5. History of Present IllnessHistory of Present Illness
2 yrs2 yrs bulging inguinal massbulging inguinal mass
5x8cm5x8cm
straining, prolonged standingstraining, prolonged standing
reduciblereducible
((--) pain, fever) pain, fever
((--) changes in bowel movement) changes in bowel movement
((--) urinary symptoms) urinary symptoms
((--) respiratory symptoms) respiratory symptoms
6. 10 months PTA10 months PTA increase size ofincrease size of mass,mass,
reaches the scrotal areareaches the scrotal area
Persistence of symptomsPersistence of symptoms
ConsultConsult
AdmissionAdmission
8. Physical ExaminationPhysical Examination
General Survey:General Survey:
Conscious, coherent, ambulatoryConscious, coherent, ambulatory
not innot in cardiorespiratorycardiorespiratory distressdistress
BP130/90BP130/90 HR 81HR 81 RR 19RR 19 T 37.1T 37.1
C&LC&L symmetrical chest expansionsymmetrical chest expansion
no retractions, clear breath soundsno retractions, clear breath sounds
9. Heart:Heart:
normal rate regular rhythm, (normal rate regular rhythm, (--) thrills,) thrills,
murmurmurmur
Abdomen:Abdomen:
flat, NABS, soft, non tender,flat, NABS, soft, non tender,
nono organomegalyorganomegaly
10. InguinoInguino scrotal mass rightscrotal mass right
Inguinal ring 4.5 cmInguinal ring 4.5 cm
ReducibleReducible
SoftSoft
((--) bowel sounds) bowel sounds
((--)) transilluminationtransillumination
((--)) erythemaerythema
((--) tenderness) tenderness
11. Salient featuresSalient features
--5959--yearyear--old Maleold Male
--inguinoscrotalinguinoscrotal massmass
--ReducibleReducible
--Noted when patient strains &Noted when patient strains &
prolonged standingprolonged standing
--Soft, nonSoft, non--tendertender
-- ((--) bowel sounds) bowel sounds
-- ((--)) transilluminationtransillumination
4.5 cm external
inguinal ring
16. INGUINOSCROTAL MASS, RIGHT
NON INFLAMMATORY
Malignant
Soft tissueSoft tissue
SarcomaSarcoma
Large size,Large size,
superficial or deepsuperficial or deep
FibrosarcomaFibrosarcoma
SubcutaneousSubcutaneous
fatfat
DisorganizedDisorganized
growthgrowth
LyposarcomaLyposarcoma
Deep muscleDeep muscle
TesticularTesticular
TumorTumor
Nodule, firm,Nodule, firm,
nonnon--tendertender
17. INGUINOSCROTAL MASS, RIGHT
NON INFLAMMATORY
Non-malignant
Soft tissue
Sebaceous cysts
Lipoma
Lipoma of the
cord
Spermatocoele
Torsion of the
testis
18. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of
the cord
•Sebaceous
cysts
hernia
Swelling and rapidSwelling and rapid
progression of painprogression of pain
fever, chillsfever, chills
red, edematousred, edematous
19. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of
the cord
•Sebaceous
cysts
hernia
20. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of
the cord
•Sebaceous
cysts
hernia
Multiple, tenderMultiple, tender
Obvious are ofObvious are of
inflammationinflammation
21. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of
the cord
•Sebaceous
cysts
hernia
22. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of
the cord
•Sebaceous
cysts
hernia
Soft tissueSoft tissue SercomaSercoma
Large size, superficialLarge size, superficial
or deepor deep
23. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of
the cord
•Sebaceous
cysts
hernia
FibrosercomaFibrosercoma
Subcutaneous fatSubcutaneous fat
Disorganized growthDisorganized growth
24. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of
the cord
•Sebaceous
cysts
hernia
LyposercomaLyposercoma
Deep muscleDeep muscle
25. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of
the cord
•Sebaceous
cysts
hernia
Testicular TumorTesticular Tumor
Nodule, firm, nonNodule, firm, non--
tendertender
26. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Sebaceous cysts
•Lipoma
•Lipoma of the cord
•Spermatocoele
•Torsion of the testis
hernia
No cough impulseNo cough impulse
27. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Sebaceous cysts
•Lipoma
•Lipoma of the cord
•Spermatocoele
•Torsion of the testis
hernia
Cyst ofCyst of reterete testestestes
Cystic massCystic mass
+ transillumination+ transillumination
bilateralbilateral
28. Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal
abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Sebaceous cysts
•Lipoma
•Lipoma of the cord
•Spermatocoele
•Torsion of the testis
hernia
Sudden onset of painSudden onset of pain
Scrotal enlargementScrotal enlargement
with edemawith edema
29. Hernia
direct indirect
History:
•55M, Recurrent bulging mass,
inguinosrotal area, R
•Aggravated by straining, relieved
by lying down
PE:
•inguinoscrotal mass, R
•Soft, non-tender, reducible
•No transillumination
•+ cough impulse
•No bowel sound
Prevalence
•Indirect, more common
•Rutledge report, 1,437 patients
•60% indirect
•36% direct
•4% femoral
•Lichtenstein report
• 44.4% Indirect
•43.1% direct
•12.5% others
31. ParaclinicalParaclinical Diagnostic ProcedureDiagnostic Procedure
Do I needDo I need paraclinicalparaclinical procedure?procedure?
Certain of my primary diagnosisCertain of my primary diagnosis
pattern recognitionpattern recognition
prevalenceprevalence
NO.NO.
32. Goal of TreatmentGoal of Treatment
Reduce herniated organ/bowelReduce herniated organ/bowel
repair defectrepair defect ≥≥4cm4cm
Ligation of the sacLigation of the sac
33. Treatment OptionsTreatment Options
There are at present three general options forThere are at present three general options for
the surgical repair of indirect inguinal hernia,the surgical repair of indirect inguinal hernia,
namely:namely:
open repair with mesh grafting,open repair with mesh grafting,
open repair without mesh grafting,open repair without mesh grafting,
laparoscopic repair with mesh graftinglaparoscopic repair with mesh grafting
34. Not availableNot available
P 8000P 8000--
P10000P10000
IntraIntra
abdominalabdominal
complicationcomplication
samesame
LAPAROLAPARO--
SCOPICSCOPIC
Available most ofAvailable most of
the timethe time
P 5000P 5000Graft rejectionGraft rejection
RR 0.2%RR 0.2%
LowLow
recurrence raterecurrence rate
Less postLess post--opop
painpain
Easy toEasy to
performperform
Early back toEarly back to
workwork
OPEN WITHOPEN WITH
MESHMESH
AvailableAvailableP 2000P 2000
InfectionInfection
recurrencerecurrence
Repair floorRepair floor
anatomicalanatomical
OPENOPEN
WITHOUTWITHOUT
MESHMESH
AVAILABILITYAVAILABILITYCOSTCOSTRISKRISKBENEFITBENEFIT
4 cm internal4 cm internal
ringring
35. At present, although open repair with meshAt present, although open repair with mesh
and laparoscopic repair are now commonlyand laparoscopic repair are now commonly
done especially in developed countries, thedone especially in developed countries, the
controversy is far from being settled becausecontroversy is far from being settled because
of the tendency for blanket recommendationsof the tendency for blanket recommendations
and randomized controlled trials and metaand randomized controlled trials and meta--
analyses showing conflicting results, someanalyses showing conflicting results, some
favoring open repair without mesh (1,5,7).favoring open repair without mesh (1,5,7).
36. others favoring open repair with mesh (9others favoring open repair with mesh (9--10)10)
and still others, laparoscopic approach (11and still others, laparoscopic approach (11--
13).13).
37. Protocol on HerniaProtocol on Hernia
A departmental consensus was made usingA departmental consensus was made using
the diameter of the external inguinal ring (>4the diameter of the external inguinal ring (>4
centimeters) as predictor for preoperativecentimeters) as predictor for preoperative
preparation of mesh in patients for indirectpreparation of mesh in patients for indirect
inguinal hernia repair.inguinal hernia repair.
38. Protocol on HerniaProtocol on Hernia
The protocol was then prospectively validatedThe protocol was then prospectively validated
on adult patients with unilateral indirect inguinalon adult patients with unilateral indirect inguinal
hernia from January to August, 2003 using intrahernia from January to August, 2003 using intra--
operative measurement of the external andoperative measurement of the external and
internal inguinal ring as the indicator for meshinternal inguinal ring as the indicator for mesh
grafting.grafting.
39. The department believes that there areThe department believes that there are
indications for the use of mesh in theindications for the use of mesh in the
treatment of indirect inguinal hernia.treatment of indirect inguinal hernia.
Recurrence and large size of hernia defect areRecurrence and large size of hernia defect are
the basic indicationsthe basic indications
favoring open repair without mesh (1,5,7)favoring open repair without mesh (1,5,7)
open repair with mesh (4, 13) and still others,open repair with mesh (4, 13) and still others,
laparoscopic approach (3, 6, 11).laparoscopic approach (3, 6, 11).
40. PrePre--op preparationop preparation
Psychological supportPsychological support
Screen for previous medical problemScreen for previous medical problem
HypertensionHypertension
MetoprololMetoprolol 50mg BID x 2 weeks50mg BID x 2 weeks
Optimize patientOptimize patient’’s conditions condition
ConsentConsent
Preparation of materialsPreparation of materials
41. Operative TechniqueOperative Technique
Oblique incision over LangerOblique incision over Langer’’s lines line
External oblique aponeurosis openedExternal oblique aponeurosis opened
42. IntraIntra--op findingsop findings
HernialHernial sac locatedsac located
anteromediallyanteromedially to theto the
cord containingcord containing
omentumomentum
Internal ring measures 4Internal ring measures 4
cm in widest diametercm in widest diameter
49. PostPost--op supportop support
AnalgesiaAnalgesia
KetoprofenKetoprofen 100mg TIV q6 x 3 doses100mg TIV q6 x 3 doses
shifted to oral Paracetamol 500mg q4shifted to oral Paracetamol 500mg q4
Early ambulationEarly ambulation
Diet as toleratedDiet as tolerated
Daily wound careDaily wound care
Discharged on the 2nd PODDischarged on the 2nd POD
50. Prevention and HealthPrevention and Health
Anticipate complicationsAnticipate complications
AdequateAdequate hemostasishemostasis
Avoid vascular compromiseAvoid vascular compromise
Avoid infectionAvoid infection
Avoid dehiscenceAvoid dehiscence
51. Prevention and HealthPrevention and Health
Alive patientAlive patient
PatientPatient’’s health problem resolveds health problem resolved
No complaintNo complaint
No disabilityNo disability
No medical suitNo medical suit
Satisfied patientSatisfied patient
55. Inguinal Hernia
Muscle
Deficiency
•Congenital or acquired insufficiency of
internal oblique expose the deep ring and
inguinal floor
t Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle
deficiency
Fascial factor
Processus
vaginalis
58. Inguinal Hernia
Patent Processus Vaginalis
•Evagination of the peritoneum
•60% at two months, 40% at two years, 30%
adult
Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle
deficiency
Fascial factor
Processus
vaginalis
61. NyhusNyhus ClassificationClassification
Type IType I Indirect, smallIndirect, small
Type IIType II Indirect, mediumIndirect, medium
Type IIIType III A. DirectA. Direct
B. Indirect, largeB. Indirect, large
C. FemoralC. Femoral
Type IVType IV RecurrentRecurrent
69. Recurrent herniaRecurrent herniaType 4Type 4
Femoral herniaFemoral herniaCC
Indirect inguinal hernia. Internal ring dilated. PosteriorIndirect inguinal hernia. Internal ring dilated. Posterior
wall defectivewall defective
BB
Direct inguinal herniaDirect inguinal herniaAA
Posterior wall defectPosterior wall defectType 3Type 3
Indirect hernia with dilated internal ring. Posterior wallIndirect hernia with dilated internal ring. Posterior wall
intactintact
Type 2Type 2
Indirect hernia with normal internal ringIndirect hernia with normal internal ringType 1Type 1
NyhusNyhus Classification of InguinalClassification of Inguinal
Hernias.Hernias.
70. GilbertGilbert’’s Classification of Inguinals Classification of Inguinal
Hernias.Hernias.
Femoral herniaFemoral herniaType VIIType VII
Pantaloon herniaPantaloon herniaType VIType VI
DirectDirect diverticulardiverticular defect 1defect 1--2 cm2 cm suprapubicsuprapubic, but anywhere, but anywhere
along flooralong floor
Type VType V
Defective canal floor, ring is soundDefective canal floor, ring is soundType IVType IV
Ring > 4 cm, sliding component, displaces inferiorRing > 4 cm, sliding component, displaces inferior
epigastricepigastric vesselsvessels
Type IIIType III
Indirect, ring < 4 cmIndirect, ring < 4 cmType IIType II
Indirect, tight ring, sac any size, reducibleIndirect, tight ring, sac any size, reducibleType IType I
DescriptionDescriptionTypeType
71. ReferencesReferences
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8.8. PingulPingul J. et al. Health Process Evidence basedJ. et al. Health Process Evidence based
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Inguinal HerniaInguinal Hernia
9.9. ScottScott--ConnConn, C., C. ChassinChassin’’ss Operative Strategy inOperative Strategy in
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