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Strangulated hernia

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defination of hernia,epidemiology,etiology,parts of hernia,classification,clinical features,pathophysiology,predisposing factors and surgical management of strangulated hernia,

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Strangulated hernia

  1. 1. By DR BADAL KHAN PGR SU425-8-2015 1
  2. 2. DEFINATION IT IS AN ABNORMAL PROTRUSION OF A VISCOUS OR A PART OF A VISCOUS THROUGH AN OPENING ARTIFICIAL OR NATUERAL WITH A SAC COVERING IT. 25-8-2015 2
  3. 3. 0 10 20 30 40 50 60 70 80 Series 3 Series 2 Series 1 25-8-2015 3
  4. 4. AETIOLOGY OF HERNIA •STRAINING •LIFTING OF HEAVY WEIGHT •CHRONIC COUGH (TB,CH BRONCHITIS,ASTHMA) •CHRONIC CONSTIPATION •URINARY CAUSES • OLD AGE; BPH CA PROSTATE •YOUNG AGE;STRICTURE URETHRA •VERY YOUNG AGE ;PHIMOSIS,METAL STENOSIS • OBESITY •PREGNENCY •SMOKING •ASCITES •APPENDICECTOMY •FAMILIAL COLLEGEN DISORDER 25-8-2015 4
  5. 5. PARTS OF HERNIA 1.COVERING 2. SAC 3.CONTENTS 25-8-2015 5
  6. 6. •COVERING OF THE SAC ARE THE LAYERS OF THE ABDOMINAL WALL THROUGH WHICH THE SAC PASESS 25-8-2015 6
  7. 7. IT IS A DIVERTICULAM OF PERITONEUM WITH .MOUTH .NECK .BODY .FUNDUS •NECK IS NARROW IN INDIRECT BUT WIDE IN DIREC HERNIA •BODY IS THIN IN INFANTS, CHILDREN AND IN INDIRECT BUT IS THICK IN DIRECT AND LONG STADING HERNIA 25-8-2015 7
  8. 8. 1. OMENTUM-OMENTOCELE 2. INTESTINE-ENTEROCELE COMMONLY SMALL BOW 3. PORTTION OF CIRCUMFERENCE OF BOWEL 4. URINARY BLADDER-CYSTOCELE 5. MECKLE,S DIVERTICULAM-LITTRE,S HERNIA 6. OVARY 7. FALLOPIAN TUBE 25-8-2015 8
  9. 9. 1. CLASSIFICATION NO 1 CONGENITAL ACQUIRED 25-8-2015 9
  10. 10. CLASSIFICATION NO 2 •ACCORDING TO CONTENTS •OMENTUM-OMENTOCELE •ENTEROCELE-INTESTINE •CYSTOCELE-URINARRY BLADDER •LITTRE,S HERNIA-MECKLE,S DIV.. •SLIDING HERNIA •PART OF BOWEL-RICHTER,S HERNIA25-8-2015 10
  11. 11. CLASSIFICATION NO 3 •ACCORDING TO SITES •INGUINAL •FEMORAL •OBTURATOR •DIAPHRAGMATIC •LUMBAR •UMBLICAL •EPIGASTRIC 25-8-2015 11
  12. 12. CLASSIFICATION NO 4 •CLINICAL CLASSIFICATION •REDUCIBLE HERNIA •IRREDUCIBLE HERNIA •OBSTRUCTED HERNIA •INFLAMED HERNIA •STRANGULATED HERNIA 25-8-2015 12
  13. 13. 25-8-2015 13
  14. 14. A HERNIA IN WHICH BLOOD SUPPLY OF THE HERNIATED VISCUS IS SO CONSTRICTED BY SWELLING AND CONG- -STION AS TO ARREST ITS CIRCULATION 25-8-2015 14
  15. 15. •STRANGULATION COMMONLY OCCURS IN SMALL BOWEL AND ALSO OCCURE IN LARGE BOWEL . •OCCASIONALLY STRANGULATED OMENTOCELE CAN ALSO OCCURE WITHOU ANY INTESTINAL OBSTRUCTION 25-8-2015 15
  16. 16. •STRANGULATION CAN OCCUR IN •INGUINAL •FEMORAL •OBTURATOR •UMBLICAL •ANY OTHER HERNIA 25-8-2015 16
  17. 17. •BUT INDIRECT INGUINAL HERNIA IS MORE PRONE FOR STRANGULATION BECAUSE OF CONSTRICTING AGENTS 1. NECK OF SAC 2. SUP ING RING IN CHILDREN 3. ADHESIONS WITHIN SAC 25-8-2015 17
  18. 18. Strangulated inguinal hernia 25-8-2015 18
  19. 19. EPIDEMIOLOGY •INCIDENCE RATE OF STRANGULATED INGUINAL •HERNIA VARIES BETWEEN 0.29%AND 2.9% •MORTALITY RATE RANGES BETWEEN 2.6% TO 9% BUT A DELAY OF 12H INCREASE CHANCE OF INTESTINAL RESECTION RATE. •ABOUT 95% OF INGUINAL HERNIA PATIENT PRESENT •AT CLINICS AND ONLY 5% PRESENT AS AN •EMERGENCY WITH IRREDUCIBLE HERNIA WHICH •PROGRESS TO STRANGULATION 25-8-2015 19
  20. 20. MORTALITY RISK IS SEVEN TIME HIGHER IN CASES AFTER EMERGENCY STRANGULTED INGUINAL HERNIA SURGERY AND 20 TIME HIGHER IF BOWEL RESECTION WAS UNDERTAKEN DURING INFANCY INCIDENCE IS 4% FEMALE TO MALE RATIO IS 5;1 IN FEMALE INFANTS THE CONTENTS MAY BE OVARY WITH OR WITHOUT FALLOPIAN TUBE25-8-2015 20
  21. 21. •STRANGULATED HERNIAS ARE MORE FREQUENTLY SEEN IN ELDERLY PATIENTS,AND THEIR PREVELANCE IN THE 60 YEAR OLD POPULATION HAS BEEN REPORTED TO BE 9.8% COMPARED WITH 1.8% FOR YOUNGER PATIENTS 25-8-2015 21
  22. 22. OBSTRUCTION VENOUS RETURN IMPAIRED CONGESTION OF THE BOWEL FURTHER DILATATION OF THE BOWEL WHICH BECOMES PURPLE COLOUREDCONT… 25-8-2015 22
  23. 23. FLUID COLLECT IN THE SAC EVEVTUALLY ARTERIAL SUPPLY IS IMPAIRED BOWEL BECOMES DARK, BROWNISH BLACK COLOURED WITH FLABBY AND FRIABLE WALL 25-8-2015 23
  24. 24. BACTERIA MIGRATE TRAN SEROSALLY AND MULTIPLY IN FLUIDE OF THE SAC PERFORATION OCCURE AT THE SITE OF CONSTRICTION RING PERITONITIS OCCURE25-8-2015 24
  25. 25. •E.COLI •ANAEROBIC STREPTOCOCCI •ANEROBIC BACTERIA •KLEBSELLA 25-8-2015 25
  26. 26. 1.OBLIQUE INGUINAL HERNIA 2.TRUSS WORN FOR LONG TIME 3.PARTIALLY REDUCIBLE HERNIA 1.LARGE HERNIA IN ELDERLY 25-8-2015 26
  27. 27. 1.NARROW NECK 2.ADHESIONS 3.IRREDUCIBILITY 4.LONG TIME HERNIA 25-8-2015 27
  28. 28. 1.SMALL INTESTINE (USUALLY) 2.LARGE INTESTINE (RARELYY) 3.BOTH SMALL INTESTINE AND OMENTUM (SOMETIME) 25-8-2015 28
  29. 29. 1. HISTORY TAKING 2. EXAMINATION 3. INVESTIGATION 25-8-2015 29
  30. 30. •SEVERE PAIN INITIALLY AT HERNIAL SITE THEN BECOME GENERALISED •PERSISTENT VOMITING •ABDOMINAL DISTENSION •CONSTIPATION •RECENT SUDDEN INC IN SIZE OF LUMP 25-8-2015 30
  31. 31. I. INSPECTION PALPATION  SITE  SIZE  SHAPE  COLOUR  TEMP  EXTREMELY TENDER (MAYDLE,S HERNIA TENDERNESS ABSENT)  REBOUND TENDERNESS IS DIAGNOSTIC  COUGH IMPULSE ABSENT  IRREDUCIBLE 25-8-2015 31
  32. 32. PERCUSSION AUSCULTATION  NOT POSSIBLE DUE TO TENDERNESS IF DONE THEN….  DULL IN CASE OF OMENTUM  RESONENT IN CASE OF GUT  GUT SOUNDS MAY BE AUDIBLE IN CASE OF ENTEROCELE  SILENT ABDOMEN IN CASE OF PERITONITIS (PARALYTIC PARALYSIS) 25-8-2015 32
  33. 33. BLOOD TESTS IMAGING  CBC (TOTAL COUNT  BLOOD SUGAR  SERUM ELECTROLYTES  BLOOD UREA  SERUM CRITININE  PLAIN XRAY ABDOMEN IN ERECT POSITION IN CASE OF OBS MULTIPLE AIR FLUIDE LEVELS  U/S ABDOMEN 25-8-2015 33
  34. 34. Treatment 25-8-2015 34
  35. 35. •OFTEN IN IRREDUCIBLE HERNIA, REDUCTION OF HERNIA IS TRIED BY 1.ELEVATION 2.SEDATION 3.TAXIS 25-8-2015 35
  36. 36. •IT IS A TRIAL TO REDUCE PARTIALLY REDUCED OR IRREDUCIBLE HERNIA WHILE FLEXING AND MEDIALLY ROTATING THE HIP •IT IS DANGEROUS IN OBS AND MAYDLES HERNIA 25-8-2015 36
  37. 37.  PREOPERATIVE MEASURES  OPERATION 1. HERNIOTOMY (SHAMIM) 2. BASSINI,S (SRB) 3. LIGHT WEIGHT SYNTHETIC MESH (BAILEY &LOVE) 25-8-2015 37
  38. 38. 1. PREOP TREATMENT •PT ADMITTED • IV CANULA •RYLE,S TUBE (NG) ASPIRATION •IV FLUIDS TO CORRECT DEHYDRATION AND ELECTROLYTE IMBALANCE •ANTIBIOTICS •CATHETERISATION •SHIFT PT FOR EMERGENCY SURGERY 25-8-2015 38
  39. 39. OPERATION – NO 1.INGUINAL HERNIOTOMY 1.INCISION •INCISION IS MADE OVER THE MOST PROMINENT PART OF THE SWELLING 25-8-2015 39
  40. 40. 2.DELIVERING & OPENING OF SAC •SAC IS EXPOSED •CONSTRICTION RING AND SUP RING IS RELEASED •DELIVER BODY AND FUNDUS OF SAC WITH COVERING ONTO SURFACE •SAC IS OPENED WITHOUT SPILLAGE OF FLUIDE •FLUID IS SUCKED AND MOPPED 25-8-2015 40
  41. 41. 3.EXCISION OF STRANGULATED CONTENTS 1.IN CASE OF OMENTUM •DEVITSLISED OMENTUM IS EXCISED AFTER BEING SECURELY LIGATED 25-8-2015 41
  42. 42. 2.IN CASE OF INTESTINE •BOWEL IS HELD WITH FINGERS SO AS TO PREVENT IT FROM GETTING REDUCED •VIABILITY OF THE BOWEL IS CHECKED BY •COLOUR •PERISTALSIS •PULSATION •BLEEDING VIABLE INTESTINE IS RETURNED TO PERITONEAL CAVITY WHEN GANGRENOUS RESECTION AND ANASTOMOSIS IS DONE AND DRAIN IS PLACED 25-8-2015 42
  43. 43. 4.EXCISION OF SAC 1. MODERATE SIZED HERNIAL SAC CAN BE EXCISED AND CLOSED BY A PURSE STRING SUTURES 2. LARGE SIZED &ADHERENT HERNIAL SAC IS CUT ACROSS AND NECK OF SAC IS TIED AND SUTURED 6.WOUND CLOSER •WOUND CLOSE LAYER BY LAYER25-8-2015 43
  44. 44. NO.2 BASSINI,S REPAIR •IT IS DONE BY PLACING INTERUPTED NON- -ABSORBABLE SUTURES NO.3 LIGHTWEIGHT MESH •SOME SURGOENS STILL USE A LIGHWEIGHT SYNTHETIC MESH COVERED BY APPROPRIATE ANTIBIOTIC 25-8-2015 44
  45. 45. •ANESTHESIA COMPLICATIONS •BLEEDING •URINARY RETENTION •SEROMA •WOUND INFECTION •SEPTICEMIA •LEAK WITH FISTULA •CHRONIC PAIN 25-8-2015 45
  46. 46. 1. BAILEY,S AND LOVE 2. SRB,S MANUAL OF SURGERY 3. ESSENTIALS OF SURGERY BY DR SHAMIM 4. WIKIPEDIA 5. TOPIC UPON HERNIA FROM UNIVERSITY OF COLORADO HOSPITAL 25-8-2015 46
  47. 47. 25-8-2015 47

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