Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Hernia & PR
Dr.AbdulWAHID M Salih
M.D. Surgery
Hernia
• protrusion of an organ
or the fascia of an
organ through the
wall of the cavity that
normally contains
• Congenit...
a Hernia composed of;
1.Sac: a folding of peritoneum
consisting of a mouth, neck,
body and fundus.
2.Body: which varies in...
In children,
• Specifically in infants, the parents"
observation of a swelling or protusion
may be the only positive featu...
Inguinal
• Superficial inguinal ring—
1.25 cm above and lateral to
the pubic tubercle
• Deep inguinal ring—1.25 cm
above a...
Ingiunal canal Boundaries
MALT: 2M 2A, 2L, 2T:
Superior wall [roof]: 2 Muscles:
• Internal oblique Muscle
• Transverse abd...
Ingiunal canal Contents
Ilioinguinal nerve.
Spermatic cord, which contains:
3 arteries:
• Testicular a.
• Ductus deferens ...
Types of indirect inguinal hernia
1. Incomplete;
Bubonocele—limited within the inguinal canal
Funicular—limited just above...
• Introduce yourself
• Wash hands
• Chaperone
• Standing up
• Undressed from waist down
• Look for an visible lumps
• Any ...
position
•Pt. stands, exposed area
visible.
•best performed with the patient
standing and in supine
•the physician seated ...
prepare
• Stand at the side of the patient,
• one hand on the patients back to support him.
• hand and arm should be rough...
• Observation of the groin area in
oblique light
• Visible swelling. Examine as a mass;
(STEM; site,skin,size,shape,…)
Mass
Most important
1. Can you get above it?
2. Reducibility test
3. Expansile Cough Impulse;
4. Invagination test
5. Three fin...
Also Asses
• Intra or extra abdominal
• Tension
• Composition
• Percussion and auscultation;
Bowel Sounds
• Always examine...
1-Cough Impulse
•Pt. coughs to highlight hernia.
•May not ;if the neck is blocked by
adhesions
•Visible & Palpable cough i...
2-Reducibility test
• Ask pt. to reduce hernia himselves
• usually done in lying position.
• The thigh of the affected sid...
Relation to Pubic
Tubercle
INGUINAL HERNIA;
The neck above
and medial to the
pubic tubercle
FEMORAL HERNIA;
The neck below...
3-Get above the swelling test
• Done in standing position
• At the root of the scrotum place the
thumb in front and the in...
4-Invagination test
•The scrotum on each side is inverted
with the examining index finger
•Entering the inguinal canal alo...
5-Three finger test / Zieman’s technique
Index finger; deep inguinal ring (indirect hernia)
Middle finger; superficial ing...
6-Ring occlusion test
•Reduce the hernia
•Occlusion of the deep ring by thumb.
•Then holding the thumb in position ask
The...
Beside
• Beside; at the level of inguinal region
at the affected side;
Notice a small bulge
Compare to the other side.
• S...
Examine the abdomen;
Causes Of raised intraabd. pressure;
• Enlarged bladder (BPH)
• Ascites
Search; predisposing factors;
describe the hernia
1. Site (inguinal)
2. Right/Left
3. Reducible/Irreducible
4. Complete/Incomplete
5. Direct/Indirect
•Any hernia that is tender
•Nausea and vomiting;
•No attempt to
reduce it manually.
•An acute surgical
emergency.
Strangul...
indirect summary
•Relation to epigastric vessels;Relation to epigastric vessels; LataralLataral
•Processus vaginalis;Proce...
Direct summary
•Bilateral
•AcqiuredAcqiured
•Processus vaginalis;Processus vaginalis; AbsentAbsent
•Rarely strangulate;
me...
Femoral Hernia (cont..)
Femoral hernias are more common in women,
present as a groin lump.
the cause of unexplained sma...
Umbilical Hernia:
• In infants & children.
• Boys more than girls.
• Tend to resolve without any treatment
by around the a...
Paraumbilical Hernia:
• Affects adults.
• either supra or infraumbilical
through the linea alba.
• The female to male rati...
Incisional Hernia
• weakness is the result of an
incompletely healed surgical wound.
• more along a straight line from the...
Epigastric Hernia
a defectin the linea alba between the
xiphoid process and umbilicus
Starts as a protrusion of the
extr...
Rare external Hernias
1. Spiglian Hernia:
 spaces of the semilunar line and the
lateral edge of the rectus muscle (inferi...
2-Lumbar Hernias:
broad bulging hernia
not vulnerable to incarceration.
A. Petit’s hernia: inferior lumbar triangle.
B. Gr...
9 hernia
9 hernia
9 hernia
9 hernia
Upcoming SlideShare
Loading in …5
×

9 hernia

26,791 views

Published on

Published in: Health & Medicine
  • Be the first to comment

9 hernia

  1. 1. Hernia & PR Dr.AbdulWAHID M Salih M.D. Surgery
  2. 2. Hernia • protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains • Congenital, acquired • Most have an expansile cough impulse
  3. 3. a Hernia composed of; 1.Sac: a folding of peritoneum consisting of a mouth, neck, body and fundus. 2.Body: which varies in size and is not necessarily occupied. 3.Coverings: derived from layers of the abdominal wall. 4.Contents: which could be anything from the omentum, intestines, ovary or urinary bladder.
  4. 4. In children, • Specifically in infants, the parents" observation of a swelling or protusion may be the only positive feature. • In the infancy may beTransilluminable
  5. 5. Inguinal • Superficial inguinal ring— 1.25 cm above and lateral to the pubic tubercle • Deep inguinal ring—1.25 cm above and medial to the mid point of inguinal ligament • Length of the inguinal canal —3.25cm
  6. 6. Ingiunal canal Boundaries MALT: 2M 2A, 2L, 2T: Superior wall [roof]: 2 Muscles: • Internal oblique Muscle • Transverse abdominus Muscle Anterior wall: 2 Aponeuroses: • Aponeurosis of external oblique • Aponeurosis of internal oblique Lower wall [floor]: 2 Ligaments: • Inguinal Ligament • Lacunar Ligament Posterior wall: 2Ts: • Transversalis fascia [laterally] • Conjoint Tendon [medially]
  7. 7. Ingiunal canal Contents Ilioinguinal nerve. Spermatic cord, which contains: 3 arteries: • Testicular a. • Ductus deferens a. • Cremasteric a. 3 nerves: • Cremasteric n. • Genital branch of the genitofemoral n. • Autonomics 3 other things: • Ductus deferens • Pampiniform plexus • Lymphatics
  8. 8. Types of indirect inguinal hernia 1. Incomplete; Bubonocele—limited within the inguinal canal Funicular—limited just above the epididymis 2.Complete; traverses to the bottom of the scrotum
  9. 9. • Introduce yourself • Wash hands • Chaperone • Standing up • Undressed from waist down • Look for an visible lumps • Any scars, overlying skin changes. • The lump extends into the scrotum
  10. 10. position •Pt. stands, exposed area visible. •best performed with the patient standing and in supine •the physician seated on a stool
  11. 11. prepare • Stand at the side of the patient, • one hand on the patients back to support him. • hand and arm should be roughly parallel to the inguinal ligament when palpating the lump.
  12. 12. • Observation of the groin area in oblique light • Visible swelling. Examine as a mass; (STEM; site,skin,size,shape,…) Mass
  13. 13. Most important 1. Can you get above it? 2. Reducibility test 3. Expansile Cough Impulse; 4. Invagination test 5. Three finger test Zieman’s technique 6. Ring occlusion test
  14. 14. Also Asses • Intra or extra abdominal • Tension • Composition • Percussion and auscultation; Bowel Sounds • Always examine both groins • Tranillumination
  15. 15. 1-Cough Impulse •Pt. coughs to highlight hernia. •May not ;if the neck is blocked by adhesions •Visible & Palpable cough impulse. •Reappear on straining, standing or coughing
  16. 16. 2-Reducibility test • Ask pt. to reduce hernia himselves • usually done in lying position. • The thigh of the affected side should be flexed, adducted and internally rotated. • Finger guard of the inguinal canal by thumb and index finger and then the scrotum is gently squeezed.
  17. 17. Relation to Pubic Tubercle INGUINAL HERNIA; The neck above and medial to the pubic tubercle FEMORAL HERNIA; The neck below and lateral to pubic tubercle
  18. 18. 3-Get above the swelling test • Done in standing position • At the root of the scrotum place the thumb in front and the index behind •Try to reach above the swelling. • Inguinal hernia; cannot get above • Pure scrotal swelling; will get above
  19. 19. 4-Invagination test •The scrotum on each side is inverted with the examining index finger •Entering the inguinal canal along the course of the cord structures. •The size of the external ring. •The finger push up to the superf inguinal ring. •The pulp should feel the ring. •Pat is asked to cough, •A palpable impulse will confirm the hernia; felt on the pulp then direct felt on the tip then indirect hernia.
  20. 20. 5-Three finger test / Zieman’s technique Index finger; deep inguinal ring (indirect hernia) Middle finger; superficial ing. Ring (direct hernia) Ring finger; saphenous opening (femoral hernia) The patient is asked to cough.
  21. 21. 6-Ring occlusion test •Reduce the hernia •Occlusion of the deep ring by thumb. •Then holding the thumb in position ask The pt to stand then cough •If no bulging; indirect •If bulging; direct .
  22. 22. Beside • Beside; at the level of inguinal region at the affected side; Notice a small bulge Compare to the other side. • Stand beside the pt; your shoulder behind the opposite shoulder of pt; Reduce the hernia. Ask the pt to cough
  23. 23. Examine the abdomen; Causes Of raised intraabd. pressure; • Enlarged bladder (BPH) • Ascites Search; predisposing factors;
  24. 24. describe the hernia 1. Site (inguinal) 2. Right/Left 3. Reducible/Irreducible 4. Complete/Incomplete 5. Direct/Indirect
  25. 25. •Any hernia that is tender •Nausea and vomiting; •No attempt to reduce it manually. •An acute surgical emergency. Strangulation
  26. 26. indirect summary •Relation to epigastric vessels;Relation to epigastric vessels; LataralLataral •Processus vaginalis;Processus vaginalis; PresentPresent •congenitalcongenital •Unilateral (usually). •always descends the scrotum •prone to obstruction and strangulation
  27. 27. Direct summary •Bilateral •AcqiuredAcqiured •Processus vaginalis;Processus vaginalis; AbsentAbsent •Rarely strangulate; medial tomedial to epigastric vessels;epigastric vessels;
  28. 28. Femoral Hernia (cont..) Femoral hernias are more common in women, present as a groin lump. the cause of unexplained small bowel obstruction. an absent Cough impulse globular lump than the pear shaped lump of the inguinal hernia. • Differential Diagnoses: Inguinal Hernia. Femoral Artery Aneurism. Femoral Lymphadenopathy. Psoas Abscess.
  29. 29. Umbilical Hernia: • In infants & children. • Boys more than girls. • Tend to resolve without any treatment by around the age of 5 years. • Obstruction and strangulation is rare.
  30. 30. Paraumbilical Hernia: • Affects adults. • either supra or infraumbilical through the linea alba. • The female to male ratio is 20:1. • Clolicky pain and/or irreducibilty due to omental adhesions.
  31. 31. Incisional Hernia • weakness is the result of an incompletely healed surgical wound. • more along a straight line from the sternum down to the pubis. • Swelling at the incisional site +/- pain.
  32. 32. Epigastric Hernia a defectin the linea alba between the xiphoid process and umbilicus Starts as a protrusion of the extraperitoneal fat Swelling +/- pain similar to a peptic ulcer pain.
  33. 33. Rare external Hernias 1. Spiglian Hernia:  spaces of the semilunar line and the lateral edge of the rectus muscle (inferior to the arcuate line).  The posterior rectus sheath is weak  Preoperative diagnosis is diffucult  u/s & c.t are helpful tools in the diagnosis
  34. 34. 2-Lumbar Hernias: broad bulging hernia not vulnerable to incarceration. A. Petit’s hernia: inferior lumbar triangle. B. Grynfeltt’s Hernia:superior lumbar triangle and is less common than Petit’s.

×