Hernia Terminology And Examination.pptx

Hernia terminology And Examination Dr Ömer Faruk İNANÇ Aydın University Faculty Of Medicine 2023 What is a hernia? • A hernia occurs when part of your insides bulges through an opening or weakness in the muscle or tissue that contains it. • They can also result from an injury, surgery or birth dis...

Hernia terminology And Examination Dr Ömer Faruk İNANÇ Aydın University Faculty Of Medicine 2023 What is a hernia? • A hernia occurs when part of your insides bulges through an opening or weakness in the muscle or tissue that contains it. • They can also result from an injury, surgery or birth disorder. A basic illustration of abdominal hernia and repair Anterior Abdominal Wall Types of hernias • Inguinal hernia. Inguinal hernias are the most common type, accounting for 75% of all hernias. They mostly affect men or people assigned male at birth (AMAB). They happen when part of your bowel protrudes into your inguinal canal, a passageway that runs down your inner thigh. • Femoral hernia: A femoral hernia is a less-common type of groin hernia that occurs in the femoral canal, which runs underneath the inguinal canal. Fatty tissue may poke through. • Obturator Hernia: A rare type of hernia occurs in obturator cannal • Hiatal hernia: Herniation of stomach to the mediastinum through the eusofageal opening of diaphragma. • Incisional hernia: An incisional hernia occurs when tissue protrudes through a former incision in your abdominal wall that weakened over time. It’s a common side effect of abdominal surgery. • Umbilical hernia. An umbilical hernia occurs when part of your intestine pokes through an opening in your abdominal wall near your belly button. Most umbilical hernias are congenital (present from birth). • Ventral hernia. A ventral hernia is any hernia that occurs through the front wall of your abdomen. It includes umbilical hernias and incisional hernias. • Epigastric hernia is a ventral hernia above the belly button. • Spiegel Hernia: A spigelian hernia is a rare, abnormal protrusion of abdominal contents or peritoneum through a defect (spigelian fascia), which is comprised of the transversus abdominis and the internal oblique aponeuroses • Lombar Hernia: Lumbar hernias occur through defects in the lumbar muscles or the posterior fascia, below the 12 th rib and above the iliac crest Inguinal Hernia • The anatomic arrangement of muscular and fascial layers in the lower abdomen makes this area a site of potential weakness with possible development of inguinal hernias. Passage through this region by the vas deferens and spermatic vessels in the male and by the round ligament in the female makes the area more vulnerable to hernia protrusions. Amerson JR. Inguinal Canal and Hernia Examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 96. Available from: https://www.ncbi.nlm.nih.gov/books/NBK423 https://www.youtube.com/watch?v=XrUGnE_qf3w Anamnesis • A history of pain, swelling, or presence of a mass in the groin area is significant. Specific questions need to be asked: • How long have you noticed the discomfort (swelling, mass, pain)? • Does standing or activity such as lifting intensify or evoke the pain? • Does coughing or sneezing make the lump more prominent? • Will lying down relieve the symptoms or allow the swelling to disappear? • Can you push the mass back in with your hand? • Have you ever had difficulty pushing the mass back into the abdomen? • Have you ever had a hernia or operation on the other side? Examination • Examination of the inguinal region in both men and women is best performed with the patient standing and the physician seated on a stool facing the patient. Observation of the groin area in oblique light with the patient relaxed and then actively coughing may reveal a bulge or an abnormal motion. Scrotal masses may also be noted by inspection and palpation. Carefully observe whether any bulge noted is above (inguinal hernia) or below (femoral hernia) the inguinal ligament crease. The examiner should then stand to the side of the patient with the fingers lightly applied to the groin, the left hand on the patient's left side and the right hand on the patient's right side. With the fingers placed over the femoral region, the external inguinal ring, and the internal ring, have the patient cough. A palpable bulge or impulse located in any one of these areas may indicate a hernia. • Any mass found on groin examination should be gently pressed with the examining fingers in an attempt to reduce the hernia and thereby cause the contents of the sac to return to the peritoneal cavity. Incarcerated hernias may be reduced more easily with the patient recumbent on the examining table. Mild sedation may be necessary to provide sufficient muscle relaxation to allow for reduction. Any hernia mass that is tender to palpation or associated with symptoms of nausea and vomiting should be considered possibly strangulated (compromised vascularity of entrapped bowel), and no attempt should be made to reduce it manually. This condition represents an acute surgical emergency. Basic Science • Indirect inguinal hernias are due to a persistence of the processus vaginalis through the internal ring for a varying distance along the course of the spermatic cord or round ligament. This protrusion of peritoneum constitutes the so-called hernia sac. The hernia does not become detectable, however, until intra-abdominal fat, fluid, or a viscus enters the sac. The processus vaginalis is always located anterior and medial to the structures of the spermatic cord or round ligament. With time, pressure applied by the intraabdominal contents in the sac causes enlargement of the sac and dilation of the internal inguinal ring. After prolonged enlargement, the transversalis fascia, which is the primary support of the posterior wall of the inguinal canal, becomes attenuated. Basic Science • A direct inguinal hernia develops medial to the internal inguinal ring. The posterior wall weakens as the transversalis fascia thins, and a bulge results. These hernias usually contain properitoneal fat and bladder wall and are rarely found to extend into the scrotum. • Indirect inguinal hernia develops through the internal inguinal ring to the inguinal canal. They can extend to the scrotum. Direct & Indirect Inguinal Hernia Specific Types Of İnguinal Hernia • Littre’s Hernia: Herniation of Meckel diverticulum • Amyand Hernia: Herniation of appendicitis • Richter Hernia: Herniation of animesenteric wall of intestine Femoral Hernia • Femoral hernias, which exit from the retroperitoneal space along the femoral vessels in the femoral canal, can on occasion be confused with inguinal canal hernias. • Defects medial to the femoral vein as it passes beneath the inguinal ligament allow for the development of femoral hernias. Approximately 80% of all inguinal hernias occur in males, whereas 85% of all femoral hernias occur in females. Terminology and Pathogenesis of Stragulation • Strangulation • İncarceration • Reductable • Irreductable Clinical Significance • Indirect inguinal hernias not only may cause discomfort and pain but also may lead to severe problems requiring urgent or emergency surgery to prevent or correct lifethreatening complications Clinical Significance • An incarcerated hernia represents entrapped viscera (usually small bowel or omentum) that cannot be easily reduced into the peritoneal cavity through the internal inguinal ring by gentle pressure on the hernia mass. Although the vascularity of the incarcerated bowel may not be compromised, the patient develops intestinal obstruction. This requires early surgical release of the entrapped bowel and repair of the hernia defect. Prolonged entrapment of bowel in the hernia sac by a tight internal ring leads to edema of the bowel, subsequent venous occlusion, arterial congestion, and finally gangrenous changes in the involved bowel wall and mesentery. Clinical Significance • Such strangulated hernias result not only in intestinal obstruction but also in bowel perforation, peritonitis, septicemia, and vascular collapse. Rapid resuscitation and surgical intervention with resection of the compromised segment of bowel are required to prevent ensuing complications that may lead to a fatal outcome. Elective surgical repair of hernias found on physical examination prevents problems that may develop with incarcerated or strangulated viscera. Emergency surgical correction is mandatory when an incarcerated or strangulated inguinal hernia develops. Umblical Hernia • An umbilical hernia is a ventral hernia located at or near the umbilicus. The European Hernia Society classification for abdominal wall hernias defines the umbilical hernia as a hernia located from 3 cm above to 3 cm below the umbilicus. • It is the second most common type of hernia in an adult following inguinal hernia. It accounts for 6%-14% of all abdominal wall hernias in adults. Pathophysiology Of Umblical hernia • Anatomically, the umbilical hernia could occur either through a potential weakness present at the exit site of involuted umbilical vessels, most importantly the umbilical vein or through weakened umbilical fascia (Richet's fascia). Therefore, umbilical hernia covering consist of skin, subcutaneous tissue, weakened superficial fascia, weakened umbilical fascia and peritoneum, practically all these layers are greatly attenuated and fused together Physical Examination Of Umblical Hernia Adult with umbilical hernia typically presents with protrusion or bulging from the umbilicus. Pain and GI discomfort are other possible but infrequent presenting symptoms while tenderness and incarceration are common physical finding. Small-sized umbilical hernia often asymptomatic and only sometimes causes some degree of discomfort. Strangulation of the umbilical hernia is a frequent complication; typically patients present with irreducible tender umbilical bulge with skin color changes and signs of intestinal obstruction if the sac contains a loop of small bowel. Coste AH, Jaafar S, Parmely JD. Umbilical Hernia. [Updated 2023 Mar 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Hiatal Hernia Spigelian Hernia • A spigelian hernia is a rare, abnormal protrusion of abdominal contents or peritoneum through a defect (spigelian fascia), which is comprised of the transversus abdominis and the internal oblique aponeuroses. It typically results from an underlying pathology that increases intraabdominal pressure, abdominal wall trauma, or degeneration of abdominal aponeurotic layers. Lumbar Hernia • Lumbar hernias occur through defects in the lumbar muscles or the posterior fascia, below the 12th rib and above the iliac crest. Sapanca/Sakarya/TÜRKİYE