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PRESENTED BY:INUSAH ADAMS

(Ternopil State Medical Univ.)Nov, 2013

HERNIA HERNIORRHAPHY

PLAN OF PRESENTATION DEFINITION EPIDEMIOLOGY TYPES ANATOMY ETIOLOGY PATHOGENESIS SIGNS &SYMPTOMS DIAGNOSIS/INVESTIGATIONS DIFFERENTIALS TREATMENT COMPLICATIONS HERNIORRHAPHY PROGNOSIS

What is hernia?

It is the outlet of the visceral organs from their physiological placement through natural channels or defects of the abdominal and pelvic wall.

Epidemiology

Hernias comprise approximately 7% of all surgical outpatient visits.

Male: female ratio is 8:1.They affect 1-3% of young children.In men, the incidence rises from 11

per 10,000 person-years, aged 16-24 years,

200 per 10,000 person-years, aged 75 years or above.[1]

Classification of abdominal Hernias?Etiology: Congenital and acquired herniasAnatomical location1. Inguinal hernia2. Femoral hernia3. Umbilical hernia4. Epigastric hernia5. Diaphragmatic hernia6. Incisional/recurrent hernia• clinical presentations: incarcerated hernia

(complete and incomplete), reducible and nonreducible, complicated and noncomplicated.

• External (through wall of abdomen) and internal (through the peritoneum) hernias

What is the etiology of hernia?Risk factors are:Malformation of abdominal wallsex age hereditaryObesityAscites weight losspostoperative scar improper weight liftingChronic Constipationchronic coughpregnancy

What is the pathogenesis of hernia?1. incomplete closure of the

abdominal wall in case of congenital hernia

2. increased abdominal pressure 3. increasing dehiscence of fascial

structure with accompanying loss of abdominal wall strength

Where are the most common sites of hernias?

Describe the inguinal canalSite: is situated just above the medial half of

the inguinal ligament. Content: It transmits the spermatic cord

(male) and the round ligament (female); the ilioinguinal nerve.

Length: approx..  3.75 to 4 cm (4-5cm)Direction: It is obliquely directed

anteroinferiorly and mediallyBoundaries/walls: Superior wall: fasciae of internal oblique and transversal abdominal musclesInferior wall: inguinal ligamentAnterior wall: fascia of a external oblique abdominal musclePosterior wall: fascia of transverse abdominal muscle

What is inguinal hernia?hernia in which a loop of intestine

enters the inguinal canalThey make up 75% of all abdominal

wall hernias

Types of inguinal hernia Direct and indirect-Reducible vs. irreducible-Strangulated hernias -unilateral or bilateral

.

.

Indirect inguinal hernia: protrusion of parts of the intestines into the inguinal canal via the internal/deep inguinal ring.

Its sac is lateral to the inferior epigastric artery

Direct inguinal canal: protrusion of parts of the intestines into the inguinal canal through a weak point in the fascia of the abdominal wall.

Its sac is medial to the inferior epigastric artery.

Differences b/n indirect & direct inguinal hernias?

Indirect inguinal hernia Direct inguinal hernia

Hernia gate is deep inguinal ring

Hernia gate is in Inguinal space

Hernia sac is lateral to the spermatic cord or inferior epigastric vessel

Hernia sac is medial to the spermatic cord or inferior epigastric vessel

Shape: oval Shape: round

It can be acquired or congenital

It can Only be acquired

3 elements of herniaHernia gate

Hernia sac (3 parts; neck, body and fundus)

Hernia content

Signs and symptoms?swelling/protrusion

Weakness or pressure in the groin

Pain or discomfort in the groin, especially when bending over, coughing or lifting

Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum

Severe pain in strangulated hernia

Physical examination of patient?Examine the patient (inspection and

palpation) both standing and lying positions

Place your finger on the swelling and instruct patient to cough or strain

positive symptom of "cough push“ is elicited in case of hernia

Assessment of inguinal hernia (Symptom of the "cough push"

what can be done to diagnose hernia?

Anamnesis (weight lifting, chronic cough or constipation, previous abdominal surgeries etc.)

physical examination.(Digital investigation of the hernia channel)

Sonography of the hernia pouch. herniography with injection of X-ray contrast

agent into the peritoneum Common blood analysis. Bacteriological examinations Common urine analysis.

Ultrasound of right inguinal hernia

Differential diagnosis of inguinal hernia?

DISEASE FINDINGS

1. Abscess of groin region Hyperemia of skin, fluctuation, intoxication syndrome, constant pain, leukocytosis, bacterieia

2. Femoral hernia Protrusion below inguinal canal

3. Undescended testes Empty scrotum, negative’’ cough push’’ symptom, ultrasound shows testes in abdomen

4. Varicocele Feeling of heaviness in the testicleMild to Moderate painVisible or palpable enlarged vein

5. Testicular torsion Acute onset, severe pain, testicle is positioned high than normal, ultrasound shows decrease testicular blood flow

.

Left-sided varicocele

How can diagnosis of hernia be formulated?

LocationType Reducible vs. irreducibleComplication (s)

Dx: Indirect Right inguinal hernia, irreducible with strangulation

What are the treatment options of inguinal hernia?

Treatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated.

◦ Reducible hernia Can be treated with surgery but does not have to

be.

◦ Irreducible hernia Urgent surgical treatment because of the risk of

strangulation. An attempt to push the hernia back can be made

◦Strangulated hernia Emergency operation

What are the possible complications of hernia?

Incarcerated (irreducible hernia)

Strangulated herniaSigns and symptoms of strangulated hernia:Nausea, vomiting or bothFeverRapid heart rateSudden pain that quickly intensifiesA hernia bulge that turns red, purple or

darkAbsent bowel sounds on auscultation

Herniotomy & Herniorrhaphy

Open method and

Laparoscopic method

Anterior abdominal wall layers

Preoperative careHistory, physical findings, Lab. Works:

blood test, grouping and cross-matching, urinalysis, ultrasound, etc.

signed informed consent form anesthesiologist examination and

recommendationNPO, urinary catheter if necessary correction of hemodynamics; IV access for

fluids, drugs (sedatives, antibiotics etc.)Explanation of the procedure to patient and

Reassurance

Steps of Herniotomy Skin incision (3-5cm) above and parallel to

inguinal ligament, then subcutaneous tissueLigation of superficial epigastric veinOpening of scarpa’s fasciaOpening of external oblique aponeurosis (follow

fiber direction and avoid nerve damage; ilioinguinal, genitofemoral, iliohypogastric nerves,)

Identify inguinal ligament (poupart’s ligament) Isolate spermatic cord (using a Penrose drain for

convenient retraction)Dissect the spermatic cord (using the index finger

in a sweeping and medially encircling fashion) to the internal ring

Identify and isolate hernia sac (peritoneum)Reposition hernia into abdominal cavityClose the defect

Steps of Herniorrhaphy(Lichtenstein technique)

Identify the conjoint tendon (lateral rectus border)First suture on lateral rectus border (not on pubic

tubercle) to the mesh and tie securely but not too tight

Then over (not through) pubic tubercleSuture to lower part of inguinal ligamentProceed until just beyond the internal inguinal ringCreate a new internal ring and attach upper part of

mesh to inguinal ligamentSize the mesh and secure upper part with single

suturesClose external oblique aponeurosis, then scarpa’s

fasciaSuture skin, infiltrate local anesthetic and apply

sterile dressing

Video (Lichtenstein technique)

.

Herniorrhapy (Bassini Repair)tension method

A technique in which the surgeon sutures the conjoined tendon to the inguinal ligament, which slides the patient’s own muscles together to cover the hole in the abdominal wall and repair the hernia.

Conjoint tendon (falx inguinalis)Common tendon of insertion of the transversus

and obliquus internus muscles into the crest and spine of the pubis and iliopectineal line

Postoperative carePatient is discharged the same

day of operation once anesthesia wears off, but some may need to stay in the hospital overnight.

Drugs: only analgesic is necessary

Diet: start with sips of water, if patient can take it then semi-liquid foods until he can tolerate solid foods

Wound dressing until removal of sutures

Possible complications after herniorrhapy

chronic painejaculation disordersHemorrhage infectionadhesionsImpotencyRecurrent hernias

Prognosis?

The outcome of this surgery is usually very good. In a few persons, the hernia returns.