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inguinal hernia
- 1. INGUINAL HERNIA Dr FaisalAli PGR SU2
- 2. WHAT IS AN INGUINALHERNIA? Protrusion of a peritoneal sac through a musculoaponeurotic barrier in inguinal area
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- 4. ABDOMINALWALL Skin Subcutaneousfat Scarpa’s fascia External oblique muscle Internal oblique muscle Transversus abdominis Transveralis fascia Preperitoneal fat Peritoneum
- 5. INGUINALCANAL 4-6 cm long Anteroinferiorof pelvic basin Cone-shaped Base superolateral margin Apex Inferomedially
- 6. BOUNDARIES Anterior externaloblique aponeurosis Posterior fusion of the transversalis fascia and transversus abdominus muscle, Superior arch formed by the fibers of the internal oblique muscle. Inferior inguinal ligament
- 7. DEFENCE MECHANISM OFINGUINAL CANAL Obliquity of inguinal canal Arching of conjoint tendon Shutter mechanism of internal oblique ‘Ball valve mechanism’ due to contraction of cremaster muscle which plugs to superficial ring When External oblique muscle contracts intercrural fibers of superficial ring appose causing ‘Slit valve mechanism’ Hormones
- 8. SPERMATICCORD Cremasteric muscle fibers Vas deferens Testicular artery Testicular pampiniform venous plexus Genital branch of the genitofemoral
- 9. HESSELBACH’S TRIANGLE Medial aspectof Rectus abdominis muscle Inferior epigastric vessels Inguinal ligament
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- 11. MYOPECTINEALORIFICE OF FRUCHAUD Superior Arch of IO Muscle and TAbdominis. Lateral Iliopsoas muscle Medial Lateral edge of RA and Pubic pectin Iliopubic tract Spermatic cord Iliac vessels
- 12. TRIANGLE OF DOOM External iliac vessels Deep circumflex iliac vein Femoral nerve Genital branch ofGFnerve
- 13. TRIANGLE OF PAIN Nerves Lateral femoral cutaneous Femoral branch of GF nerve Femoral nerve
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- 15. A.ANATOMICAL CLASSIFICATION DIRECT INGUINALHERNIA Within the floor of Hesselbach’s triangle Acquired defectfrom mechanical breakdown over the years ~1% Lifetime risk
- 16. INDIRECT INGUINAL HERNIA Throughthe internal ring of inguinal canal Congenital Patent processus vaginalis ~5% Lifetime risk Higher risk of strangulation than direct
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- 18. ACCORDING TO EXTENT INDIRECTINGUINAL HERNIA INCOMPLETE BUBONOCELE: Here sac is confined to the inguinal canal FUNICULAR: Here sac crosses the superficial ring but does not reach the bottom of the scrotum. Complete : Here sac descends to the bottom of scrotum
- 19. INDIRECT Can occurat any age from childhood to adults Occurs in pre-existing sac Protrusion through deep ring Pyriform/oval in shape, descends obliquely Can become complete Neck of sac is narrow and lateral to inferior epi- artery Sac is anterolateral to cord Ring occlusion is positive Commonly unilateral but can be bilateral Obstruction/strangulation is common Sac should be opened during surgery DIRECT Common in elderly Always acquired Herniation through posterior wall Globular/round in shape, descends directly forward Descent down in the scrotum is rare Wide neck and medial to inf epigastric artery Ring occlusion test is negative Commonly bilateral Obstruction/strangulation is rare Sac is not necessarily opened unless obstruction is present
- 20. PENTALOON HERNIA (DOUBLE,SADDLE,ROMBERG) Here bothdirect and indirect inguinal sacs are present and clinically present as direct hernia During surgery , indirect sac may be missed and so leads to recurrent hernia through retained or unidentified indirect sac Here both medial and lateral sacs straddle the inferior epigastric artery
- 21. Sliding hernia Here posteriorwall of the sac is not only formed by parietal peritoneum but also by sigmoid colon with its mesentery on left side; cecum on right side and often with a portion of bladder. It occurs exclusively in males and mainly on left side.
- 22. CLINICAL CLASSIFICATION REDUCIBLE Canbe reduced by the patient,surgeon or by it self when pt. lies supine. Has expansile impulse on coughing. IRREDUCIBLE Cant be returned to the abdomen, usually due to adhesion b/w sac and its contents or over crowding of the contents. OBSTRUCTED Bowel is obstructed but there in no interference to the blood supply.
- 23. STRANGULATION When bloodsupply of contents of hernia is seriously impaired leading to formation of gangrene. Obstruction impaired venous return Congestion Further dilatation of bowel which becomes purple colored Fluid collects in the sac Eventually arterial supply is compromised Bowel becomes dark brownish with friable wall Bacteria migrate to fluid of sac Perforation occurs at site of constriction ring Peritonitis
- 24. CAUSES OF STRANGULATION Narrow neck Adhesions Irreducibility Long time large hernia with adhesions
- 25. RICHTERS HERNIA Thisis the partial enterocele when only the anti-mesenteric margin of the gut is strangulated in the sac.
- 26. MAYDLS HERNIA Whena W-shaped loop of gut lies in the hernia sac and the intervening loop is strangulated within the main abdominal cavity Hernial sac containing a strangulated MECKELS diverticulum. It can progress to gangrene . LITTRES HERNIA
- 27. NEWER CLASSIFICATION Gilbertclassification NYHUS classification BENDAVID classification Halverson and McVay classification Ponka classification
- 28. NYHUS CLASSIFICATIONSYSTEM Type IINDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, smalladults Type II INDIRECT HERNIA; internal ring enlarged without impingement on the floor of theinguinal canal; does not extend to the scrotum Type IIIA DIRECT HERNIA; size is not taken intoaccount Type IIIB INDIRECT HERNIA that has enlarged enough to encroach upon the posterior inguinalwall; INDIRECT SLIDINGOR SCROTAL HERNIAS are usually placed in this category because theyare commonly associated with EXTENSIONTOTHE DIRECT SPACE; also includes PANTALOON HERNIAS Type IIIC FEMORAL HERNIA Type IV RECURRENT HERNIA; modifiers A–D are sometimes added, which correspondTOINDIRECT, DIRECT, FEMORAL,AND MIXED,RESPECTIVELY
- 29. EPIDEMIOLOGY One of themost common surgical procedures Incidence: ~5-10% lifetime 75% of abdominal wall hernias Male > Female Indirect > Direct Right > Left 1/3 may develop a contralateral inguinalhernia
- 30. ETIOLOGY Multifactorial Weaknessin abdominal wall musculature PRESUMEDCAUSESOF GROIN HERNIATION Coughing Valsalva's maneuvers Chronic obstructive pulmonary disease Ascites Obesity Upright position Straining Congenital connective tissue disorders Constipation Defective collagen synthesis Prostatism Previous right lower quadrant incision Pregnancy Arterial aneurysms Birthweight <1500 g Cigarette smoking Family history of a hernia Heavy lifting Physical exertion (?)
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- 32. HISTORY More commonin males(20:1) Dragging pain and swelling in the groin which is better seen while coughing and standing. History of Constipation Cough and Smoking Urological symptoms Duration Progressiveness Any h/o surgery (appendectomy) Reccurent hernia or contralateral
- 33. PHYSICAL EXAMINATION Properexposure from umbilicus to mid thigh Inspection Standing lying Palpation Can you get above the swelling Reducibility Cough impulse Head or leg raise to look for abdominal muscle tone Internal Ring Occlusiontest
- 34. EXAMINATION Zieman’s test indexfinger on deep ring middle finger on superficial ring ring finger on femoral opening Ring invagination test little/index finger is invaginated from Bottom of scrotum gradually pushed to enter In superficial inguinal ring, impulse on coughing is felt At tip of invaginated finger.
- 35. EXAMINATION Always abdominal,urological and respiratory examination is done to rule out any precipitating factor like Chronic Bronchitis , Ascites, Stricture urethra and BPH.
- 36. DIFFERENTIAL DIAGNOSIS Malignancy Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumor Primary testicular Varicocele Epididymitis Testicular torsion Hydrocele Ectopic testicle Undescended testicle Femoral artery aneurysm or pseudoaneurysm Lymph node Sebaceous cyst Hidradenitis Cyst of the canal of Nuck (female) Saphenous varix Psoas abscess Hematoma Ascites
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- 40. MANAGEMENT PRINCIPLES Notall hernias require surgical repair Small hernias can be more dangerous than large Pain, tenderness and skin colour changes imply high risk of strangulation Femoral hernia should always be repaired
- 42. CONSERVATIVE MANAGEMENT Aimed atalleviating symptoms such as pain, pressure, and protrusion of abdominal contents Assuming a recumbent position Truss, an elastic belt or brief
- 43. EMERGENT REPAIR Incarcerated hernias Strangulatedhernias Sliding hernias
- 44. TAXIS The patientis sedated and placed in aTrendelenburg position. The hernia sac is grasped with both hands, elongated, and then milked back through the hernia defect. Pressure applied to the most distal portion of the sac will cause the contents to mushroom and prevent reduction.
- 45. STRANGULATED HERNIA Femoral> Indirect > Direct Fever, leukocytosis, and hemodynamic instability. The hernia bulge usually is very tender, warm, and may exhibit red discoloration. Taxis should not be applied to strangulated hernias as a potentially gangrenous portion of bowel may be reduced into the abdomen without being addressed
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- 47. PRINCIPLES OF SURGICALREPAIR Reduction of the hernia content into the abdominal cavity Excision and closure of peritoneal sac Reapproximation of the walls of the neck of the hernia Permanent reinforcement of the abdominal wall defect with sutures or mesh
- 48. SURGICAL OPTIONS Herniotomy: excision of hernia sac in children Hernirraphy : strengthening of posterior wall of inguinal canal Hernioplasty : placement of mesh
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- 52. BASSINI REPAIR Isfrequently used for indirect inguinal hernias and small direct hernias The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament
- 53. LYTLE’S REPAIR Only internalring is narrowed by placing interrupted sutures over the medial side of the ring to the fascia transversalis
- 54. MCVAY REPAIR inguinaland femoral canal defects The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally
- 55. SHOULDICE REPAIR Multilayered Transversalis fascia isincised, lower flap is sutured to posterior part of upper flap Upper flap is sutured to inguinal ligament. Then conjoint tendon and inguinal ligament is further approximated by two layers in front of cord . Then Ext Oblique apo is sutured in two layers.
- 56. MALONY DARN REPAIR Posteriorwall is re-inforced with monofilament nylon darn. The Darn is made in crisscross fashion between the conjoint tendon and inguinal ligament Excellent results. Most commonly performed in countries where mesh is too expensive
- 57. MESH Gross structure Netmeshes or flat sheets Synthetic mesh Polypropylene, polyester and polytetrafloroethylen PTFE Weight and porosity Dense or heavy weight and Light weight, Large pore meshes Biological mesh Sheets of sterilized, decellularised, non immunogenic connective tiisue
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- 59. LICHTENSTEINTENSION- FREE REPAIR Initialpart of surgery is same as Bassini repair. Once hernia has been removed and any medial defect closed, a piece of mesh measuring 8-15cm is placed over posterior wall, behind the spermatic cord and is split to wrap around the spermatic cord at deep inguinal ring. Loose sutures with Prolone hold mesh to inguinal ligament and conjoint tendon ADVANTAGES Lowered recurrence rates Accelerated postoperative delivery
- 60. Open plug/device/complex mesh repair. Gillbertmesh repair ; plug and patch, internal ring is plugged by a cone shaped piece of prolene mesh PHS (Prolene hernia system) onlay and sublay sandwich technique
- 61. LAPAROSCOPIC HERNIA REPAIRTransabdominal PreperitonealProcedure(TAPP) Totally Extraperitoneal (TEP) Repair Indications include bilateral inguinal hernia, recurrent hernia, need for early recovery
- 62. Transabdominal Preperitoneal Procedure (TAPP) Surgeon enters the peritoneal cavity incises the peritoneum above the hernia defects and reflects it away from the muscles entering Pre- peritonealy Hernia is reduced and a 10*15 cm mesh is placed just deep to the abdominal wall extending across midline into retropubic space and 5cm lateral to the deep inguinal ring.
- 63. Totally Extraperitoneal (TEP)Repair Space is created just deep to the abdominal msucles without entering the peritoneal cavity Hernia is reduced and mesh is inserted preperitonealy.
- 64. RECURRENCE Bassini repair 10% Around1% for Shouldice repair Hernioplasty 1-3% Most recurrences are of the same type as the original hernia Recurrence Factors Patient Technical Tissue
- 65. RECURRENCE Patient factors malnutrition,immunosuppression, diabetes, steroid use, and smoking. Technical factors mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors wound infection, tissue ischemia, and increased tension within the surgical repair
- 66. COMPLICATIONS The overall riskof complications of inguinal hernia repair is low. CommonComplications EARLY: pain, bleeding, urinary retention, anaesthesia related Medium : seroma, wound infection Late: chronic pain, testicular atrophy, recurrance
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