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Cpd Hernia

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Cpd Hernia Presentation Transcript

  • 1. GOOD MORNING!
  • 2. CASE PRESENTATION & DISCUSSION ON INGUINOSCROTAL MASS martinjosephscabahugmd
  • 3. General Data C.P. 59-year-old male Sampaloc, Manila
  • 4. Chief complaint Inguinoscrotal mass on the right
  • 5. History of Present Illness 2 yrs bulging inguinal mass 5x8cm straining, prolonged standing reducible (-) pain, fever (-) changes in bowel movement (-) urinary symptoms (-) respiratory symptoms
  • 6. 10 months PTA increase size of mass, reaches the scrotal area Persistence of symptoms Consult Admission
  • 7. Past Medical Hx: (-) Hypertention (-) Diabetes Mellitus (-) Bronchial Asthma (-) Heart Disaese
  • 8. Physical Examination General Survey: Conscious, coherent, ambulatory not in cardiorespiratory distress BP130/90 HR 81 RR 19 T 37.1 C&L symmetrical chest expansion no retractions, clear breath sounds
  • 9. Heart: normal rate regular rhythm, (-) thrills, murmur Abdomen: flat, NABS, soft, non tender, no organomegaly
  • 10. Inguino scrotal mass right Inguinal ring 4.5 cm Reducible Soft (-) bowel sounds (-) transillumination (-) erythema (-) tenderness
  • 11. Salient features -59-year-old Male -inguinoscrotal mass -Reducible -Noted when patient strains & prolonged standing -Soft, non-tender 4.5 cm external - (-) bowel sounds inguinal ring - (-) transillumination
  • 12. INGUINOSCROTAL MASS, RIGHT INFLAMMATORY NON INFLAMMATORY
  • 13. INGUINOSCROTAL MASS, RIGHT INFLAMMATORY Swelling and rapid Multiple, progression of pain tender fever, chills redness, edematous Epididymoorchitis Inguinoscrotal Lymphadenopathy abscess
  • 14. INGUINOSCROTAL MASS, RIGHT NON INFLAMMATORY Malignant Non-malignant
  • 15. INGUINOSCROTAL MASS, RIGHT NON INFLAMMATORY Malignant Non-malignant
  • 16. INGUINOSCROTAL MASS, RIGHT NON INFLAMMATORY Malignant Soft tissue Lyposarcoma Testicular Fibrosarcoma Sarcoma Deep muscle Tumor Subcutaneous Large size, fat Nodule, firm, superficial or deep Disorganized non-tender growth
  • 17. INGUINOSCROTAL MASS, RIGHT NON INFLAMMATORY Non-malignant Soft tissue Sebaceous cysts Lipoma Lipoma of the cord Spermatocoele Torsion of the testis
  • 18. Inguinoscrotal mass right inflammatory Non-inflammatory malignant Non-malignant hernia Soft tissue Epididymoorchitis Swelling and rapid progression of pain •Lipoma of Inguinoscrotal fever, chills the cord abscess red, edematous •Sebaceous Lymphadenopathy cysts
  • 19. Inguinoscrotal mass right inflammatory Non-inflammatory malignant Non-malignant hernia Soft tissue Epididymoorchitis •Lipoma of Inguinoscrotal the cord abscess •Sebaceous Lymphadenopathy cysts
  • 20. Inguinoscrotal mass right inflammatory Non-inflammatory malignant Non-malignant hernia Soft tissue Epididymoorchitis •Lipoma of Inguinoscrotal the cord abscess Multiple, tender •Sebaceous Lymphadenopathy Obvious are of cysts inflammation
  • 21. Inguinoscrotal mass right inflammatory Non-inflammatory malignant Non-malignant hernia Soft tissue Epididymoorchitis •Lipoma of Inguinoscrotal the cord abscess •Sebaceous Lymphadenopathy cysts
  • 22. Inguinoscrotal mass right inflammatory Non-inflammatory Soft tissue Sercoma Large size, superficial or deep malignant Non-malignant hernia Soft tissue Epididymoorchitis •Lipoma of Inguinoscrotal the cord abscess •Sebaceous Lymphadenopathy cysts
  • 23. Inguinoscrotal mass right inflammatory Non-inflammatory Fibrosercoma Subcutaneous fat Disorganized growth malignant Non-malignant hernia Soft tissue Epididymoorchitis •Lipoma of Inguinoscrotal the cord abscess •Sebaceous Lymphadenopathy cysts
  • 24. Inguinoscrotal mass right inflammatory Non-inflammatory Lyposercoma Deep muscle malignant Non-malignant hernia Soft tissue Epididymoorchitis •Lipoma of Inguinoscrotal the cord abscess •Sebaceous Lymphadenopathy cysts
  • 25. Inguinoscrotal mass right inflammatory Non-inflammatory Testicular Tumor Nodule, firm, non- malignant Non-malignant tender hernia Soft tissue Epididymoorchitis •Lipoma of Inguinoscrotal the cord abscess •Sebaceous Lymphadenopathy cysts
  • 26. Inguinoscrotal mass right inflammatory Non-inflammatory malignant Non-malignant hernia Soft tissue •Sebaceous cysts Epididymoorchitis •Lipoma Inguinoscrotal •Lipoma of the cord No cough impulse abscess •Spermatocoele Lymphadenopathy •Torsion of the testis
  • 27. Inguinoscrotal mass right inflammatory Non-inflammatory malignant Non-malignant hernia Soft tissue •Sebaceous cysts Epididymoorchitis •Lipoma Inguinoscrotal •Lipoma of the cord abscess Cyst of rete testes •Spermatocoele Cystic mass Lymphadenopathy + transillumination •Torsion of the testis bilateral
  • 28. Inguinoscrotal mass right inflammatory Non-inflammatory malignant Non-malignant hernia Soft tissue •Sebaceous cysts Epididymoorchitis •Lipoma Inguinoscrotal •Lipoma of the cord abscess •Spermatocoele Lymphadenopathy Sudden onset of pain Scrotal enlargement •Torsion of the testis with edema
  • 29. Hernia direct indirect Prevalence History: •Indirect, more common •55M, Recurrent bulging mass, inguinosrotal area, R •Rutledge report, 1,437 patients •Aggravated by straining, relieved •60% indirect by lying down •36% direct PE: •4% femoral •inguinoscrotal mass, R •Lichtenstein report •Soft, non-tender, reducible • 44.4% Indirect •43.1% direct •+ cough impulse •12.5% others •No bowel sound •No transillumination
  • 30. Impression Certainty Treatment Primary Indirect 95% Surgical Inguinal Hernia Secondary Direct Inguinal 5% Surgical Hernia
  • 31. Paraclinical Diagnostic Procedure Do I need paraclinical procedure? NO. Certain of my primary diagnosis pattern recognition prevalence
  • 32. Goal of Treatment Reduce herniated organ/bowel Ligation of the sac repair defect ≥4cm
  • 33. Treatment Options There are at present three general options for the surgical repair of indirect inguinal hernia, namely: open repair with mesh grafting, open repair without mesh grafting, laparoscopic repair with mesh grafting
  • 34. 4 cm internal BENEFIT RISK COST AVAILABILITY ring OPEN Infection Repair floor WITHOUT P 2000 Available anatomical recurrence MESH RR 0.2% Low recurrence rate Less post-op OPEN WITH Available most of pain Graft rejection P 5000 MESH the time Easy to perform Early back to work Intra LAPARO- P 8000- same abdominal Not available SCOPIC P10000 complication
  • 35. At present, although open repair with mesh and laparoscopic repair are now commonly done especially in developed countries, the controversy is far from being settled because of the tendency for blanket recommendations and randomized controlled trials and meta- analyses showing conflicting results, some favoring open repair without mesh (1,5,7).
  • 36. others favoring open repair with mesh (9-10) and still others, laparoscopic approach (11- 13).
  • 37. Protocol on Hernia A departmental consensus was made using the diameter of the external inguinal ring (>4 centimeters) as predictor for preoperative preparation of mesh in patients for indirect inguinal hernia repair.
  • 38. Protocol on Hernia The protocol was then prospectively validated on adult patients with unilateral indirect inguinal hernia from January to August, 2003 using intra- operative measurement of the external and internal inguinal ring as the indicator for mesh grafting.
  • 39. The department believes that there are indications for the use of mesh in the treatment of indirect inguinal hernia. Recurrence and large size of hernia defect are the basic indications favoring open repair without mesh (1,5,7) open repair with mesh (4, 13) and still others, laparoscopic approach (3, 6, 11).
  • 40. Pre-op preparation Psychological support Screen for previous medical problem Hypertension Metoprolol 50mg BID x 2 weeks Optimize patient’s condition Consent Preparation of materials
  • 41. Operative Technique Oblique incision over Langer’s line External oblique aponeurosis opened
  • 42. Intra-op findings Hernial sac located anteromedially to the cord containing omentum Internal ring measures 4 cm in widest diameter
  • 43. Operative Technique •Spermatic cord identified •Hernial sac identified and opened •Hernial contents reduced •Ligation of the hernial sac
  • 44. Operative Technique •Mesh approximated over the defect •Medial corner of the mesh overlaps the pubic bone •And sutured with interrupted prolene 3-0
  • 45. Operative Technique Spermatic cord placed between the two tails of the mesh
  • 46. Operative Technique Two tails crossed –over and sutured together
  • 47. Operative Technique •Hemostasis •Instrument and sponge checked •Fascial closure with vicryl 0 •Subcuticular skin closure with vicryl 4-0 •Dry sterile dressing
  • 48. Final Diagnosis Indirect Inguinal Hernia, Right Grade III-B
  • 49. Post-op support Analgesia Ketoprofen 100mg TIV q6 x 3 doses shifted to oral Paracetamol 500mg q4 Early ambulation Diet as tolerated Daily wound care Discharged on the 2nd POD
  • 50. Prevention and Health Anticipate complications Adequate hemostasis Avoid vascular compromise Avoid infection Avoid dehiscence
  • 51. Prevention and Health Alive patient Patient’s health problem resolved No complaint No disability No medical suit Satisfied patient
  • 52. Pathophysiology genetic metabolic Fascial factor Inguinal Hernia Muscle Processus deficiency vaginalis Physical exertion
  • 53. genetic metabolic Fascial factor Inguinal Hernia Muscle Processus deficiency vaginalis Physical exertion Inguinal Hernia genetic •Autosomal dominant •Preferential paternal factor •Multiple, familial or part of connective tissue disorder
  • 54. genetic metabolic Fascial factor Inguinal Hernia Muscle Processus deficiency vaginalis Physical exertion Inguinal Hernia metabolic •Decrease hydroxyprolene •Altered collagen precipitability and impaired hydroxylation •Increase elastase, decrease anti-proteolytic inhibitor capacity (emphysema)
  • 55. genetic metabolic Fascial factor t Inguinal Hernia Muscle Processus deficiency vaginalis Physical exertion Inguinal Hernia Muscle Deficiency •Congenital or acquired insufficiency of internal oblique expose the deep ring and inguinal floor
  • 56. genetic metabolic Fascial factor Inguinal Hernia Muscle Processus deficiency vaginalis Physical exertion Inguinal Hernia Physical exertion •Increase in intraabdominal pressure
  • 57. genetic metabolic Fascial factor Inguinal Hernia Muscle Processus deficiency vaginalis Physical exertion Inguinal Hernia Physical exertion •Increase in intraabdominal pressure
  • 58. genetic metabolic Fascial factor Inguinal Hernia Muscle Processus deficiency vaginalis Physical exertion Inguinal Hernia Patent Processus Vaginalis •Evagination of the peritoneum •60% at two months, 40% at two years, 30% adult
  • 59. genetic metabolic Fascial factor Inguinal Hernia Muscle Processus deficiency vaginalis Physical exertion Inguinal Hernia Fascial factor •Myopectineal Orifice Fruchaud •Boundaries: superior, internal oblique + transverse abd muscle; lateral, iliopsoas; medial, rectus; inferior, pecten •Transversalis fascia
  • 60. Internal oblique and transverse abdominis Myopectineal orifice of Fruchaud Pecten pubis Ileopsoas m.
  • 61. Nyhus Classification Type I Indirect, small Type II Indirect, medium Type III A. Direct B. Indirect, large C. Femoral Type IV Recurrent
  • 62. Type 1 Indirect, small
  • 63. Type II Indirect, medium
  • 64. Type III A. Direct
  • 65. B. Indirect, large
  • 66. Type III C
  • 67. Unified Classification
  • 68. Unified Classification
  • 69. Nyhus Classification of Inguinal Hernias. Type 1 Indirect hernia with normal internal ring Indirect hernia with dilated internal ring. Posterior wall Type 2 intact Type 3 Posterior wall defect A Direct inguinal hernia Indirect inguinal hernia. Internal ring dilated. Posterior B wall defective C Femoral hernia Type 4 Recurrent hernia
  • 70. Gilbert’s Classification of Inguinal Hernias. Type Description Type I Indirect, tight ring, sac any size, reducible Type II Indirect, ring < 4 cm Type III Ring > 4 cm, sliding component, displaces inferior epigastric vessels Type IV Defective canal floor, ring is sound Type V Direct diverticular defect 1-2 cm suprapubic, but anywhere along floor Type VI Pantaloon hernia Type VII Femoral hernia
  • 71. References 1. Barth R J, Burchard K W, Tosteson A et al. Short- term outcome after mesh or Shouldice herniorrhaphy: A randomised, prospective study. Surgery. 1998; 123: 121-126. 2. Cameron J. Current Surgical Therapy. VII Ed. 2001; 600-616. 3. Chung RS, Rowland DY.Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs. Surg Endosc. 1999; 13(7):689-94. 4. Fitzgibbons R. et al. Hyhus and Condon’s Hernia. V Ed. 2002;, 3-7; 71-79; 149-156.
  • 72. 5. Friis E, Lindahl F. The tension-free hernioplasty in a randomized trial. Am L Surg. 1996; 172 (4): 315-9 6. Go PM. Overview of randomized trials in laparoscopic inguinal hernia repair. Semin Laparosc Surg. 1998; 5(4): 238-41. 7. Pavlidis TE, Atmatzidis KS, Lazardis CN, Papaziogas BT, Makris JG. Comparison between modern mesh and conventional non-mesh methods of inguinal hernia repair. Minerva Chir. 2002; 57(1): 7-12 8. Pingul J. et al. Health Process Evidence based Clinical Practice Guidelines in Patient with Inguinal Hernia 9. Scott-Conn, C. Chassin’s Operative Strategy in General Surgery. III Ed. 747
  • 73. 10. Schwartz, S. et al. Principles of Surgery. VII Ed. 1999; 1585- 1609. 11. The EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg. 2002; 235(3):322-32. 12. Vrijland W W, van den Tol M P, Luijendijk R W et al. Randomised clinical trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg. 2002; 89: 293-297. 13. Wantz GE. Experience with the tension-free hernioplasty for primary inguinal hernias in men. J Am Coll Surg. 1996; 183(4): 351-6.
  • 74. Bassini Repair Uses interupted sutures
  • 75. Shouldice Repair Uses continuous, imbricated sutures
  • 76. McVay’s Repair Approximates the transversus abdominis and the tranversalis fascia
  • 77. Paraclinical Diagnostic Process Diagnostic Benefit Risk Cost Availability Procedure herniography Will Peritonitis P500.00 Not available differentiate a Hypersensitivi direct from an ty indirect hernia ultrasound Will r/o other Acceptable P300.00 Not readily causes of available groin masses x-ray Will r/o Exposure to P150.00 Available intestinal radiation obstruction CT-scan Will r/o other Exposure to P3000.00 Not readily causes of radiation available groin masses
  • 78. THANK YOU!