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  1. 1. Ellery Ivan E. Apolinario Zamboanga City Medical Center DEPARTMENT OF SURGERY
  2. 2. General Objective:  To present a case of Indirect Inguinal Hernia Specific Objectives: To present a clinical picture of a patient with IIH  To discuss the approach to a patient with IIH  To discuss the management options of a patient with IIH
  3. 3.  EV, a 55 year old  Male  Married  Self-employed  ZamboangaCity.
  4. 4. ChiefComplaint: Inguinoscrotal mass
  5. 5.  2 years PTA, onset of inguino scrotal mass on the right, reducible, with no other associated signs and symptoms.  2 days PTA, inguinoscrotal mass noted but this time associated with pain, dragging sensation and a pain scale of 6/10 non-radiating and irreducible.  A few hours PTA, prompted consult at the ER for persistence of symptoms hence admission.
  6. 6.  No previous surgery and no known allergy to food and drugs
  7. 7. No known Heredo- familial diseases
  8. 8.  has a son and a wife  Smoker  Non-alcohol drinker  A retired driver
  9. 9. General: (-) weight loss Skin: (-) rashes, (-) itchiness, (-) changes of color Head: (-) dizziness, (-) headache Eyes: (-) redness, (-) visual changes, (-) blurring of vision Ears: hearing good, (-) tinnitus, (-) vertigo Nose: (-) nosebleed, (-) nasal congestion, (-) sinus trouble Mouth andThroat: (-) dry lips, (-) bleeding gums Neck: (-) neck pain, (-) stiffness, (-) swollen glands Respiratory: (-) colds Cardiovascular: (-) dyspnea, (-) orthopnea, (-) chest pain, (-) palpitations Gastrointestinal: (-) dysphagia, (-) heartburn, (-) abdominal pain, (-) constipation, (-) diarrhea
  10. 10. Urinary: (-) oliguria, (-) flank pain PeripheralVascular: (-) varicose veins, (-) leg cramps Musculoskeletal system: (-) bone or joint pains and muscle cramps (-) bipedal edema, (-) tremors or involuntary movements Neurologic system: memory good, (-) fainting, (-) numbness and tingling, (-) weakness, paralysis and loss of sensation,(-) involuntary movements Hematologic: (-) anemia, (-) easy bruising or bleeding Endocrine system: (-) excessive sweating, hunger or thirst, (-) polyuria, (-) heat or cold intolerance
  11. 11.  GENERAL SURVEY Conscious, coherent, cooperative , NIRD  VITAL SIGNS Temperature - 36.2 C, Respiration - 22 bpm, Blood pressure - 100/ 60 mmHg and a Pulse Rate - 71 bpm.  SKIN No jaundice noted. No pallor.  HEENT Eyes: Anicteric sclerae. Conjunctivae is pink, , reactive to light. Ears: (-) discharges,With good acuity to whispered voice. Nose: No alar flaring. (-) discharges Throat: Oral mucosa is pink, tongue midline.Tonsils (-) infection / inflamed. Pharynx: (-) exudates  NECK Trachea midline. No palpable lymph nodes.
  12. 12.  THORAX AND LUNGS Thorax are symmetrical. Clear breath sounds. No rales or wheezes noted.  CARDIOVASCULAR SYSTEM AP, NRRR, distinct sounds with no heart murmurs.  ABDOMEN flat, soft, normoactive bowel sound, percussed and revealed a dull sound, palpated with tenderness on hypogastric area, 6 x9 cm.  RECTAL AND GENITALIA No discharges/ulcers noted on genitalia, inguino-scrotal mass on the right, no cyanosis noted, (-) transillumination, 6x7cm.
  13. 13.  EXTREMITIES Warm to touch, no edema, CRT < 2 secs.  MUSCULOSKELETAL No deformities and with good range of motion.  NEUROLOGIC Oriented to time and place, is conscious and has a stable gait.
  14. 14.  Indirect Inguinal Hernia Right, Incarcerated  BASIS: Hx of scrotal mass that was formerly reducible PE: Irreducible scrotal mass with inguinal component, no cyanosis noted. No tachycardia. NABS.
  15. 15. Rule in Rule out 1. Hydrocele -scrotal mass (-) soft fullness within the hemiscrotum (-) transillumination Usually presents with painless scrotal mass 2. Testicular tumor - scrotal mass - age of the patient (-) Painless swelling or nodule of one testicle (-) mass/nodule exclusively within the testis (-) Unilateral or bilateral lower extremity swelling may be present (-) lymphadenopathy (-) weight loss
  16. 16. Rule in Rule out 3.Epidydimitis - scrotal mass (-) acute scrotal pain (-) epididymal pain and inflammation (-) Dysuria, frequency and/or urgency (-) Fever and chills (-) preceded by Urethral discharge (-)Tenderness and induration in the epididymal tail 4. Orchitis - scrotal mass (-) testicular pain and swelling (-) Associated systemic symptoms: (Fatigue, Malaise, Myalgias Fever and chills, Nausea, Headache) (-) Testicular enlargement (-)Tenderness (-) edematous scrotal skin (-) discharges
  17. 17. Rule in Rule out 5. Testicular Torsion - scrotal mass (-) Peak incidence occurs in adolescents aged 13 years (-) acute-onset scrotal discomfort which may occur at rest or may relate to sports or physical activities
  18. 18.  Admitted  Secure consent  NPO  IVF D5lr 1 L at 40 gtts/ min  Labs: cbc, platelet, blood typing  Chest xray and 12 lead ECG for CP evaluation  Meds: Cefoxitin 2 gm IVTT ANST 1 hour before induction  For emergency Hernioplasty right mesh inguinal  Notify OR/ Anesthesiologist  Insert FBC and attach to urine bag collector  Insert NGT
  19. 19.  CBC -hgb 152 -hct 0.45 -rbc 4.64 -wbc 19.7 -plt 284 -bt O+
  20. 20. Subjective Objective Assessment Plan Pain at surgical site Vital Signs: BP- 100/80 T- 37 RR-19 O2 Sat- 97% PR – 68 (-) discharges on surgical site (-) hx of febriles episodes for the past 24 hours S/P Hernioplasty right with mesh inguinal; iih right with incarcerated bowel DAT Hydration Cont. cefoxitin Cont. pressure dressing Advise ambulation
  21. 21.  MGH with home meds of:  1. Cefuroxime 500mg BID x 7 days  2. Celecoxib 200mg BID PRN pain  3. MV tab OD
  22. 22. Indirect Inguinal Hernia Right with incarcerated small bowel; Hernioplasty Right with Inguinal Mesh
  23. 23. Hernia- is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.
  24. 24.  Types of Hernia - Location
  25. 25. follows the tract through the inguinal canal.This results from a persistent process vaginalis. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring, located approximately midway between the pubic symphysis and the anterior iliac spine.The canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.[
  26. 26.  A direct inguinal hernia usually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle.The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon.
  27. 27.  follows the tract below the inguinal ligament through the femoral canal.The canal lies medial to the femoral vein and lateral to the lacunar (Gimbernat) ligament. Because femoral hernias protrude through such a small defined space, they frequently become incarcerated or strangulated.
  28. 28.  Reducible hernia:This term refers to the ability to return the contents of the hernia into the abdominal cavity, either spontaneously or manually.  Incarcerated hernia:An incarcerated hernia is no longer reducible.The vascular supply of the bowel is not compromised; however, bowel obstruction is common.  Strangulated hernia:A strangulated hernia occurs when the vascular supply of the bowel is compromised secondary to incarceration of hernia contents.
  29. 29.  Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect and one third direct.[2]  Indirect inguinal hernias are the most common hernias in both men and women; a right-sided predominance exists.  Femoral hernias (although rare) occur almost exclusively in women because of the differences in the pelvic anatomy.
  30. 30. Any condition that increases the pressure in the intra- abdominal cavity may contribute to the formation of a hernia, including the following:  Marked obesity  Heavy lifting  Coughing  Straining with defecation or urination  Ascites  Peritoneal dialysis  Ventriculoperitoneal shunt  Chronic obstructive pulmonary disease (COPD)  Family history of hernias[16]
  31. 31. Borders of the triangle: 1. Inguinal ligament - forms the inferior margin 2. Edge of rectus abdominis - medial border 3. Inferior epigastric vessels - superior or lateral border
  32. 32. Inguinal canal  Approx. 4 to 6 cm long  situated in the anteroinferior portion of the pelvic basin  Shaped like a cone  begins intra-abdominally on the deep aspect of the abdominal wall, where the spermatic cord passes through a hiatus in the transversalis fascia (in females, this is the round ligament)  This hiatus is termed the deep or internal inguinal ring
  33. 33. Spermatic cord  consists of three arteries, three veins, and two nerves  it contains the pampiniform venous plexus anteriorly and the vas deferens posteriorly, with connective tissue and remnant of the processus vaginalis
  34. 34.  Arteries: testicular artery, deferential artery, cremasteric artery  Nerves: nerve to cremaster (genital branch of the genitofemoral nerve), testicular nerves (sympathetic nerves)  Vas deferens (ductus deferens)  Pampiniform plexus  Lymphatic vessels  Tunica vaginalis (remains of the processus vaginalis)
  35. 35. Inguinal ligament - spans the anterior superior iliac spine to the pubic bone Cooper's ligament - seen as the lateral extension of the lacunar ligament, which is the fanning out of the inguinal ligament as it joins the pubic tubercle Iliopubic tract - originates and inserts in a similar fashion to the inguinal ligament
  36. 36. Inguinal ligament (Poupart's ligament)  is comprised of the inferior fibers of the external oblique aponeurosis.  stretches from the anterior superior iliac spine to the pubic tubercle  serves an important purpose as a readily identifiable boundary of the inguinal canal, as well as a sturdy structure used in various hernia repairs. Cooper's ligament (Pectineal ligament)  lateral portion of the lacunar ligament that is fused to the periosteum of the pubic tubercle  may include fibers from the transversus abdominus, iliopubic tract, internal oblique, and rectus abdominus
  37. 37. Iliopubic tract  often is confused with the inguinal ligament secondary to common origin and insertion points.  forms on the deep side of the inferior margin of the transversus abdominus and transversalis fascia. Inguinal ligament  is on the superficial side of the musculoaponeurotic layer  The shelving edge of the inguinal ligament is a structure that more or less connects the iliopubic tract to the inguinal ligament.
  38. 38. Nyhus Classification System Type I Indirect hernia; internal abdominal ring normal; typically in infants, children, small adults Type II Indirect hernia; internal ring enlarged without impingement on the floor of the inguinal canal; does not extend to the scrotum Type IIIA Direct hernia; size is not taken into account Type IIIB 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 commonly associated with extension to the direct space; also includes pantaloon hernias Type IIIC Femoral hernia Type IV Recurrent hernia; modifiersA–D are sometimes added, which correspond to indirect, direct, femoral, and mixed, respectively • assesses not only the location and size of the defect, but also the integrity of the inguinal ring and inguinal floor • most widely used classifications • is limited by its subjectivity in assessment of distortion of the inguinal ring and posterior floor, especially laparoscopically.
  39. 39. Gilbert Classification System Type 1 Small, indirect Type 2 Medium, indirect Type 3 Large, indirect Type 4 Entire floor, direct Type 5 Diverticular, direct Type 6 Combined (Pantaloon) Type 7 Femoral • requires intraoperative assessment Type 1 - have a small internal ring Type 2 - have a moderately dilated internal ring, < 4 cm Type 3 - have a ring that is greater than 4 cm Type 4 - involved complete disruption of the inguinal floor Type 5 – no more than 2 cm, without complete weakness
  40. 40. ANTERIOR REPAIRS, NONPROSTHETIC BASSINI REPAIR • Recurrence rate - 8.6 % • importance of the Bassini repair lies in the paradigm shift it promoted, which included dissection of the spermatic cord, dissection of the hernia sac with high ligation, and extensive reconstruction of the floor of the inguinal canal • A triple-layer repair is then performed to restore integrity to the floor
  41. 41. A. The transversalis fascia is opened from the internal inguinal ring to the pubic tubercle exposing the preperitoneal fat. B. Reconstruction of the posterior wall by suturing the transversalis fascia (TF), the transversus abdominis muscle (TA), and the internal oblique muscle (IO) (Bassini's famous "triple layer") medially to the inguinal ligament (IL) laterally. BASSINI REPAIR
  42. 42. SHOULDICE REPAIR • principles of the Bassini repair were revitalized, resulting in superior recurrence rates (6%) • its success rates are equivalent to that of tension-free repairs in many studies comparing the two approaches • involve extensive dissection and reconstruction of inguinal canal anatomy • The use of a continuous suture in multiple layers resulted in the dual advantage of distributing tension over several layers and preventing subsequent herniation between interrupted sutures
  43. 43. • Original descriptions of the Shouldice technique involved the use of a stainless steel wire • modern modifications have resulted in the use of a synthetic nonabsorbable suture • Care is taken to avoid injury to any preperitoneal structures, and these are bluntly dissected to mobilize the upper and lower fascial flaps.
  44. 44. THE SHOULDICE REPAIR A. The iliopubic tract is sutured to the medial flap, which is made up of the transversalis fascia and the internal oblique and transverse abdominis muscles. B. This is the second of the four suture lines. After the stump of the cremaster muscle is picked up, the suture is reversed back toward the pubic tubercle approximating the internal oblique and transversus muscles to the inguinal ligament.Two more suture lines will eventually be created suturing the internal oblique and transversus muscles medially to an artificially created "pseudo" inguinal ligament developed from superficial fibers of the inferior flap of the external oblique aponeurosis parallel to the true ligament.
  45. 45. MCVAY (COOPER'S LIGAMENT) REPAIR • advantage is the ability to address both inguinal and femoral canal defects • Recurrence rate 11.2% • Femoral hernias that are approached via a suprainguinal ligament approach, or situations where the use of prosthetic material is contraindicated, are amenable to this type of repair. • Once the cord has been isolated, a transverse incision is performed through the transversalis fascia, thereby entering the preperitoneal space. • A small amount of dissection of the posterior aspect of the fascia is performed to allow mobilization of the upper margin of the transversalis fascia. • The floor of the inguinal canal is then reconstructed to restore its strength. Cooper's ligament is identified medially, and it is bluntly dissected to expose its surface.The upper margin of the transversalis fascia is then sutured to Cooper's ligament.The repair is continued laterally along Cooper's ligament, occluding the femoral canal.
  46. 46. • An essential component of the procedure is the relaxing incision, which helps reduce the considerable amount of tension that normally results. • Before suturing the transversalis fascia to Cooper's and the inguinal ligament, an incision in the anterior rectus sheath is made. • The incision begins at the pubic tubercle and is extended superiorly for approximately 2 to 4 cm. • Potential consequences of the relaxing incision include increased postoperative pain and less likely herniation at the anterior abdominal wall. • Disadvantages of routinely performing the McVay Cooper's ligament repair include elevated recurrence rates due to the tissue-based nature of the operation. • Furthermore, the procedure requires extensive dissection and may result in injury to the underlying femoral vessels.
  47. 47. MCVAY REPAIR
  48. 48. ANTERIOR REPAIRS, PROSTHETIC • mesh herniorrhaphies were developed to circumvent the high recurrence rates of tissue-based repairs and adhere to no-tension principles of effective surgical repair. • The addition of a mesh prosthesis effected a reconstruction of the posterior inguinal canal, without placing tension on the floor itself, hence a tension-free repair, as championed by Lichtenstein.
  49. 49. Medially, the prosthesis is sutured to the anterior rectus sheath 2 cm medial to the pubic tubercle. Laterally, a continuous suture is used to fix the prosthesis to the shelving edge of the inguinal ligament. The tails of the mesh are placed around the cord and secured with an interrupted suture. LICHTENSTEINTENSION-FREE HERNIOPLASTY
  50. 50. PLUG AND PATCHTECHNIQUE • modification of the Lichtenstein repair • In addition to placement of the prosthesis in a similar fashion to the Lichtenstein repair (i.e., the patch), the technique includes placement of a prosthesis (i.e., the plug) through the internal ring • Further modifications have involved shaping the plug into a flower or umbrella configuration, with the apex pointed intra-abdominally, in effect serving as a preperitoneal prosthesis. • In this case, the plug is fixed to Cooper's and the inguinal ligament inferiorly and the internal oblique aponeurosis superiorly.
  51. 51. A. Plug may be created from a flat piece of mesh, or a preformed, commercially available plug is placed in the internal ring. B. Final view of the repair following placement of the plug and patch. A common modification is to use the flat mesh to overlap the plug, after it is placed. PLUG AND PATCHTECHNIQUE
  52. 52.  The definitive treatment of all hernias is surgical repair.  is aimed at alleviating symptoms related to the inguinal hernia, such as pain, pressure, and protrusion of abdominal contents.  Simple maneuvers include assuming a recumbent position, which aids in self-reduction of the hernia.  A truss, an elastic belt or brief that aims to keep the hernia reduced, may also be worn; however, its use does not prevent hernia progression or incarceration.  A truss may provide relief in up to 65% of patients; however, many will use it only intermittently as it does not provide continuous control of the hernia and may actually lead to an increased rate of hernia incarceration.
  53. 53.  conservative management is applied to asymptomatic or minimally symptomatic inguinal hernias.  One study has calculated the cumulative probability of developing a strangulated hernia to be 2.8% at 3 months for an inguinal hernia, and rising to 4.5% after 2 years.  The figures were much higher for development of a strangulated femoral hernia at 3 months and 2 years, 22 and 45%.
  54. 54.  Thank you!