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PPT HERNIA
- 1. Inguinoscrotal hernia -examination Dr.Velineni Bharath Final year Post graduate Dept. of general surgery SRMMCH &RC
- 2. History (elective presentation) University of Alexandria Local Symptoms – Swelling – Discomfort Ask about PPT factors – Chronic constipation – Cough – Straining with micturation
- 3. History (emergency presentation) University of Alexandria Irreducible Obstructed Strangulated
- 4. ln, guin. al Region D isse· c t iu n .. P o st, e,r i o r (In't, e,r n a l ) View· Rectus sheath (posterior layer) Arcuate line Inferior epigastric vessels Tra nsversaIis fascia (cut away) Rectus abdominis muscle - - - - - Anterior superior iliac spine Linea alba --- Inguinal (HesselbachOs) triangle Deep in guin a I ring Testicular vessels and genital branch of gen itofem oraI nerve Inguinal falx (conjoint tendon) ffr + " ;...+.J...iJ.1 Femoral ring (dilated) (circle) Obturator-pubic arterial anastomosis Ductus (v as) defe rens Pectin eaI Ii game nt (Coo per) Pubic symphysis Obturator artery Lacunar ligament (Gimbemat)
- 6. University of Alexandria Standing position Exposure (nipple t o knee) Inspection – Site Right or left Above or below groin cease Reaches the scrotum or not – Size – Shape
- 7. Standing position University of Alexandria Palpation from front – Scrotal neck test technique Inguinal, scrotal, inguinosrotal – Superficial ring test Technique Direct, indirect inguinal
- 8. Superficial ring test University of Alexandria
- 9. Standing position University of Alexandria Palpation from side – Stand at the same side of the hernia – Findings Site Size shape Temperature Tenderness Composition Reducibility Expansile impulse with cough
- 10. Standing position University of Alexandria Expansile impulse with cough – Technique – The swelling should become tense and expand with cough not moves up and down only It is diagnostic for hernia but can be absent in complicated ones.
- 11. Expansile impulse with cough University of Alexandria
- 12. Standing position University of Alexandria Pubic tubercle test (refers to site of reduction of the hernia not the position of the whole hernia) – Above and medial – Above and lateral – Below and medial – Below and latera
- 13. Standing and supine position Reducibility – Can be tried on standing position, if failed, repeat in supine position – Technique – Finding Reducible, irreducible Direction of reduction Difficulty in reduction University of Alexandria
- 14. Standing and supine position University of Alexandria Deep ring test – Only if the hernia is reducible – Technique – Findings Indirect, direct inguinal hernia – Why false results?
- 15. Standing and supine position University of Alexandria
- 16. Standing and supine position University of Alexandria Three finger test (Zieman’s technique) technique Findings Indirect, direct, femoral hernia
- 17. Standing or supine position University of Alexandria Percussion – Intestinal or omental contents Auscultation – Peristalsis.
- 18. DO NOT FORGET University of Alexandria To examine the contra-lateral side of the hernia, To examine the scrotum, To examine the abdomen.
- 19. Examine the abdomen University of Alexandria For any cause can elevate the intra- abdominal pressure – Ascites – Enlarged prostate – Intestinal obstruction – Pregnancy Scar of previous operation
- 20. University of Alexandria Indirect inguinal hernia Direct inguinal hernia Elderly Via transversalis fascia (hasselbach’s triangle) Weak abdominal wall/muscle Bilateral in > ½ case Does not enter scrotum (incomplete) Reduced on lying down (automatically) Broad neck Impulse on middle finger Bulge out Any age but common in young Via deep inguinal ring and long the inguinal canal Patent or reopen processus vaginalis Unilateral in 2/3 case (right side more common) Enter scrotum (complete) Reduced by patient/doctor (manually) Narrow neck- more liable to strangulate Zieman technique- impulse on index finger Deep ring occlusion test- control Little finger invagination test- impulse on finger tip Impulse on pulp
- 21. Differential diagnosis University of Alexandria Femoral hernia Inguinal lymphadenopathy Saphena Varix Femoral aneurysm Lipoma Ectopic testis Psoas abscess
- 22. Differential diagnosis University of Alexandria
- 23. Some definitions University of Alexandria Strangulated Incarceration ? Richter’s hernia? Maydl’s hernia? Sliding hernia? Pantaloon hernia?
- 24. Types of indirect inguinal hernia University of Alexandria Incomplete; – – Bubonocele—limited within the inguinal canal Funicular—limited just above the epididymis Complete; – traverses to the bottom of the scrotum
- 25. Diagnosis Right, Left, Site (inguinal, femoral), Direct or indirect, Complete or incomplete, Hernia, Content (omentum or bowel), Uncomplicated (Reducible) or complicated (irreducible, obstructed, stranguU ln ai v e tr es i t dyo )f , PPT factors.