The document discusses complicated hernias, including their definition, epidemiology, classification, clinical presentation, investigations, and treatment options. It highlights the differing presentations and complications of groin hernias, including femoral and obturator hernias, and emphasizes the importance of surgical intervention in cases of obstruction or strangulation. The management of hernias involves careful investigation, resuscitation, and potentially laparoscopic or open surgical repair, particularly in emergency situations.

1. Complicated Hernia
Chea Chan Hooi
General Surgeon
Sibu Hospital

2. Content
• Definition
• Epidemiology
• Classification
• Clinical presentation
• Investigations
• Treatment

3. Definition
• Hernia
• Abnormal exit of tissue/organ through the wall of the cavity in which it
normally resides
• Complicated
• Obstructed
• Strangulated
• Incarcerated
• Recurrent

4. Epidemiology
• 5 - 10% in the US
• IH > FH > others
• Men 8x more likely to develop hernia and 20x more likely to need
repair compared with women
• Women manifest groin hernias at a later age

5. Classification
External
• Ventral
• Epigastric
• Spigelian
• Umbilical
• Umbilical per se
• Paraumbilical
• Groin
• Inguinal
• Femoral
• Obturator
• Incisional
• Dorsal
• Lumbar
• Sciatic
Internal
• Cerebral
• Hiatal

6. Clinical presentation
• Uncomplicated
• Impulse on coughing/straining
• Reducible
• Extent
• Bubonocele - within inguinal canal
• Funicular - exited superficial ring
• Complete inguinoscrotal - into
scrotal sac

7. Complicated
• Obstructed
• Features of intestinal obstruction
• Irreducible
• Strangulated
• Irreducible
• Tender, indurated, erythematous skin
• Sepsis
• Features of intestinal obstruction
• Incarcerated
• Irreducible
• Relatively well
• No features of obstruction/strangulation
• Recurrent
• Evidence of prior repair

9. Investigations

10. • FBC - leukocytosis
• BUSEC - electrolyte derangements, AKI
• ABG - acid-base imbalance
• PT/PTT - sepsis with coagulopathy
• Blood C+S - sepsis
• GSH

12. Management of Complicated Inguinal Hernia
• Resuscitation
• Volume
• Perfusion
• Acid-base disturbance
• Electrolyte imbalance
• Symptomatic relief
• Ryle's tube
• Analgesics
• Antipyretic
• Antibiotics
• Closed loop obstruction
• Strangulation
• Bowel perforation

13. Manual reduction
• Rule out strangulation
• Cold pack for 30 mins
• Adequate analgesia and sedation
• Trendelenburg position
• Patient group
• Adults
• Pressure to fundus of the hernia while guiding the proximal portion into the abdomen through the fascial
defect
• Only 1 - 2 attempts
• Controversial
• Children
• Ipsilateral frog leg position
• Deep ring in infants is more medial, i.e. the canal more vertical
• First choice treatment

15. • Ultrasonography
• Identify the nature of hernia content
• Helps locate the deep ring
• Gives the operator an inside 'view' on the forces & direction for reduction
• Possible complications
• Unrecognised strangulated hernia --> bowel perforation
• Reduction en masse
• Retroperitoneal haematoma

16. Reduction en-masse
• Migration of a hernial sac along
with its entrapped content into
the properitoneal space
• Usually due to forceful reduction
of a hernia
• Although non-visible, the
pathologic process is on-going
• Patient does not improve or
continues to deteriorate after
'reduction'

17. Transferring to another hospital
• Resuscitation
• NG tube
• CBD
• Adequate analgesia
• Blood investigations
• Empirical antibiotics
• Trendelenburg position

18. Surgery
• Anticipate omental & bowel resection
• Mode depends on hernia content involved, degree of contamination,
available equipments & expertise
• Modes
• Open
• Hernioplasty, herniorraphy, herniotomy
• Laparotomy
• Laparoscopic
• Minimal bowel dilatation
• No overt, generalised peritonitis
• Esp. if suspect complicated omentocele

21. Femoral hernia
• About 10% of groin hernias
• More commonly occur in females (gynecoid pelvis)
• More commonly present with complications

22. Problems
• Signs not clear-cut
• Location of fundus tends to vary
• Variety of differential diagnoses -
LN, pseudoaneurysm, saphena
varix, psoas abscess pointing,
soft tissue tumour/abscess
• Commonly present with
complication

23. Management
• Identify complicated FH
• Resuscitate
• Empirical antiobiotics
• Investigations
• Abdominal x-ray
• Ultrasonography
• In ambiguous cases TRO other differentials
• Blood tests
• Surgery
• NO ROLE OF MANUAL REDUCTION

24. Surgery
• Anticipate bowel resection
• Modes
• Laparoscopic
• Open
• High approach
• Better access & visualisation
• Trans-inguinal approach
• Infra-inguinal approach

25. Obturator hernia
• Typically an elderly, frail lady who had lost
significant body fat thus opening up the
obturator foramen
• Pain
• In medial thigh/region of greater trochanter
• Relieved by thigh flexion
• Worsened by lateral rotation & extension of
ipsilateral hip (Howship-Romberg sign)
• Intestinal obstruction
• Sepsis from strangulated bowel +- perforation

26. Diagnosis
• Pre-op: high index of clinical suspicion, notorious to be
missed on x-ray, confirmed on CT scan
• Intra-op: during exploratory laparotomy

27. Treatment
• NO ROLE FOR MANUAL
REDUCTION
• Emergency laparotomy
• Bowel gangrene is common
• Elderly patient with multiple
significant co-morbidities
• Effects of
pneumoperitoneum
• Elective repair
• Laparoscopic or open

28. Conclusion
• Groin hernias are common --> patients presenting with complications
therefore proportionately high
• Potentially life-threatening
• FH & OH might present with diagnostic dilemma
• Surgical exploration, resection of devitalised tissue and repair is the
main-stay treatment
• Laparoscopic repair is feasible in well-selected emergency patients

29. Thank you!
Questions?