Hernia Lecture 1 PDF

mad Dr. Yasir Mehmood All hernia Same g/f not only inguinal MBBS, MCPS, FCPS In children the Tx is Herniotomy only In Adults Hernioplasty ; herniorrhaphy; Operation for inguinal hernia Lichtenstein repair herniorrhaphy Options: Bassini and Shouldice Laparoscopic repair( TEP...

mad Dr. Yasir Mehmood All hernia Same g/f not only inguinal MBBS, MCPS, FCPS In children the Tx is Herniotomy only In Adults Hernioplasty ; herniorrhaphy; Operation for inguinal hernia Lichtenstein repair herniorrhaphy Options: Bassini and Shouldice Laparoscopic repair( TEP +TAPP) when Bilateral and Recurrence Hernia Pt present as Lump sometimes appears and disappear  Protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity.  Anatomical types Common  Inguinal hernia  I Umbilical hernia  Incisional hernia  Femoral hernia  Epigastric hernia Uncommon  Spigelian  Obturator  Lumbar  Gluteal  Causes Post.wall of inguinal canal is weak “only fascia” so when raised  Basic design weakness Abdominal Pressure = Hernia __  Weakness due to structures entering and leaving the abdomen inguinal canal  Developmental failure If 2 linea alba don’t United = Umbilical hernia  Genetic weakness of collagen Collagen is a Part of the muscle  Sharp and blunt trauma + surgery weakness Weak in facial transversals  Weakness due toeaging and pregnancy Stretching of anterior abdominal wall-> weakness of linea alba ( around umbilical) -> per umbilical hernia common in mulipara women  Primary neurological and muscle disease Muscle abnormal  Excessive intra-abdominal pressure ?  Pathophysiology  Condition that raises intra-abdominal pressure  powerful muscular effort (lifting weight)  Chronic cough c  Straining on micturation Elderly = BPH  Straining on defecation  Smokers Abnormal college + chronic cough  Obesity  Composition of a hernia 3  The sac--diverticulum of peritoneum, consisting of mouth, neck, body and fundus.  The covering--layers of the abdominal wall through which the sac passes.y 3 muscles: External oblique Internal oblique  Contents Fascia transversalis  Intestine = enterocele  Omentum = omentocele  Fluid, as part of ascites  Portion of the bladder  Ovary and corresponding fallopian tube t  Meckel’s diverticulum = a Littre’s hernia Appendix  Clinical features Symptoms Typical : Lump sometimes appears and disappear  Painless lump on abdominal wall  Aching or heavy feeling Not pain Cardinal signs Signs  Occur at a weak anatomical spot Abdomen + operation site  Reduce on lying down or with direct pressure  Expansile cough impulse Reducibllty: when press it disappear and Remains disappear -> Hernia Compressabllty: when press it disappear But when rising hand comes back -> Vascular lesions —> aneurism  6 Ma Clinical Types of hernia  Occult – not detectable clinically Only by Hx from pt , he said I have swelling so in examination no hernia  Reducible – contents can be returned to abdomen  Irreducible – contents cannot be returned but there are no other complications Lump at weak spot only ( not reducible or expansile cough impulse)  Obstructed – bowel in the hernia has good blood supply but bowel is obstructed Pain , vomiting, conestipation, distinction If Ischemia  Strangulated – blood supply of bowel is compromised I Dealyed>5-6hr  Infarcted – contents of hernia become gangrenous Twisted = obstructed or streangulated pt come SAME Pain with irreducible hernia ,vomiting, constipation and distension  Investigations  Clinical diagnosis 3 sign: Cough pulse, Reducibility, weak anatomical spot So No investigations are required, unless if in doubt: swelling irreducible or complication -> painful  If in doubt  Ultrasound ining Sac  CT Scan – incisional hernia Se how many sac present  MRI Scan – sportsman groin with pain i i  Contrast radiology – inguinal hernia Herniogram  Laparoscopy – to identify occult contra-lateral inguinal hernia  Management principles 3  Not all hernias require surgical repair (watchful waiting)  Small hernia can be more dangerous than large one __ sudden  Pain, tenderness and skin colour changes imply high risk of strangulation  Femoral hernia should always be repaired B.c it’s heve narrow neck = strangulations risk  Operative approaches to hernia Herniotomy : its 1st step; opening of the sac ,take content,and close the defeat Hernorraphy : herinotomy + sutuer “ |. hernioplasty :herinotomy + mesh  Reduction of the hernia content into the abdominal cavity with removal of any non-viable tissue and bowel repair if necessary 3  Excision and closure of a peritoneal sac if present or replacing it deep to the muscles  Re-approximation of the walls of the neck of the hernia if possible  Permanent reinforcement of the abdominal wall defect with sutures or mesh.  The inguinal canal Passage in lower part of ant.abdominal wall through which Spermatic cord ( male ) or round ligament of uterus ( female ) In infants  No inguinal canal In adults  3.75 cm long  Directed downwards and medially from the deep to the superficial inguinal ring.  In the male, the inguinal canal transmits the spermatic cord (testicular artery, vein, lymphatics and vas deferens), the ilio- inguinal nerve, ilio-hpogastric and the genital branch of the genito-femoral nerve.  In the female, the round ligament replaces the spermatic cord.  HMP Boundaries MQ  Anterior External oblique aponeurosis Thick  Posterior Fascia transversalis. Very thin  Superior Conjoined muscles (internal oblique and transversus)  Inferior Inguinal ligament.  Medially Superficial inguinal ring  Laterally Deep inguinal ring Deep ring – 2-3 cm above the point midway between Inca anterior superior iliac spine and pubic tubercle (mid inguinal point) l Boundaries Types of inguinal hernia: Inguinal hernia Lateral hernia  An indirect hernia comes through deep inguinal ring and travels down the canal on the outer (lateral and anterior) side of the spermatic cord.  Medial hernia  A direct hernia comes out directly forwards through the posterior wall of the inguinal canal. a Fascia transversalis. MCR  The neck of the indirect hernia is lateral to the inferior epigastric vessels, the direct hernia usually emerges medial to this. of  Digital control of the internal ring may help in distinguishing between an indirect and a direct inguinal hernia. DDx Inguinal ligament P  In inguinal hernia the neck is above and medial, whereas that of a Femoral hernia is below and lateral to the pubic tubercle Inguinal ligament Anatomical relationship Indirect her Direct to scram nags  Dual hernia  Dual (synonym: saddle-bag, pantaloon) hernia  This type of hernia consists of two sacs that straddle the inferior epigastric artery  One sac being medial and the other lateral to this vessel. Hasselbach’s triangle  Inferior epigastric vessel laterally  Lateral edge of rectus abdominus muscle medially  Inguinal ligament and pubic bone inferiorly  Osd Differences Indirect Direct  Through deep ring  Through fascia transversalis  Common in children and young  Uncommon in children and young adults adults In Elderly  Comes through deep inguinal  Comes directly through posterior ring wall  Does not descend into the  Descend into the scrotum scrotum  Reduce upward, laterally and  Reduce upward and then then backward backward  Controlled, after reduction, by  Not controlled, after reduction, by pressure over deep inguinal ring pressure over deep inguinal ring Ask pt cough-> Not appear Ask pt cough-> appear  Ring occlusion test ‫تفرق بينهم‬ me  Lie patient supine on bed  Reduce hernia  Identify deep ring  Apply gentle pressure on deep ring  Ask patient to cough  If hernia is controlled and do not appear – indirect  If hernia appear medial to this point - direct deepRing  Differential diagnosis In male  Femoral hernia  Vaginal hydrocele  Encysted hydrocele of the cord Trans illuminated test  Spermatocele J  Incompletely descended testis in the inguinal canal Scrotal empty  Lipoma of the cord w I  Inguinal lymph nodes In female  Hydrocele of the canal of Nuck  Femoral hernia.  Not Managed observtivly Operative approach In children the Tx is Inguinal herniotomy Herniotomy only “b.c no  Dissecting out and opening the hernial sac inguinal canal”  Reducing any contents  Transfixing the neck of the sac and removing the remainder. suture Broen Herniorrhaphy recurrenceo rate Up to 15%  Herniotomy and repair of the posterior wall of the inguinal canal. e.g. Shouldice operation. e I Hernioplasty Tx of choice ,