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Hernia surgery lecture mbbs Maharashtra.pptx
- 1. -Dr.Dnyanoba S. Holambe. M.S.;D.N.B.(Surgery). HERNIA
- 2. HERNI A • PROTRUSION OFA VISCUS OR A PART OF VISCUS THROUGH A NORMAL OR ABNORMAL OPENING IN TH E WALL S OF IT S CONTAINING CAVITY
- 3.
- 4. • MOST COMMONHERNIA (BOTH IN MALES & FEMALES) INDIRECT • FEMORAL HERNIA IS COMMON IN FEMALES • DIRECT HERNIA IS ABSENT IN FEMALES & CHILDREN IN FEMALES PELVIS IS TILTED ANTERIORLY APEX & BASE OF HSSELBACH TRIANGLE AT THE SAME LEVEL OBLITERATEDLESS CHANCE
- 5. PRESENTING COMPLAINTS 1.SWELLING • 1.Duration • 2. Onset: Sudden/incidious • 3. Site of start: • From groin to scrotum (hernia) • From scrotum to groin (hydrocele and varicocele) • 4. Aggravating factors: • – On straining • – On standing • – On coughing • 5. Relieving factors: • – By lying down • – Manually by himself • 6. Associated with pain: Usually painless
- 6. 2.PAIN • PAIN= DRAGGING& ACHING TYPE Appears b4 Increase with time the swelling Subsides when it is fully formed
- 7. HISTORY SUGGESTIVE OFCOMPLICATIONS • Irreducibility • severe pain in the groin over the swelling • colicky abdominal pain, abdominal distension, vomiting, • constipation
- 8. COLICKY ABDOMINAL PAIN •SYMPTOMS OF OBSTRUCTION VOMITING •BILIOUS •FAECAL (USUALLY) ABDOMINAL DISTENSION ABSOLUTE CONSTIPATION
- 9. PAS T HISTOR Y • TB BA •PREVIOUS SURGERY •Damage to ilioinguinal nerve weak abdominal wall DIRECT hernia APPENDICECTOM Y •Same side •Opposite side RECURRENT HERNIA
- 10. FAMILY HISTOR Y • CONNECTIVETISSUE DISORDERS
- 11. PERSONA L HISTOR Y • History ofSmoking: • Smoking leads to chronic bronchitis • Collagen deficiency occurs in smokers.
- 12.
- 13. INSPECTIO N • • • • • • • • • • • • • Patient in standingposition 1. Site 2. Size 3. Shape 4. Extent 5. Surface 6. Skin over the swelling 7. Visible peristalsis 8. Cough impulse 9. Draining lymph nodes 10. Penis 11. Urethral meatus 12. Opposite scrotum
- 14.
- 15. POSITIO N & EXTEN T • Inguinalhernia above the inner part of inguinal ligament Congenital (complete) Extend in to scrotum Inguinal hernia acquired (funicular) Stops above testis
- 16. POSITION & EXTENT • Femoralhernia starts below the inginal ligament and ascend over it
- 17. SKIN OVER THE SWELLING •Uncomplicated=normal • Strangulated=reddened • Truss 4 long time=discolouration, due to deposition of hemosiderin streaks, • Scar=recurrence • Wide irregular puckered=wound infectionrecurrence
- 18. PALPATION • 1. Temperature •2. Tenderness • 3. Site • 4. Size • 5. Shape • 6. Extent • 7. Surface • 8. Skin over the swelling • 9. Consistency • 10. Reducibility • 11. Get above the swelling • 12. Cough impulse • 13. Invagination test • 14. Ring occlusion test • 15. Zieman's technique.
- 19. GET ABOVE THE SWELLIN G • DISTINGUISHB/W INGUINAL & INGUINOSCROTAL SWELLING • NO USE IN FEMORAL HERNIA ROOT OF SCROTUM IS HELD B/W THUMB IN FRONT & OTHER FINGERS BEHIND THE SWELLING IN AN ATTEMPT TO GET ABOVE THE SWELLING
- 20. CONSISTENC Y • DOUGHY &GRANULAR- OMENTUM=OMENTOCELE • ELASTIC- INTESTINE=ENTEROCELE • TENSE & TENDER- STRANGULATED HERNIA
- 21. EXPANSILE IMPULSE ON COUGHING • STANDINGPOSITION • ABSENT IN CASE OF STRANGULATED & INCARCERATED HERNIA 1. MOMENTARY BULGE IN SUPERFICIAL RING ON COUGHING 2. ROOT OF SCROTUM B/W INDEX FINGER & THUMB IS SEPARATED ON COUGHING
- 22.
- 23. EXPANSIL E IMPULSE IS ALSOPRESEN T IN • Meningocele •Laryngocele • Empyema necessitans
- 24. ZEIMANN’S TECHNIQUE • Distinguish b/wdirect, indirect or femoral hernia • Can be used only when the swelling is completely reduce when there is no visible swelling Index finger deep inguinal ring (1/2 “ above mid inguinal point) (superomedial to pubic tubercle) (4cm blw & lateral 2 pubic tubercle) Middle finger superficial inguinal ring Ring finger saphenous opening Hold the nose & blow or cough
- 25. ZEIMANN’S TECHNIQUE Indirect inguinal hernia Directinguinal hernia Femoral hernia Impulse on Index finger Middle finger Ring finger
- 26. REDUCIBILIT Y • Reduces onlying down • Using TAXIS direct hernia Relaxes superficial inguinal ring + oblique muscles • Flexes the thigh • Adduct the thigh • Rotate internally • Reduces with gurgling=>ENTEROCELE Difficult to reduce initially but last part slips of easily • First part reduces easily last part difficultomentocele
- 27. INVAGINATION TES T • Afterreduction of hernia in recumbent position • Using little finger rt. Hand side for rt. Side lt. hand side for lt. side • Invaginate skin 4m the bottom of scrotum & the little finger is pushed to palpate pubic tubercle • Finger is then rotated & pushed further up in to superficial inguinal ring • Nail will be against spermatic cord pulp will feel walls of ring • Normal ring transmits only tip of finger ,>1 finger}abnormally large
- 28.
- 29.
- 30. RING OCCLUSION TES T •Swelling appears even when deep ring is occluded=direct hernia • No swelling when deep ring is occluded = indirect hernia
- 32. PERCUSSIO N • Resonant=enterocele • Dull=omentum/extraperitoneal fatty tissue
- 33.
- 34. EXAMINATION OF TESTIS ,SPERMATIC CORDS& EPIDIDYMIS • Testis traction test: pull testis downwards encysted hydrocele – descends Slightly & become fixed inguinal Hernia-cant be fixed
- 35. EXAMINATION OF TONE OFABDOMINAL • Inspectionprotrusion of lower abdominal wall • Malgaigne’s bulging: • oval shaped b/l bulge on straining above & parallel to medial ligament • weakness of abdominal wall • DIRECT HERNIA • HERNIOPLASTY IS REQUIRED MUSCLE S half of inguinal
- 36.
- 37. MALGAGNES BULGING • Heador leg raising test: to test for abdominal muscle tone & malgaignes bulging
- 38. SYSTEMI C EXAMINATION • RESPIRATORY SYSTEM • R/O •C/C BRONCHITIS ,TB • ABDOMEN • MASS • ASCITES
- 39. • Abdominal examination •Respiratory system • Urinary systems • Per rectal examination
- 40. PER- RECTAL EXAMINATION • 1. BenignProstate hypertrophy—micturition difficulty • 2.Malignant obstruction • 3. Chronic fissure—constipation
- 41. • Diagnosis • •Side—right/left • • Type—indirect/direct • • Inguinal—femoral • • Complete/Incomplete • • Complicated/Uncomplicated • • Content—enterocele/omentocele
- 42. DIFFERENTI AL DIAGNOSIS • 3. Cloquet’snode • 5. Femoral aneurysm Femoral Hernia • 1. Inguinal hernia • 2. Saphenavarix • 4. Lipoma • 6. Psoas abscess Inguinoscrotal Swelling • 1. Encysted hydrocele of cord • 2. Varicocele • 3. Lymphvarix • 4. Diffuse lipoma of cord • 5. Inflammatory thickening of cord Inguinal Swelling • 1. Enlarged lymph nodes • 2. Undescended testis • 3. Lipoma • 4. Femoral hernia • 5. Saphena varix • 6. Psoas abscess • 7. Femoral aneurysm
- 43. DIFFERENTIAL DIAGNOSIS In females • hydroceleof the canal of Nuck – In males • Hydrocele – infantile/encysted/large vaginal/ • Undescended testis • Femoral hernia • Lipoma of the cord • Hydrocele of the canal of nuck (in females) • Inguinal lymph node enlargement • Groin abscess this is the most common dif- ferential diagnostic problem • femoral hernia.
- 44. INVESTIGATION S • I. Routine •• Hemoglobin • • Bleeding time/Clotting time • • Total count, differential count, ESR • • Urine—albumin, sugar deposits • • Blood—urea, sugar • • Blood grouping/typing—for irreducible hernia/huge hernia • II. Anesthetic Purpose • • X-ray chest (Chronic TB, Asthma—precipitate hernia) • • ECG all leads • III. USG Abdomen and Pelvis • • In old age group—to find benign prostate hyperplasia calculate post-voidal residual urine. If >100 ml it is significant • • To find any mass
- 45. TREATMEN T • TREATMENT • Treatthe precipitating cause of hernia first. • 1. Benign prostate hypertrophy • 2. Tuberculosis • 3. Stop smoking • Conservative management • indicated only in cases of very old man with direct hernia; since there is no chance of obstruction. • TRUSS • surgery
- 46. TRUS S • Not Curativefor hernia. • It is a special belt devised to keep the hernia reduced at the deep ring or Hesselbach triangle for those who are unfit or unwilling for surgery • Hernia should be reducible to • Contraindicated • cases of irreducible hernia, • undescended testis, • associated huge hydrocele, • unintelligent people. wear a truss.
- 47. TAXI S • Supine hip& knee flexed hip internally rotated • Contents are pushed with one hand directed with the other
- 48. TREATMEN T • Surgery= treatmentof choice • Under LA/GA/spinal/epidural Hernioplasty surgery herniorraphy
- 49. Herniorraphy(strenghthenin g of posteriorwall) • 1. Original Bassini • 2. Modified Bassini • 3. McVay’s • 4. Shouldice Hernioplasty (prosthetic repair ) • 1. Lichtenstein • 2. Gilbert’s plug • 3. Prolene hernia system • 4. Laparoscopic mesh repair • 5. Stoppas repair
- 50. HERNIORRHAPH Y • 1. Herniotomy •2. Narrowing of the deepring with 2'0 prolene (Lytle'sRepair) • 3. Approximation of conjoint tendon with inguinal ligament using 1‘ polypropylene material
- 51. In indirect inguinalhernia HERNIOTOM Y • Dissecting out and opening of hernia sac ,reducing any contents ,transfixing neck of sac & removing the remainder • NO NEED TO OPEN UP CANAL IN CHILDREN BECAUSE SUPERFICIAL AND DEEP RING ARE SUPERIMPOSED ……THERE FORE NO NEED • HENCE DONE ALONE IN CHILDREN,ADOLESCENT OF REPAI R
- 53. PROCEDUR E • ANAESTHESIA: spinalor G/A • Incision is made parallel to medial 2/3rd of inguinal ligament about 1.25 cm above inguinal ligament • After dividing superficial fascia and securing hemostasis • Identify external oblique muscle & superficial inguinal ring • External oblique Apo neurosis is incised in the line of its fibers and is reflected above and below.thus visualize inguinal ligament • Ilioinguinal nerve is thus identified and preserved
- 54. • Herniotomy =ligation & excision of sac only • Herniorraphy = herniotomy + repair of posterior wall • Hernioplasty= herniotomy + reconstruction of posterior wall with prosthetics
- 55. HERNIORRHAPH Y • HERNIOTOMY+ REPAIROF THE POSTERIOR WALL OF INGUINAL CANAL BY APPOSING CONJOINED MUSCLE TO THE INGUINAL LIGAMEN T • INDICATION • IN ALL INDIRECT HERNIA EXCEPT IN CHILDREN • IN ADULTS WITH GOOD MUSCLE TONE
- 56. BASSIN I REPAI R • Is frequentlyused for indirect inguinal hernias and small direct hernias • The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to ligament the inguinal
- 57. BASSINI REPAIR • The conjoinedtendon is retracted upward • the aponeurosis of the transversus abdominis muscle is approximated to the iliopubic tract that lies adjacent to the inguinal ligament with several interrupted 3-0 silk sutures. • The second layer of the repair involves suturing the conjoined tendon to the inguinal ligament with interrupted 2-0 silk sutures. • This suture line extends from the pubic tubercle to the medial border of the internal ring.
- 58. MODIFIED BASSINIS REPAIR • Mostcommonly used EARLIER • Using non absorbable monofilament interrupted suture material strengthening of posterior wall of inguinal canal approximation of conjoint tendon to inguinal ligament • Nonsorbable adequate tensile strength for about 6 months • Monofilamentpolyfilament has crevices=infn • Interrupted continuous suture= decrease blood supply interfere with healing
- 59. SHOULDICE REPAIR • With ano. 15 scalpel an incision is made in the transversalis fascia. This incision is extended from the internal ring to the pubic tubercle. • The repair involves placing four lines of sutures.
- 60. SHOULDICE REPAIR • The firstsuture line • is started at the pubic tubercle using 3-0 continuous polypropylene, and the white line is approximated to the free edge of the inferior transversalis fascial flap. 2nd • The suture line : • At the internal ring the suture is tied and then continued medially by approximating the free edge of the superior flap to the shelving edge of the inguinal ligament. When the pubic tubercle is reached, the suture is tied and divided.
- 61. SHOULDICE REPAIR • The thirdsuture line is started at the level of the internal ring where the conjoined tendon is approximated to the inguinal ligament and tied when the pubic tubercle is reached. • Using the same suture, the fourth suture line attaches these same structures to one another and istied at the level of the internal ring.
- 62. SHOULDICE REPAIR • The cordis replaced within the inguinal canal, and the external inguinal aponeurosis isreapproximated with continuous 2-0 absorbable sutures
- 66.
- 67. DARNING • • Atype of herniorrhaphy which is done by suturing the conjoined tendon with inguinal • • The suture ligament using 1 prolene without tension. material appears like mesh due to multiple crossings.
- 68. HERNIOPLAST Y • SOME FORMOF supportive MATERIAL IS USED TO STRENGTHEN POSTERIOR ABDOMINAL WALL Synthetic non absorbable prolene, Dacron are used SYNTHETI C HERNIOPLAST Y Tensor fascia lata,temporal fascia,skin BIOLOGICAL
- 69. INDICATION FORHERNIOPLAST Y • Directhernia, • Indirect hernia with poor muscle tone • Recurrent hernia • Re-recurrent hernia • Incisional hernia • Old age • Sliding hernia
- 70. COMPLICATION • Mesh extrusion •Foreign body reaction • infection
- 71. PRINCIPL E • Size ofmesh >size of defect • Attached above & below to conjoint tendon & inguinal ligament/abdominal wall using non absorbable sutures • Haemostasis, reduce risk of infection
- 72. TYPE S OF MES H REPAI R • 1.In lay mesh • 2. On lay mesh • 3. Nyhus preperitoneal mesh repair • 4. Stoppa procedure • 5. Gilbert mesh repair • 6. Lichtenstein’s method • 7. TAPP • 8. TEP
- 74. ONLAY MESH METHOD: • repairby placing mesh in front…..using monofilament non absorbable suture material….above to conjoint tendon & below to inguinal ligament
- 75. INLAY MES H METHOD • meshdeep to conjoint tendon
- 76. NYHUS PREPERITONEAL MESH REPAIR •Broad mesh is kept in the preperitoneal space in b/l direct or recurrent hernia
- 77. LICHTENSTE IN TENSION FREE MESH REPAI R • Lessrecurrence • Cord is covered with mesh and is sutured as in onlay method
- 78.
- 79. LAPAROSCOPI CHERNI A REPAI R • Transabdominal PreperitonealProcedure (TAPP) • Totally Extraperitoneal (TEP) Repair • Indications include bilateral inguinal hernia, recurring hernia, need for early recovery
- 81.
- 82.
- 83.
- 84. COMPLICATIONS OF HERNI A REPAI R IMMEDIATE 1.Injury to the LATE 1. Recurrence 2. Numbness over the local region if the nerve was cut during surgery EARLY 1. Urine retention blood vessels 2. 3. 4. Hematoma Infection Periostitis of pubic tubercle (as (inferior epigastric and femoral) 2. Injury to bowel and the stitch is taken from periosteum) 5. Postherniorrhaphy hydrocele (due to obstruction of lymphatics At deep ring when narrowed tightly) bladder 3. Injury to ilioinguinal and iliohypogastric nerves 4. Injury to cord structures
- 85.
- 86. INGUINAL HERNIA • ANATOMY Superficial inguinalring: triangular opening in aponeurosis of external oblique muscle 1.25 above pubic tubercle normally ring does not admit tip of little finger
- 87. • Deep inguinalring: u shaped defect in transversalis fascia 1.25cm above mid inguinal point • Inguinal ligament: It is formed by the lower border of the external oblique aponeurosis which is thickened and folded backwards on itself , extending from anterior superior iliac spine to pubic tubercle.
- 88. • Inguinal canal: It is an oblique passage in lower part of abdominal wall, 4 cm long, situated above the medial ½ of inguinal ligament, extending from deep inguinal ring to superficial inguinal ring.
- 89. BOUNDARIE S • Anteriorly: externaloblique muscle fleshy fibres of internal oblique lateral 1/3rd skin & superficial fascia • Posteriorly: transversalis fascia conjoint tendon reflected part of inguinal • Floor inguinal ligament • Roof fibres of internal oblique ligament
- 90. 1, External obliquefascia (fascia of Gallaudet); 2, External oblique aponeurosis; 3, Internal oblique muscle; 4, Transversus abdominis muscle and its aponeurosis; 5, Transversalis fascia anterior lamina (third layer); 6, External spermatic fascia; 7, Cooper's ligament; 8, Pubic bone; 9, Pectineus muscle; 10, Possible union of transversalis fascia laminae; 11, Transversalis fascia posterior lamina (second layer); 12, Vessels (second space); 13, Peritoneum (first layer); 14, Space of Bogros (first space); 15, Preperitoneal fat; 16, Transversus abdominis aponeurosis and anterior lamina of transversalis fascia; 17, Femoral artery; 18, Femoral vein. TONY 2010 MBBS
- 92. CONTENTS OF INGUINALCANAL SPERMATIC CORDIN MALE • Vas deferens • Artery to vas • Testicular & cremasteric artery • Pampiniform plexus • Remains of processus vaginalis ROUND LIGAMENT FEMALE IN ILIO INGUINAL NERV E • Genital branch of genitofemoral nerve • Sympathetic plexus • lymphatics
- 93.
- 94.
- 95. DEFENCE MECHANISM OF INGUINAL CANAL •Obliquity of inguinal canal • Arching of conjoint tendon • Shutter mechanism of internal oblique • Ball valve mechanism due to contraction of cremasteric muscle • Slit valve mechanism due to contraction of external oblique muscle • hormone
- 96. HASSELBACHS TRIANGLE The boundaries ofthe inguinal triangle are as follows • Medial: Lower 5 cm of the lateral border of the rectus abdominis muscle. • Lateral: Inferior epigastric artery. • Inferior: Medial half of the inguinal ligament. • The floor of the triangle is covered by the peritoneum, extraperitoneal transversalis. tissue, and fascia
- 97. ETIOLOG Y • STRAINING C/C CONSTIPATION (HABITUAL,STRICTURE) URINARYPROBLEMS OLD AGE =BPH, Ca prostate YOUNG AGE=STRICTURE URETHRA VERY YOUNG=PHIMOSIS,MEATAL STENOSIS LIFTING OF HEAVY WEIGHT • C/C COUGH =T.B, B.A, C/C BRONCHITIS • OBESITY • PREGNANCY • SMOKING • ASCITES
- 98. ETIOLOG Y • APPENDICECTOMY McBURNEYS INCISION DESTROYILIO INGUINAL NDIRECT INGUINALHERNIA • FAMILIAL COLLAGEN DISORDER • CONGENITAL PREFORMED SAC (REMAINS OF PROCESSUS VAGINALIS)
- 99. PART S OF A HERNI A •SAC • COVERING OF SAC • CONTENTS OF SAC
- 100. CONTENTS OF SAC • OMENTOCELE: omentum….easyto reduce initially,…but difficult later • ENTEROCELE: usuaslly SI,….difficult to reduce initially…easy later • RICHTERS HERNIA :a portion of circumference of bowel • LITTRE’S HERNIA: meckels diverticulum • CYSTOCELE :bladder • Ovary,fallopian tube • Fluid :ascitic, blood from strangulated hernia, from congested bowel
- 102.
- 103. CLINICAL CLASSIFICATION • REDUCIBLE HERNIAcontents can be reduced by the patient or surgeon expansile impulse on coughing
- 104. • IRREDUCIBLE HERNIA can’tbe reduced …due to adhesions b/w contents and sac…or due to crowding irreducibility + no other symptoms}OMENTOCELE Irreducibility predisposes to strangulation
- 105. OBSTRUCTED HERNIA: bowel is obstructed…but blood supply is good
- 106. INCARCERATED HERNIA that thelumen of that portion of the colon occupying a hernial sac is blocked with faeces. In this case, the scybalous contents of the bowel should be capable of being indented with the finger, like putty. In incarcerated hernia, sac and contents are densely adherent to each other (contents are fixed to sac). It is always irreducible; often obstructed but may not be strangulated.
- 107. STRANGULATED HERNIA bloodsupply is impaired ISCHAEMIAGANGRENE OF INTESTINE TENDERNESS…. TENSE SAC NO IMPULSE ON COUGHING FEATURE S OF INTESTIN AL OBSTRUCTIO N
- 108. • INFLAMMED HERNIA inflammationof contents appendicitis,salpingitis of hernia sac
- 109.
- 110. TYPES OF INGUINAL HERNIA Throughhesselbachs triangle in posterior wall of inguinal canal (medially by lateral border of rectus sheath,below by inguinal ligament,laterally by inferior epigastric artery) Direct Inguinal hernia Through deep ring along spermatic cord,lateral to inferior epigastric artery with indirect
- 111. Indirect inguinal herniaDirect inguinal hernia 1.any age from childhood to adult 1.Common in elderly 2.Occurs in a pre-existing sac 2.Always acquired 3. Protrusion through the deep ring; herniation occurs later 3.Herniation through posterior wall of the inguinal canal 4.Pyriform /oval in shape; descends obliquely and downwards 4.Globular/round in shape; descends directly forward bulge 5.Can become complete by descending down into the scrotum 5.Rarely descend down into the scrotum 6.Sac is antero-lateral to the cord 6.Sac is posterior to the cord 7.Ring occlusion test no impulse after occluding the deep ring 7. impulse even after occluding the deep ring 8.Invagination test shows impulse on the tip of the little finger 8.Invagination test shows impulse on the pulp of the little finger 9.Zieman’s test impulse on the index finger 9.impulse on the middle finger 10.Commonly unilateral may be bilateral 10.Commonly bilateral 11.Obstruction/strangulation areTO cN o Y m 201m 0 M o BB n S 11.Rare but can occur
- 113. Deep ring Weakpost wall of inguinal canal (hesselbachs triangle) Whole of inguinal canal Part of inguinal canal Superficial ring Superficial ring DIRECT HERNIA INDIRECT HERNIA
- 114. INDIREC T INGUINAL HERNI A • Commonestmore in males • Thin sac • Narrow neck • Lateral to inferior epigastric vessels
- 116. CLASSIFICATION ( BASED ON EXTEN T) Sac isconfined to inguinalcanal bubonocele incomplete Sac crosses superficial ring but not reaches bottom of scrotum Inguinal hernia funicular Reaches bottom of scrotum complete
- 118. NYHU S CLASSIFICATIO N SYSTEM small adults inguinal canal;does not extend to the scrotum category because they are commonly associated with EXTENSIO N TO THE DIREC T INDIRECT, DIRECT, FEMORAL, AND MIXED, RESPECTIVELY Type I INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, Type II INDIRECT HERNIA; internal ring enlarged without impingement on the floor of the 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 SPACE; also includes PANTALOON HERNIAS Type IIIC FEMORAL HERNIA Type IV RECURRENT HERNIA; modifiers A–D are sometimes added, which correspond TO
- 119. DIREC T INGUINAL HERNI A • ALWAYSACQUIRED • MEDIAL TO INFERIOR EPIGASTRIC ARTERY • SAC IS THICK • THROUGH HESSELBACHS TRIANGLE….. HESSELBACHS TRIANGLE IS DIVIDED IN TO LATERAL & MEDIAL HALVES BY OBLITERATED UMBILICAL ARTERY(LATERAL UMBILICAL LIGAMENT) DIRECT HERNIA CAN B E DIVIDEDIN TO LATERA L AND MEDIAL BASED UPON THIS LIGAMENT
- 120. 2 CLASSICAL SIGNS OF UNCOMPLICATEDHERNI A • Impulse on coughing • Reducibility
- 121. COMPLICATIONS OF HERNI A •Irreducibility • Obstructed hernia • Strangulated hernia • Inflammation • Incarceration
- 122. IRREDUCIBILI TY • Adhesions ofits contents to each other • Adhesion of its contents with the sac • Adhesion of one part of sac to other • Sliding hernia • Massive hernia (scrotal abdomen)
- 123. OBSTRUCTE D HERNI A • Irreducibility +intestinal obstruction ( lumen obstruction) • It does not occur in • Richters hernia • Omentocele • Littres hernia • Features of obstructed hernia • No expansile impulse on coughing • Irreducible • No pain • Lax non tender • symptoms
- 124. INCARCERATED HERNIA • When itcontains a portion of colon with faeces indenting with fingers putty like feeling
- 125. STRANGULATE D HERNI A • Irredudicibility +intestinal obstruction + arrest of blood supply • Due to constriction at the neck
- 126. SIGN S OF STRANGULATE D HERNI A • Tense •Tender • No impulse on coughing • irreducible • Recent increase in size
- 127. TREATMEN T • Raise thefoot end (gravityredn of hernia) • Ice bag applin redue congestion & edema • Nasogastric tube for gastric aspiration • Iv fluid admn • Parenteral antibiotics. • Herniotomy open at the fundus & drain the fluid divide constriction ring & examine the bowel for viability • Nonviable Bowel • Small bowel—end to end resection anastomosis • Omentum—excise the gangrenous part.
- 128. • Non viablebowel • Greenish/blackish in colour • No peristalsis • Gut is flaccid & lusture less • Fluid of sac is bllod stained & foul smelling
- 129.
- 130. ANATOMY • Femoral canal:2 x 2 cm size • Medial compartment of femoral sheath • Base: Femoral ring • Bounded • Anteriorly—inguinal ligament • Posteriorly—cooper’s ligament • Medially—lacunar ligament • Laterally—femoral vein • Contents: • Cloquets node • Lymphatics • Areolar tissue
- 131. COVERINGS • Skin • Superficialfascia • Cribriform fscia • Anterior layer of femoral sheath • Fatty content of femoral canal • Femoral septum • peritoneum
- 132. • Increased chanceof strangulation • F>M • Uncommon in children • Symptoms • Pain • Swelling
- 133. • Position • Below& lateral to pubic tubercle • Shape • Globular/ retort (if large) • Narrow neck • Absent impulse on coughing • Irreducible • Strangulation • consistency
- 134. • Position • Zeimannstest • Impulse on ring finger • Invagination test • Empty inguinal canal • Ring occlusion of saphenous opening
- 135. DD • Saphena varix •Aneurysm • Psoas abscess • Undescended ectopic testis • Lipoma • Psoas bursa • Hydrocele of femoral hernia sac
- 136. TREATMEN T • High operationof McEvedy • A incision above the inguinal ligament. Sac is dissected from below, neck • from above and repair is done from above. It gives a • very good exposure of both neck, fundus of sac and • repair is also easier. strangulated femoral • hernia • Lotheissens operation • Lockwood operation low approach
- 137. MAYDL’S HERNI A • Bowelloop = W SHAPE (HERNIA IN W) • CENTRAL PART CAN GET STRANGULATED (INTRA ABDOMINAL) • NO LOCAL TENDERNESS AS IN OTHER CASES OF STRANGULATION PERITONITIS
- 138. RICHTER’ S HERNI A • A portionof circumference of bowel • Usually ANTIMESENTERIC BORDER • ISCHEMIA IN HERNIATED PART • NO OBSTRUCTION AS LUMEN NOT INVOLVED
- 139. SLIDIN G HERNI A • Hernia –en-glissade •Part of a viscus forms a part of herniating sac • Usually occurs on left side( caeum) & if on right side(sigmoid • In males • Some times sac less colon) bladder on both side
- 140. PANTALOON HERNIA DOUBLE HERNIA •When both direct & indirect hernia sacs are present on the same side • Hernias on both sides of epigatric vessels(like a pants)=pantaloons • Recurrent hernia
- 141. SPIGELIAN HERNIA • Lateral ventralhernia • Herniate b/w muscles of abdomen • At or blw arcuate line due to absence of posterior rectus sheath(half way b/w umbilicus & inguinal ligament) • High risk of strangulation • Rectus abdominis medially & arcuate line laterally
- 142.
- 143. UMBILICA L HERNI A Umbilical hernia Exomphalos Umbilical hernia in infants& children Para umbilical hernia of adults
- 144. EXOMPHALO S • Failure ofall or part of the midgut to return to the abdominal cavity during early fetal life Exomphalos minor • Outer } amniotic membrane • Middle } whartons jelly • Inner } peritoneum exomphalos Exomphalos major
- 146. EXOMPHALO S MAJOR • Umbilical cordattached to inferior aspect of large swelling • Contains SI… LI & part of liver
- 147. • Exomphalos majormay burst • So emergency Sx is needed
- 148. EXOMPHALO S MINOR • Sac issmall • Umbilical cord is attached to its summit
- 150. UMBILICA L HERNI A IN INFANTS & CHILDREN S • Throughumbilical cicatrix • Spherical in shape • Increase in size in crying
- 152. PARAUMBILICA L HERNIA OF ADULT S • Not throughumbilical cicatrix but through linea alba • Above (supraumbilical) • Below (infraumbilical)
- 153. INTERSTITI AL HERNI A • Hernial saclies between muscle layers of abdominal wall • Preperitoneal/intraparietal • Interparietal • Extraparietal
- 154. LITTRE’ S HERNI A • Meckels diverticulumis the content
- 155. CAUSE S OF RECURRENCE OFINGUINAL HERNI A •Failure to ligate the sac at the neck • Increased tension • Use of absorbable sutures • Fault in selection of operation • Infection • Lifting of heavy weight with in 3 months • Persistent predisposing factors • Appearance of new hernia
- 156. HERNIA OF AHYDROCELE LOCALIZED THINNING OF TUNICA LEADING TO PSEUDOPODIUM-LIKE PROJECTION, USUALLY SEEN WHEN THE SAC IS THICK AND FLUID IS UNDER TENSION through
- 157. HYDROCELE OF AHERNIA FLUID SEQUESTRATION IN A LOCULUS OF THE HERNIAL SAC, RESEMBLING HYDROCELE. THIS IS SEEN IN LONG STANDING CASES WITH ADHESIONS WITHIN THE SAC MORE COMMON IN VENTRAL HERNIA CONTAING OMENTUM
- 158. OGILVIE HERNIA • Direct herniasare always acquired. Indirect may be congenital or acquired. • Only congenital direct hernia is ogilvie hernia; through a rigid circular orifice • in the conjoined tendon just lateral to where it inserts into the rectus sheath.