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Inguinal hernia


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Inguinal Hernia report 2013, during Surgery rotation of my Post Graduate Internship at the Veterans Memorial Medical Center

Published in: Health & Medicine

Inguinal hernia

  1. 1. INGUINAL HERNIA Max Angelo G. Terrenal – Post Graduate Medical Intern – Veterans Memorial Medical Center
  2. 2. WHAT IS AN INGUINAL HERNIA? Protrusion of a peritoneal sac through a musculoaponeurotic barrier Direct or Indirect
  3. 3. DIRECT INGUINAL HERNIA  Within the floor of Hesselbach’s triangle  Acquired defect from mechanical breakdown over the years  ~1% Lifetime risk
  4. 4. INDIRECT INGUINAL HERNIA  Through the internal ring of inguinal canal  Congenital  Patent processus vaginalis  ~5% Lifetime risk  Higher risk of strangulation than direct
  6. 6. INCARCERATED  Hernia which cannot be reduced STRANGULATED  Incarcerated hernia with resulting ischemia
  7. 7. EPIDEMIOLOGY  One of the most common surgical procedures  Incidence:  ~5-10% lifetime  75% of abdominal wall hernias  Male > Female  Indirect > Direct  Right > Left  1/3 may develop a contralateral inguinal hernia
  8. 8. ETIOLOGY  Multifactorial  Weakness in abdominal wall musculature PRESUMED CAUSES OF GROIN HERNIATION Coughing Valsalva's maneuvers Chronic obstructive pulmonary disease Ascites Obesity Upright position Straining Congenital connective tissue disorders Constipation Defective collagen synthesis Prostatism Previous right lower quadrant incision Pregnancy Arterial aneurysms Birthweight <1500 g Cigarette smoking Family history of a hernia Heavy lifting Physical exertion (?)
  9. 9. ANATOMY Inguinal Hernia
  10. 10. ABDOMINAL WALL  Skin  Subcutaneous fat  Scarpa’s fascia  External oblique muscle  Internal oblique muscle  Transversus abdominis  Transveralis fascia  Preperitoneal fat  Peritoneum
  11. 11. INGUINAL CANAL  4-6 cm long  Anteroinferior of pelvic basin  Cone-shaped  Base  superolateral margin  Apex  Inferomedially
  12. 12. BOUNDARIES  Anterior  external oblique aponeurosis  Lateral  Internal oblique muscle  Posterior  fusion of the transversalis fascia and transversus abdominus muscle,  Superior  arch formed by the fibers of the internal oblique muscle.  Inferior  inguinal ligament
  13. 13. SPERMATIC CORD  Cremasteric muscle fibers  Vas deferens  Testicular artery  Testicular pampiniform venous plexus  Genital branch of the genitofemoral nerve  +/- hernia sac
  14. 14. HESSELBACH’S TRIANGLE  Medial aspect of Rectus abdominis muscle  Inferior epigastric vessels  Inguinal ligament
  15. 15. POSTERIOR
  16. 16. MYOPECTINEAL ORIFICE OF FRUCHAUD  Superior  Arch of IOM and TA  Lateral  Iliopsoas muscle  Medial  Lateral edge of RA and Pubic pectin  Iliopubic tract  Spermatic cord  Iliac vessels
  17. 17. TRIANGLE OF DOOM  External iliac vessels  Deep circumflex iliac vein  Femoral nerve  Genital branch of GF nerve
  18. 18. TRIANGLE OF PAIN  Nerves  Lateral femoral cutaneous  Femoral branch of GF nerve  Femoral nerve
  19. 19. CLASSIFICATION Inguinal Hernia
  20. 20. NYHUS CLASSIFICATION SYSTEM Type I INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, small adults INDIRECT HERNIA; internal ring enlarged without impingement on the floor of the inguinal Type II canal; does not extend to the scrotum DIRECT HERNIA; size is not taken into account Type IIIA INDIRECT HERNIA that has enlarged enough to encroach upon the posterior inguinal wall; INDIRECT SLIDING OR SCROTAL HERNIAS are usually placed in this category because they are Type IIIB commonly associated with EXTENSION TO THE DIRECT SPACE; also includes PANTALOON HERNIAS FEMORAL HERNIA Type IIIC RECURRENT HERNIA; modifiers A–D are sometimes added, which correspond TO INDIRECT, Type IV DIRECT, FEMORAL, AND MIXED, RESPECTIVELY
  21. 21. DIAGNOSIS
  22. 22. HISTORY  Groin pain  Duration  Extrainguinal symptoms  Change in bowel habits  Urinary symptoms  Progressiveness  Pressure on nerves  Generalized pressure  Local sharp pains  Referred pain  Scrotum, testicle or inner thigh
  23. 23. PHYSICAL EXAMINATION  Inspection  Standing  Palpation  Inguinal Occlusion test Direct Cough Impulse Indirect Manifested Controlled Dorsum of finger Fingertip
  24. 24. DIFFERENTIAL DIAGNOSIS  Malignancy  Lymphoma  Retroperitoneal sarcoma  Metastasis  Testicular tumor  Primary testicular  Varicocele  Epididymitis  Testicular torsion  Hydrocele  Ectopic testicle  Undescended testicle  Femoral artery aneurysm or pseudoaneurysm  Lymph node  Sebaceous cyst  Hidradenitis  Cyst of the canal of Nuck (female)  Saphenous varix  Psoas abscess  Hematoma  Ascites
  25. 25. IMAGING Inguinal Hernia
  26. 26. Ultrasound CT Scan MRI
  27. 27. MANAGEMENT
  28. 28. CONSERVATIVE MANAGEMENT Aimed at alleviating symptoms such as pain, pressure, and protrusion of abdominal contents Assuming a recumbent position Truss, an elastic belt or brief
  29. 29. EMERGENT REPAIR Incarcerated hernias Strangulated hernias Sliding hernias
  30. 30. INCARCERATED HERNIA  Reasons for incarceration  large amount of intestinal contents within the hernia sac  dense and chronic adhesions of hernia contents to the sac  small neck of the hernia defect in relation to the sac contents
  31. 31. INCARCERATED HERNIA  An incarcerated inguinal hernia without the sequelae of a bowel obstruction is not necessarily a surgical emergency
  32. 32. INCARCERATED HERNIA  Reduction should be attempted before definitive surgical intervention.
  33. 33. INCARCERATED HERNIA  Hernias that are not strangulated and do not reduce with gentle pressure should undergo taxis.
  34. 34. TAXIS  The patient is sedated and placed in a Trendelenburg position.  The hernia sac is grasped with both hands, elongated, and then milked back through the hernia defect.  Pressure applied to the most distal portion of the sac will cause the contents to mushroom and prevent reduction.
  35. 35. STRANGULATED HERNIA  Femoral > Indirect > Direct  Fever, leukocytosis, and hemodynamic instability.  The hernia bulge usually is very tender, warm, and may exhibit red discoloration.  Taxis should not be applied to strangulated hernias as a potentially gangrenous portion of bowel may be reduced into the abdomen without being addressed
  36. 36. OPERATIVE TECHNIQUES Inguinal hernia
  37. 37. ANTERIOR REPAIR NON PROSTHETIC Inguinal hernia
  40. 40. BASSINI REPAIR  Is frequently used for indirect inguinal hernias and small direct hernias  The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament
  41. 41. MCVAY REPAIR  inguinal and femoral canal defects  The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally
  43. 43. ANTERIOR REPAIR PROSTHETIC Inguinal hernia
  45. 45. LAPAROSCOPIC HERNIA REPAIR  Transabdominal Preperitoneal Procedure (TAPP)  Totally Extraperitoneal (TEP) Repair  Indications include bilateral inguinal hernia, recurring hernia, need for early recovery
  46. 46. RECURRENCE  Around 1% for Shouldice repair  Most recurrences are of the same type as the original hernia  Recurrence Factors  Patient  Technical  Tissue
  47. 47. RECURRENCE  Patient factors  malnutrition, immunosuppression, diabetes, steroid use, and smoking.  Technical factors  mesh size, prosthesis fixation, and technical proficiency of the surgeon.  Tissue factors  wound infection, tissue ischemia, and increased tension within the surgical repair
  48. 48. COMPLICATIONS  The overall risk of complications of inguinal hernia repair is low.  Common Complications  Pain, injury to the spermatic cord and testes, wound infection, seroma, hematoma, bladder injury, osteitis pubis, and urinary retention
  50. 50. EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT INGUINAL HERNIA PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES 1. What is the recommended treatment for inguinal hernia?  Mesh repair, Laparoscopic or the Open 2. If laparoscopic mesh repair is the preferred technique for inguinal hernias, what is the recommended laparoscopic technique?  Transabdominal Preperitoneal or Total Extra Preperitoneal 3. Is fixation of the mesh necessary in laparoscopic repair?  No 4. If open mesh repair, what is the recommended technique  Lichtenstein, plug and mesh or Prolene Hernia System
  51. 51. EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT INGUINAL HERNIA PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES 5. What is the recommended treatment for recurrent inguinal hernia?  Mesh repair, either laparoscopic or open method 6. What is the recommended treatment for bilateral inguinal hernia?  Mesh repair, either laparoscopic or open method 7. Is antimicrobial prophylaxis recommended for elective groin hernia surgery?  Not routinely recommended using mesh
  52. 52. THANK YOU