratory assessment • Fitness • Any chronic respiratory problem.. • Increased intraabdominal pressure7/31/2012 32
  • 33. Differences b/t direct and indirect inguinal hernia7/31/2012 33
  • 34. Indirect inguinal hernia Direct inguinal herniaAny age but common in young ElderlyVia deep inguinal ring and long the Via transversalis fascia (hasselbach’singuinal canal triangle)Patent or reopen processus vaginalis Weak abdominal wall/muscleUnilateral in 2/3 case (right side more Bilateral in > ½ casecommon)Enter scrotum (complete) Does not enter scrotum (incomplete)Reduced by patient/doctor (manually) Reduced on lying down (automatically)Narrow neck- more liable to strangulate Broad neckZieman technique- impulse on index Impulse on middle fingerfingerDeep ring occlusion test- control Bulge outLittle finger invagination test- impulse on Impulse on pulpfinger tip 7/31/2012 34
  • 35. Clinical featuresIndirect inguinal hernia Direct inguinal hernia- sudden pain at the groin - seen protruding directly forward- swelling in inguinal canal which - usually readily reducible may extend into scrotum - gradual onset- become visible when patient - Severe pain is rare If there is no stand or cough complication such as incarceration or- dragging/ discomfort strangulation- passes above and medial to pubic tubercle- palpable cough impulse- audible bowel sound +/- 7/31/2012 35
  • 36. D/Dx of inguinal hernia??? • Femoral hernia • Vaginal hydrocele • Hydrocele of cord or canal of nuck • Undescended testis • Lipoma of cord7/31/2012 36
  • 37. Some definition ????? • Strangulated hernia ? • Richter`s hernia? • Maydl`s hernia? • Sliding hernia? • Incarceration ?7/31/2012 37
  • 38. Video for inguinal hernia examination7/31/2012 38
  • 39. THANK YOU HAVE A NICE DAY7/31/2012 39