Hernia: An anatomical curse!
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Hernia is one of the commonest surgical disorder due to weakness in the anatomical structures of the region.Understanding the anatomical aspects is therefore pivitol in successfull treatment of this potentially dangerous condition. The presentation provides a road map for understanding and treating hernias.
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Hernia: An anatomical curse!
- 1. HERNIA by Dr. Ketan Vagholkar. MS, DNB, MRCS, FACS Professor of Surgery & Consultant Surgeon
- 2. Surgical Anatomy Of Anterior Abdominal Wall n Fascias n Rectus Sheath n Abdominal Muscles n Inguinal Canal
- 3. Inguinal Canal n Boundaries & Contents n External ring is a triangular n Anteriorly-External oblique aperture in the aponeurosis aponeurosis &internal oblique of the external oblique.It is laterally 1.25 cms above the pubic n Posteriorly-Transversalis fascia tubercle. and conjoined tendon n Superiorly-Conjoined tendon n Deep ring is a U shaped n Inferiorly-Inguinal ligament opening in the transversalis n Contents fascia.It lies 1.25 cms above n In males-spermatic cord and the mid inguinal point. Ilioinguinl nerne. n In Females-round ligament and Ilioinguinal nerve
- 4. Natural Mechanisms Preventing Hernia n Obliquity of the canal n Internal oblique muscle opposite the deep ring n Shutter action of the arched fibres of internal oblique and transversus abdominis n Plugging action of the spermatic cord due to contraction of the cremaster muscle n Sliding valve action of the U shaped internal ring
- 5. Definition of Hernia n Hernia is defined as an abnormal protrusion of viscus or part of viscus through a normal or abnormal opening in the wall of the cavity containing it. n Classification depending on the anatomical site of the hernia. (Inguinal, femoral, epigastric etc.) n Incidence: Inguinal- 73%,Femoral- 17%&Umbilical-8.5%)
- 6. Pathology n Composition n Contents n Sac- Diverticulum of n Intestine-enterocele peritoneum and consists n Omentum-omentocele or of mouth, neck, body and epiplocele fundus. The diameter of n Meckel’s diverticulum- the neck determines the Littre’s hernia outcome. n Circumference of bowel- n Coverings well Richter’s hernia amalgamated hence indistinguishable. n W loop of intestine- Maydl’s hernia
- 7. Natural history n Reducible n Irreducible n Obstructed n Strangulated n Inflammed
- 8. Clinical features of inguinal hernias
- 10. Morbid Anatomy
- 13. Clinical Evaluation n History n Chief complaints (odp) n Complications n Etiology n Treatment taken n Inference from history
- 14. Clinical Evaluation n Physical examination. n Inspection-site,impulse n Palpation- n Getting above n Impulse on coughing n Reducibility-Taxis n Deep ring occlusion test n Invagination test n Tone-Inspection/palpation n Other systems
- 15. Clinical Diagnosis n Site, side, complicated or not, direct or indirect inguinal hernia n Status of tone n Possible etiological factor
- 16. Investigations n Haematological n CBC n Blood sugar (fasting & postprandial) n BUN, creatinine, Electrolytes n Urine examination n Ultrasound of Abd. n ECG n CXR
- 17. Principles of repair n Herniotomy for an indirect sac n Identify n Dissect n Open n Reduce the contents n Transect n Twist, tansfix, ligate & excise the redundant portion n Slit open the distal sac
- 18. Principles of repair n Herniotomy for direct sac n Identify n Dissect around the neck n Purse string suture n Invert the sac and tighten the purse string n Direct sac never to be opened
- 19. Principles of repair n Special cases n Pantaloon hernia n Sliding hernia n Strangulated hernia
- 20. Principles of repair n Herniorrhaphy n Selection of patients n Principles (anatomic considerations) n Types n Bassini’s n Shouldice n Lichtenstein Repair(T abd to Ing Lig with relaxing incision& Ext obl behind the cord) n Other types (Ogilvie’s, Lyttle’s ,skeletonization of cord etc.)
- 21. Principles of repair n Hernioplasty (Open approach) n Patient selection n Types n Mesh plasty n Darning n Material used n Endogenous n Exogenous n Requirements of a mesh
- 22. Requirements of a mesh
- 25. Surgical Aftercare n Avoid straining n Avoid heavy work n Bowel function n Urinary system n Care to be taken for at least 3 months after surgery
- 26. Complications n Intraoperative n Post operative n Infection n Neurological complications n Recurrence n Types n True n False