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Hernia

Hernia. Abnormal protrusion of an organ or tissue, through a defect in its surrounding walls Various sites of the body Most commonly abdominal wall hernia. Hernia. External – protrudes through all layers of abdominal wall

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Hernia

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  1. Hernia • Abnormal protrusion of an organ or tissue, through a defect in its surrounding walls • Various sites of the body • Most commonly abdominal wall hernia

  2. Hernia • External – protrudes through all layers of abdominal wall • Internal – protrusion of the intestine through a defect within peritoneal cavity

  3. Groin Inguinal Femoral Anterior Umbilical Epigastric Spigelian Pelvic Obturator Perineal Posterior Lumbar Superior triangle Inferior triangle Abdominal wall hernias

  4. Hernia • Reducible – content can be replaced within the surrounding musculature • Irreductible or incarcerated – cannot be reduced • Strangulated – compromised blood supply - complications

  5. Hernia strangulation • Large hernia – small orificies • Small neck obstructs blood flow, venous drainage or both • Adhesions between content and peritoneum – obstruction and strangulation of the intestine

  6. Hernia – incidence • 600.000/y hernia repairs in US • Most common operation performed by general surgeons • 5% of population will develope abdominal wall hernia

  7. Hernia incidence • 75% of all hernias occur in the inguinal region • 2/3 – indirect hernias • Men – 25 times more likely to have groin hernia then woman • Female – femoral and umbilical hernias more often then inguinal (10/1 and 2/1 respectively)

  8. Hernia incidence • Both inguinal indirect and femoral – more commonly on the right side • Delay in atrophy of right processus vaginalis peritonei • Slower decent of thr right testis to the scrotum • Tamponading effect of sigmoid colon on the left femoral canal

  9. Hernia – inguinal canal • 4 cm lenght, 2 – 4 cm up to inguinla ligament • Extends between internal (deep) and external (superficial) inguinal ring • Contain spermatic cord or round ligament of the uterus

  10. Hernia – inguinal canal • Spermatic cord • Cremasteric muscle fibres • Testicular artery • Pampiniform plexus • Genital branch of genitofemoral nerve • Vas deferens • Cremasteric vessels • Lymphatics • Processus vaginalis

  11. Hernia – inguinal canal • Superficial – external oblique aponeurosis • Upper (cephalad) – intermnal oblique and transversus muscle • Inferior – inguinal and lacunar ligament • Posterior – transversalis fascia

  12. Hernia – diagnosis • Bulge in the inguinal region • Pain or discomfort (groin hernias are not extremely painful) • Paresthesias (compression or irritation of inguinal nerves)

  13. Hernia – differential diagnosis • Inguinal hernia • Femoral hernia • Hydrocele • Inguinal adenitis • Varicocele • Ectopic testes • Lipoma • Hematoma

  14. Hernia – differential diagnosis • Psoas abscess • Femoral adenitis • Lymphoma • Metastatic nepolasm • Epididymitis • Testicular torsion • Femoral artery aneurysm or pseudoaneurysm • Hydradenitis of inguinal apocrine glands

  15. Hernia – physical examination • Both supine and standing position • Visual and palpative inspection for mass in inguinal region • Ask patient to cough or perform Valsalva maneuver • Fingertip OVER inguinal canal • Finally fingertip into inguinal canal – small hernia

  16. Hernia – physical examination • PROBLEM – bulge of the groin described by the patient not demonstrated during examination??? • Ask patient to stand for a period of time • Repeat examination (sometimes another visit)

  17. Hernia – examination • USG – high degree of sensitivity and specificity in detection of occult direct, undirect and femoral hernias • CT – abdomen and pelvis – to diagnose unusual hernias or atypical groin masses

  18. Hernia – nonoperative management • Opertaion recomended on discovery!!! • Progressive enlargement and weakening • Potential for incarceration and strangulation • Exclusions: • Short life expectancy patients • Significant comorbid ilnesses • Minimal symptoms

  19. Hernia – nonoperative management • Trusses – provide symtomatic relief • Correct measurement and fitting are the key • Hernia control in 30% patients • Complications: • Testicular atrophy • Ilioinguinal or femoral neuritis • Hernia incarceration

  20. Hernia – nonoperative management • NOT RECOMMENDED IN FEMORAL HERNIAS!!! • High incidence of complications, particulary strangulation

  21. Hernia – operative repair Anterior repairs: • Most common technique • Tension – free techniqes are standard • Older types – indicated for small hernias

  22. Hernia – operative repair

  23. Hernia – operative repair

  24. Hernia – operative repair

  25. Hernia – operative repair

  26. Hernia – operative repair

  27. Hernia – operative repair

  28. Hernia – operative repair

  29. Hernia – operative repair

  30. Hernia – Bassini repair

  31. Hernia – Bassini repair

  32. Hernia – Bassini repair

  33. Hernia – Bassini repair

  34. Hernia – Halstead repair

  35. Hernia – Shouldice repair

  36. Hernia – Lichtenstein repair

  37. Hernia – Lichtenstein repair

  38. Hernia – Lichtenstein repair

  39. Hernia – Lichtenstein repair

  40. Hernia – other methods • Girard • Kirschner • Marcy • Mc Arthur • Mc Vay • Wolfer • Zimmerman

  41. Hernia – laparoscopic management • Minimal invasive ??? • Tension – free mesh repair • Less pain • Quicker recovery • Better visualisation of anatomy • Fixing all hernia defects • Decreased surgical site infections

  42. Hernia – laparoscopic management • Complication rate – less then 10% • Reccurrence rate 0 – 3%

  43. Hernia – laparoscopic management • TAPP – transabdominal preperitoneal approach • TEP – total extraperitoneal approach – without entering peritoneal cavity

  44. Hernia – laparoscopic management • Infraumbilical incision • Dissecting baloon inflated under vision • Created space is insuflated, aditional trocars are placed • Reduction of hernia (hernias) • Traction • Large sac shoud be cautered to inguinal ring

  45. Hernia – laparoscopic management • 10x15 cm mesh inserted through a trocar and unfolded • Mesh should cover direct, indirect and femoral area • It’s secured with a tacking stapler

  46. Hernia – femoral canal • Superficial – inguinal ligament • Lateral – femoral vein • Posterior – Cooper’s ligament

  47. Hernia – femoral canal

  48. Femoral hernia

  49. Femoral hernia - diagnosis • Mass or bulge occursbelow inguinal ligament • If it’s over inguinal ligament – it still could be femoral hernia (hernia sac is ascending) • It’s usually more painful then inguinal

  50. Femoral hernia - repair • Dissection and removal of hernia sac • Obliteration of the femoral canal defect • Cooper’s method • Mesh • In case of strangulation, hernia sac content should always be examined for viability

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