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hernia 2 .pptx
- 1. Inguinal hernias Dr A.H. ABDUL AZIZ Assistant Professor Department of Surgery, GIMS, Gulbarga
- 2. Surgical anatomy The superficialinguinal ring Triangular aperture in the aponeurosis of the external oblique muscle and lies 1.25 cm above the pubic tubercle. The ring is bounded by a superomedial and an inferolateral crus joined by the criss-crossed intercrural fibres. Normally the ring will not admit the tip of the little finger.
- 3. The deep inguinalring U-shaped condensation of the transversalis fascia and it lies 1.25 cm above the inguinal (Poupart’s) ligament, midway between the symphysis pubis and the anterior superior iliac spine. The transversalis fascia is the fascial envelope of the abdomen and the competency of the deep inguinal ring depends on the integrity of this fascia.
- 4. The inguinal canal In infants, the superficial and deep inguinal rings are almost superimposed and the obliquity of the canal is slight. In adults, the inguinal canal, which is about 3.75 cm long, is directed downwards and medially from the deep to the superficial inguinal ring. WHAT IT TRANSMITS???? In the male, the inguinal canal transmits the spermatic cord, the ilioinguinal nerve and the genital branch of the genitofemoral nerve. In the female, the round ligament replaces the spermatic cord.
- 5. An indirecthernia travels down the canal on the outer (lateral and anterior) side of the spermatic cord. A direct hernia comes out directly forwards through the posterior wall of the inguinal canal. Neck Indirect hernia - lateral to the inferior epigastric vessels, Direct hernia - medial to inferior epigastric vessels except in the saddle-bag or pantaloons type, which has both a lateral and a medial component. Digital control of the internal ring may help in distinguishing between an indirect and a direct inguinal hernia
- 6. Indirect Versus Directinguinal hernias Indirect is the most common form of hernia and its usually congenital due to patent processus viginalis Direct usually acquired occur in old men with weak abdominal muscles.
- 7. Indirect inguinal hernia Mostcommon form of hernia Most common in the young age More common on the right side in the male. Because associated with the later descent of the right testis and a higher incidence of failure of closure of the processus vaginalis. In adult males, 65% of inguinal hernias are indirect and 55% are right-sided. The hernia is bilateral in 12% of cases.
- 8. Types of indirectinguinal hernia Bubonocele-the hernia is limited to the inguinal canal. Funicular-the processus vaginalis is closed just above the epididymis. The contents of the sac can be felt separately from the testis, which lies below the hernia. Complete (synonym: scrotal). A complete inguinal hernia is rarely present at birth but is commonly encountered in infancy. The testis appears to lie within the lower part of the hernia.
- 9. Direct inguinal hernia In adult males, 35% of inguinal hernias are direct. At presentation, 12% of patients will have a contralateral hernia in addition,and there is a fourfold increased risk of future development of a contralateral hernia if one is not present at the original presentation. A direct inguinal hernia is always acquired. The sac passes through a weakness or defect of the transversalis fascia in the posterior wall of the inguinal canal.
- 10. Dual (synonym:saddle-bag, pantaloon) hernia This type of hernia consists of two sacs that straddle the inferior epigastric artery, one sac being medial and the other lateral to this vessel. The condition is not rare and is a cause of recurrence, one of the sacs having been overlooked at the time of operation.
- 11. Predisposing: All hernias occurat the site of WEAKNESS OF THE ABDOMINAL WALL which are acted on by repeated INCREASE in abdominal pressure
- 12. Repeated INCREASE inabdominal pressure is usually due to Chronic cough Straining Bladder neck or urethral obstruction Pregnancy Vomiting Sever muscular effort Ascitic fluid
- 13. Inguinal hernia History: 1.Age ( young vs. old) 2. Occupation ( nature ?? ) 3. Local symptoms: Swelling, discomfort and pain 4. Systemic symptoms: if there is obstruction or strangulation 5. Precipitating factors
- 14. Inguinal hernia Examination: 1.Inspection for site, size, shape, color and extent. 2. Palpation for surface, temp, tenderness, composition and reducibility. 3. Expansible cough impulse. 4. General exam: for common causes of increase intra abdominal pressure
- 15. Differential diagnosis inthe male In males the differential diagnosis includes the following: • vaginal hydrocele • encysted hydrocele of the cord • spermatocele • femoral hernia • incompletely descended testis in the inguinal canal – an inguinal hernia is often associated with this condition • lipoma of the cord – this is often a difficult but unimportant diagnosis and it is usually not settled until the parts are displayed by operation. Note- Examination using finger and thumb across the neck of the scrotum will help to distinguish between a swelling of inguinal origin and one that is entirely intrascrotal.
- 16. Differential diagnosis inthe female • hydrocele of the canal of Nuck – this is the most common differential diagnostic problem • femoral hernia
- 17. Indirect Versus Directinguinal hernias Direct Inguinal Hernia Indirect Inguinal Hernia Bulge from the posterior wall of the inguinal canal Pass through inguinal canal. Cannot descent into the scrotum. Can descend into the scrotum. Medial to inferior epigastric vessels. Lateral to inferior epigastric vessels. Reduced: upward, then straight backward. Reduced: upward, then laterally and backward. Not controlled: after reduction by pressure over the internal (deep) inguinal ring. Controlled: after reduction by pressure over the internal (deep) inguinal ring. The defect may be felt in the abdominal wall above the pubic tubercle. The defect is not palpable (it is behind the fibers of the external oblique muscle). After reduction: the bulge reappears exactly where it was before. After reduction: the bulge appears in the middle of inguinal region and then flows medially before turning down to the scrotum. Common in old age. Common in children and young adults.
- 18. Treatment Operation isthe treatment of choice. It must be remembered that patients who have a bad cough from chronic bronchitis should not be denied an operation, for these are the very people who are in danger of developing a strangulated hernia. In adults, local,epidural or spinal, as well as general anaesthesia, can be used
- 19. Inguinal herniotomy, whichentails Dissecting out and opening the hernial sac Reducing any contents Transfixing the neck of the sac and removing the remainder. It is employed either by itself or as the first step in a repair procedure (herniorrhaphy). By itself it is sufficient for the treatment of hernia in infants, adolescents and young adults.
- 20. Herniotomy and repair(herniorrhaphy) (1) Excision of the hernial sac (2) Repair of the stretched internal inguinal ring and the transversalis fascia (3) Reinforcement of the posterior wall of the inguinal canal. (4) must be achieved without tension resulting in the wound and various techniques exist to achieve this, e.g. Shouldice operation, fascial flaps or mesh implants.
- 21. Excision of thehernial sac (adult herniotomy) An incision the skin and subcutaneous tissue 1.25 cm above and parallel to the medial two-thirds of the inguinal ligament. In large, irreducible hernias the incision may be extended laterally or into the upper part of the scrotum. After dividing the superficial fascia and securing haemostasis, the external oblique aponeurosis and the superficial inguinal ring are identified.
- 28. The externaloblique aponeurosis is incised in the line of its fibres and the structures beneath carefully separated from its deep surface before completing the incision through the superficial inguinal ring. Ilioinguinal nerve is safeguarded. Opening of inguinal canal Separation of upper leaf of the external oblique muscle from the internal oblique muscle Separation of the lower leaf from the contents of the inguinal canal until the inner aspect of the inguinal ligament is seen. The cremasteric muscle fibres may be divided longitudinally to display the spermatic cord,
- 29. Excision of thesac The indirect sac may be distinguished as a pearly white structure lying on the outer side of the cord and, when the internal spermatic fascia has been incised longitudinally, it can usually be dissected out and then opened between artery forceps. Variations in dissection If the sac is small it can be freed in toto. If it is of the long, funicular or scrotal type, or is extremely thickened and adherent, the fundus must not be sought because in doing so the blood supply to the testis may be compromised. The sac is freed within the inguinal canal and divided circumferentially such that the fundus remains in the scrotum. Care must be taken to avoid damage to the vas and spermatic artery when freeing the sac posteriorly. An adherent sac can be separated from the cord by first injecting saline under the posterior wall from within (hydrodissection). A similar tactic is employed when dissecting the gossamer sac of infants and children.
- 30. Reduction of contents Intestineor omentum is returned to the peritoneal cavity.Omentum is often adherent to the neck or fundus of the sac: if adherent to the neck it is freed and if adherent to the fundus of a large sac it may be transfixed, ligated and cut across at a suitable point. The distal part of the omentum, like the distal part of a large scrotal sac, can be left in situ (the fundus should, however, not be ligated).
- 31. Isolation and ligationof the neck of the sac. Whatever type of sac is encountered, it is necessary to free the neck by blunt dissection until the parietal peritoneum can be seen on all sides. The dissection is considered complete only when the extraperitoneal fat has been encountered and the inferior epigastric vessels have been seen on the medial side. It used to be considered essential to open the sac to ensure that no bowel or omentum was adherent to the neck. If the sac is obviously empty, it is sufficient to simply reduce it, close the internal ring and perform a herniorrhaphy if required. If the sac is opened, all contents should be reduced and the neck transfixed as high as possible before excising the sac.
- 32. Repair of thetransversalis fascia and the internal ring When the internal ring is weak and stretched and the transversalis is bulging, the repair should include a technique of narrowing the deep ring, e.g. the Lytle method of narrowing the ring with lateral displacement of the cord, The Shouldice method, whereby the ring and fascia are incised and carefully separated from the deep inferior epigastric vessels and extraperitoneal fat before an overlapping repair (‘double breasting’) of the lower flap behind the upper flap is performed. In the classic Shouldice operation, a third and fourth layer of tension-free suturing, using monofilament materials, polypropylene, polyamide or wire, are placed between the internal oblique aponeurosis arch and the inguinal ligament.
- 33. Reinforcement of theposterior inguinal wall This is achieved by suturing without tension the tendinous aponeurotic arch of the internal oblique to the undersurface of the inguinal ligament and to the pubic tubercle. The Lichtenstein tension-free hernioplasty involves placement of an approximately 16 × 8 cm (tailored to the individual patient’s requirements) mesh as an extra lamina, anterior to the posterior wall and overlapping it generously in all directions, including medially over the pubic tubercle
- 34. Other historicaltechniques, which should now be abandoned because of poor results, include overlapping the external oblique behind the cord (making it lie subcutaneously). Special care is needed to avoid excessive narrowing of the new external ring, which could jeopardise the vascular supply to and the venous return from the testis. Completion of operation If desired, the cremasteric muscle can be reconstituted: the external oblique is directly sutured or overlapped, leaving a new external ring that should accommodate the tip of a finger.
- 39. Truss Truss may beused when operation is contraindicated or when operation is refused. A rat-tailed spring truss with a perineal band to prevent the truss slipping will, with due care and attention, control a small or moderately sized inguinal hernia. A truss must be worn continuously during waking hours, kept clean and in proper repair and renewed when it shows signs of wear. It must be applied before the patient gets up and while the hernia is reduced.
- 40. Tx- direct hernia The principles of repair of direct hernias are the same as those of an indirect hernia, with the exception that the hernia sac can usually be simply inverted after it has been dissected free and the transversalis fascia reconstructed in front of it. This reconstruction of the posterior wall of the inguinal canal should be undertaken by the Shouldice repair or by using a mesh implant according to the Lichtenstein technique.
- 41. Laparoscopic herniorrhaphy Minimallyinvasive techniques have been developed for the treatment of inguinal hernias. Two techniques are described, a transabdominal approach (TAPP) and a preperitoneal approach (TEP). The TAPP approach establishes a pneumoperitoneum and places a synthetic mesh preperitoneally by dissecting the peritoneum off the hernial orifices and positioning the mesh beneath the peritoneum before closing the peritoneum over the mesh. The TEP approach is completely preperitoneal. The preperitoneal plane is opened by either balloon dissection or direct dissection via a paraumbilical incision. The hernial orifices can be identified bilaterallly and any hernia sac reduced. Placing a large mesh over the hernial orifices.
- 42. TAPP repairsas the incidence of complications is higher than with the TEP repair. TEP repair is technically more difficult to perform and is associated with a longer learning curve. Laparoscopic repairs can be applied to primary, bilateral and recurrent inguinal hernias as well as to femoral hernias.
- 43.