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HERNIA dr sigid djuniawan

HERNIA dr sigid djuniawan. Introduction Protrusion of the peritoneum or preperitoneal fat through an abnormal opening in the abdominal wall Presents as a bulge Peritoneal contents may be trapped in “sac” Asymptomatic bulge most common Symptoms

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HERNIA dr sigid djuniawan

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  1. HERNIAdr sigid djuniawan

  2. Introduction • Protrusion of the peritoneum or preperitoneal fat through an abnormal opening in the abdominal wall • Presents as a bulge • Peritoneal contents may be trapped in “sac” • Asymptomatic bulge most common • Symptoms • Physical effects of sac and contents on surrounding tissues • Obstruction and/or strangulation of hernia sac contents

  3. Epidemiology • 700,000 hernia repairs year • Inguinal hernias -75% of all hernias • 2/3 Indirect, remainder are direct • Incisional hernias – 15 to 20% • Umbilical and epigastric – 10% • Femoral – 5%

  4. Epidemiology • Prevelance of hernias increases with age • Most serious complication – strangulation • 1 to 3% of groin hernias • Femoral – highest rate ofcomplications 15% to 20% • recommended all be repaired at time of discovery

  5. Anatomy

  6. Areas of Natural Weakness Used with permission from the American College of Surgeons

  7. Anatomy • Inguinal ligament (Poupart’s) – inferior edge of external oblique • Lacunar ligament – triangular extension of the inguinal ligament before its insertion upon the pubic tubercle • conjoined tendon (5-10%)- Internal oblique fuses with transversus abdominis aponeurosis • Cooper’s Ligament - formed by the periosteum and fascia along the superior ramus of the pubis.

  8. Inguinal Canal • Between deep and superficial inguinal rings • Boundaries • Superifical – external oblique aponeurosis • Superior – internal and transversus • Inferior – shelving edge of inguinal ligament and lacunar ligament • Posterior (floor) – transversalis fascia and aponeurosis of transversus abdominis muscle

  9. Components of Hesselbach’s triangle include which of the following anatomic landmarks? • Pectineal ligament • Lateral border of the rectus sheath • Cooper’s ligament • Inguinal ligament • Inferior epigastric vessels

  10. Hernia Diathesis • Varies with age • Pediatric: congenital remnant • Adult • Tissue weakness • Burst strength < abdominal wall tension • Varies with gender

  11. Hernia Diathesis • Pediatric: major risk is premature birth • Adult • Obesity • Previous abdominal surgery • Pregnancy • Abrupt abdominal wall exertion

  12. What is a Hernia composed of? Sac: a folding of peritoneum consisting of a mouth, neck, body and fundus. Body: which varies in size and is not necessarily occupied. Coverings: derived from layers of the abdominal wall. Contents: which could be anything from the omentum, intestines, ovary or urinary bladder.

  13. A sliding inguinal hernia on the left side is likely to involve which of the following? • Jejunum composing the posterior wall of the sac • Ovary and fallopian tube in a female infant • Omentum • Sigmoid colon composing the posterior wall of the sac • Cecum composing the anteromedial wall of the sac

  14. Terminology • Pantaloon – direct and indirect components • Richter’s – contains antimesenteric portion of small bowel • Sliding – involves visceral peritoneum of an organ , i.e. bladder, ovary • Littre’s – hernia contains Meckel’s diverticulum • Petit – hernia at inferior lumbar triangle • Grynfelt – hernia at superior lumbar triangle

  15. Clinical Evaluation: History • Demographics • Age • Gender • Presentation of bulge • When, where, how • Activities that make it better or worse • Discomfort vs. pain • Signs/symptoms of bowel obstruction

  16. Clinical Evaluation: History • Surgery: previous repairs/operations • Review of factors related to increased intra-abdominal pressure • Chronic cough • Constipation • Straining to urinate

  17. Clinical Evaluation: Location • Groin: 75% • Inguinal • Femoral • Anterior abdominal wall: 25% • Umbilical • Epigastric • Spigelian • Incisional

  18. Hernia Pathology • Contents of hernia sac • Bowel (small and large, appendix) • Incarceration of portion of bowel wall: Richter’s hernia: Strangulation occurs without obstruction • Omentum, bladder, ovary, fallopian tubes • Sac wall may be formed by large bowel, bladder, or the ovary/tube: Sliding hernia

  19. Hernia Pathology • Fascial defect may exist without peritoneal hernia sac • Preperitoneal abdominal wall contents may protrude through fascial defect • Preperitoneal fat • Lymph node

  20. Hernia Pathology • Incarceration: contents of hernia sac not reducible into peritoneal cavity • Acute: fascial margins trap contents • Chronic: contents adhesed in sac • Strangulation: incarceration with compromise of blood supply • Narrow neck at greatest risk: indirect inguinal, femoral, and umbilical

  21. Hernia Repair Indications • Asymptomatic • prevent visceral incarceration and/or strangulation • Symptomatic, non-obstructed • Treat discomfort from bulge • Prevent incarceration/strangulation • Visceral obstruction/strangulation • Release obstruction/manage viscera • Prevent recurrence

  22. Groin Hernia • Men : Women 25 : 1 • Right : Left 2 : 1 • Femoral • Women > Men • Strangulation risk > inguinal • Inguinal • Indirect : Direct 2 : 1 • Most common in men and women

  23. Groin Hernia • Inguinal: relationship of sac to inguinal canal determines external bulge • Movement from internal ring to scrotum • Bilateral hernias: direct 4x indirect • Indirect vs. direct hernia is intraoperative diagnosis, not clinical diagnosis • Femoral: relationship of sac to inguinal ligament determines external bulge

  24. Groin Hernia: Inguinal • Adults • Weakness of transversalis fascia • Indirect: sac is lateral to inferior epigastric vessels • Direct: sac is medial to inferior epigastric vessels • Pantaloon: both indirect and direct • Pediatric: patent processus vaginalis

  25. Inguinal hernia Femaleinguinal hernia Male inguinal hernia

  26. Groin Hernia: Differential Diagnosis • Tendonitis • Muscle tear • Lymph node • Lipoma • Varicose vein • Hydrocele • Epididymitis • Spermatocele

  27. Groin Hernia Management • Most hernias: ambulatory OR • Local/regional/general anesthesia • Prohibitive operative risk: truss

  28. Groin Hernia Management • Acute incarceration • Reduction (taxis) • Distal traction and gentle milking • Caution: reduction en masse • Successful reduction shows visually • Urgent elective repair if reduced

  29. Groin Hernia Management • Emergent repair • Irreducible acute incarceration • Strangulation • Fluid, electrolyte resuscitation

  30. Groin Hernia Surgical Classification (Nyhus) • I: Indirect hernia w/normal internal ring • 2: Indirect hernia w/enlarged internal ring • 3a: Direct inguinal hernia • 3b: Indirect hernia with weak floor • 3c: Femoral hernia • 4: All recurrent hernias

  31. Direct Inguinal Hernia

  32. Direct Inguinal Hernia • Medial to the inferior epigastric artery and vein, and within Hesselbach's triangle • acquired weakness in the inguinal floor

  33. Indirect Inguinal Hernia • Accepted hypothesis: incomplete or defective obliteration of the processus vaginalis during the fetal period • remnant layer of peritoneum forms a sac at the internal ring • more frequently on the right

  34. Femoral • More common in females • Up to 40% present as emergencies with hernia incarceration or strangulation • Passes medial to the femoral vessels and nerve in the femoral canal through the empty space • Inguinal ligament forms the superior border

  35. Groin Hernia Surgery: Open • Indirect sac: high ligation • Men: ligation at internal ring • Women: ligation/excision of round ligament with closure of internal ring • Cord lipoma: excision

  36. Operative • Bassini • Shouldice • McVay • Lichtenstein • Preperitoneal • Laparoscopic

  37. Bassini (early 20th Century) • Transversus abdominis to Thompson’s ligament and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament • Shouldice (1930s) • Multilayer imbricated repair of the posterior wall of the inguinal canal • McVay (1948) • Edge of the transversus abdominis aponeurosis to Cooper’s ligament; incorporate Cooper’s ligament and the iliopubic tract (transition suture)

  38. BASSINI MCVAY SHOULDICE

  39. Lichtenstein • First pure prosthestic, tension-free repair to achieve low recurrence rates

  40. Groin Hernia Surgery: Open • Inguinal floor: tension-free repair with mesh • Anterior plug and patch • Anterior patch • Posterior patch (Stoppa)

  41. Groin Hernia Surgery • Open tissue repair for risk of infection (example: strangulated hernia) • Laparoscopic • Indications • Recurrent hernia • Bilateral hernias • Must be able to tolerate general anesthesia • More expensive

  42. Groin Hernia Repair Complications • Recurrence • Tissue repair: 1.3—25% • Tension-free mesh: 0.5—5% • Greatest risk is repair of previous hernia at same location

  43. Groin Hernia Repair Complications • Chronic groin pain: up to 30% • Numbness over base of scrotum

  44. Groin Hernia Repair Complications • Wound • Hematoma: 1.0% • Infection: 1.3% • Seroma • Infertility • Injury to vas deferens • Ischemic orchitis is uncommon • Urinary retention

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