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PPT HERNIA
- 1. Inguinoscrotal hernia -examination Dr.Velineni Bharath Finalyear Post graduate Dept. of general surgery SRMMCH &RC
- 2. History (elective presentation) Universityof Alexandria Local Symptoms – Swelling – Discomfort Ask about PPT factors – Chronic constipation – Cough – Straining with micturation
- 3. History (emergency presentation) Universityof Alexandria Irreducible Obstructed Strangulated
- 4. ln, guin. al Region D isse· c tiu 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)
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- 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 ofAlexandria Palpation from front – Scrotal neck test technique Inguinal, scrotal, inguinosrotal – Superficial ring test Technique Direct, indirect inguinal
- 8. Superficial ring test Universityof Alexandria
- 9. Standing position University ofAlexandria 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 ofAlexandria 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 withcough University of Alexandria
- 12. Standing position University ofAlexandria 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 supineposition 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 supineposition University of Alexandria Deep ring test – Only if the hernia is reducible – Technique – Findings Indirect, direct inguinal hernia – Why false results?
- 15. Standing and supineposition University of Alexandria
- 16. Standing and supineposition University of Alexandria Three finger test (Zieman’s technique) technique Findings Indirect, direct, femoral hernia
- 17. Standing or supineposition University of Alexandria Percussion – Intestinal or omental contents Auscultation – Peristalsis.
- 18. DO NOT FORGET Universityof Alexandria To examine the contra-lateral side of the hernia, To examine the scrotum, To examine the abdomen.
- 19. Examine the abdomen Universityof 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 inguinalhernia 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 ofAlexandria Femoral hernia Inguinal lymphadenopathy Saphena Varix Femoral aneurysm Lipoma Ectopic testis Psoas abscess
- 22. Differential diagnosis University ofAlexandria
- 23. Some definitions University ofAlexandria Strangulated Incarceration ? Richter’s hernia? Maydl’s hernia? Sliding hernia? Pantaloon hernia?
- 24. Types of indirectinguinal 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.
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