Hernia

RSST Klaten
Koas stase bedah A13.1
IDENTITAS :
Nama : Tn S
Usia : 53 th
Alamat : Gondangan, Klaten
No CM : 82****
Tanggal masuk RS : 15 Juni 2014
melalui poli

Anamnesis
Keluhan utama: benjolan lipat paha kiri
Pasien memiliki benjolan di lipat paha
kiri sudah satu tahun namun dibiarkan,
bisa keluar masuk, BAB dan BAK tidak
terganggu
Pemeriksaan fisik
TD 130/100
N 90
RR 22
S Afebris
Keadaan umum: CM, baik
I: Tampak benjolan di lipat paha kiri dapat keluar-
masuk
P: NT (-)
P: Suara ketukan di abdomen timpani (+)
A: Peristaltik abdomen(+)

Pemeriksaan penunjang (12/6):
Kimia darah
BUN= 18,6 (>)
AST = 32,6 (>)
Darah Lengkap
Hb = 9 g/dl


Diagnosis:
Hernia inguinalis lateralis sinistra reponibilis
Anemia
Plan: perbaikan kondisi di bangsal,
transfusi PRC 2 kolf, setelah Hb > 10 g/dl
pro herniorepair
Follow up:
tanggal 23/6 dilakukan herniorepair
24/6
S: BAK (+), BAB (-), flatus (+)
O: KU: baik, CM
status lokalis inginal
I : belas operasi tertutup perban, tidak ada rembesan
P : Nyeri tekan (-)
A: HIL dextra reponibilis post herniorepair hari ke 1
P:
Inj Ceftriaxone 1 gr/12 jam
Inj Ketorolac 30 mg/8jam
Inj Ranitidine 1A/12 jam
Mobilisasi duduk
Diit bebas
Laxadine syrup 3 X C2


Definition
A hernia is a protrusion of a viscus or part
of a viscus through an abnormal opening
in the walls of its containing cavity .

Anatomy
The inguinal canal :-
The inguinal canal is approximately 4 cm long and is directed
obliquely
inferomedially through the inferior part of the anterolateral
abdominal wall. The canal lies parallel and 2-4 cm superior to
the medial half of the inguinal ligament.This ligament extends
from the anterior superior iliac spine to the pubic tubercle.
The inguinal canal has openings at either end :
The deep (internal) inguinal ring is the entrance to the inguinal
canal. It is thesite of an outpouching of the transversalis
fascia. This is approximately 1.25 cm superior to the middle of
the inguinal ligament
The superficial, or external inguinal ring is the exit from the
inguinal canal. It is a slitlke opening between the diagonal
fibres of the aponeurosis of the external oblique
Inguinal canal
walls of The inguinal canal :-
The anterior wall is formed mainly by the aponeurosis of the
external Oblique

The posterior wall is formed mainly by transversalis fascia

The roof is formed by the arching fibres of the internal oblique
andtransverse abdominal muscles.

The floor is formed by the inguinal ligament, which forms a
shallow trough. It is reinforced in its most medial part by the
lacunar ligament.


Content :-
1. Spermatic cord ( round ligament of the uterus in female )
The Cord Itself.The contents of the spermatic cord are
(a) the ductus (vas) deferens and its artery .
(b) the testicular artery and venous (pampiniform) plexus.
(c) the genital branch of the genitofemoral nerve.
(d) lymphatic vessels and sympathetic nerve fibers.
(e) fat and connective tissue surrounding the cord and its
coverings in various amounts
2. Ilioinguinal nerve .
Ilioinguinal lymph node .
Femoral Canal
The major feature of the femoral canal is the femoral sheath.
This sheath is a condensation of the deep fascia (fascia lata)
of the thigh and contains, from lateral to medial, the femoral
artery, femoral vein, and femoral canal. The femoral canal is a
space medial to the vein that allows for venous expansion
and contains a lymph node (node of Cloquet). Other features
of the femoral triangle include the femoral nerve, which lies
lateral to the sheath,

Wall of The Femoral canal
anterior is the inguinal ligament
posterior is the iliopsoas, pectineal, and long adductor muscles
(floor).
Medial is lacunar ligament
Lateral is femoral vessle
Predisposing:
All hernias occur at the site of WEAKNESS OF THE
ABDOMINAL WALL which are acted on by repeated
INCREASE in abdominal pressure
repeated INCREASE in abdominal pressure is
usually due to
Chronic cough
Straining
Bladder neck or urethral obstruction
Pregnancy
Vomiting
Sever muscular effort
Ascetic fluid
Types
Inguinal
Femoral
Epigastric
Para umbilical
Umbilical
Obturator
Superior lumbar
Inferioer lumbar
Gluteal
Sciatic
Incisional





Indirect Inguinal Hernia
Hernia through the inguinal canal
Direct Inguinal Hernia
The sac passes through a weakness or defect of the
transversalis fascia in the posterior wall of the inguinal
canal
Femoral Hernia
Hernia medial to femoral vessels under inguinal ligament
Umbilical Hernia
Hernia through the umbilical ring

Paraumbilical Hernia
A protrusion through the linea alba just
above or sometimes just below the
umbilicus
Epigastric Hernia
Protrusion of extraperitoneal fat through the
linea alba anywhere between the xiphoid
process and the umbilicus
Incisional Hernia
Hernia through an incisional site
Lumber Hernia
occur through the inferior lumber triangle of
Petit

Inguinal hernia
History:
1.Age ( young vs. old)
2.Occupation ( nature ?? )
3.Local symptoms: Swelling, discomfort
and pain
4.Systemic symptoms: if there is
obstruction or strangulation
5.Precipitating factors
Inguinal hernia
Examination:
1.Inspection for site, size, shape and
color.
2.Palpation for surface, temp,
tenderness, composition and
reducibility.
3.Expansible cough impulse.
4.General exam: for common causes of
increase intra abdominal pressure
Indirect Versus Direct inguinal hernias
Indirect is the most common form of
hernia and its usually congenital due
to patent processus viginalis


Direct usually acquired occur in old
men with weak abdominal muscles.
Indirect Versus Direct inguinal hernias
Indirect Inguinal Hernia Direct Inguinal Hernia
Pass through inguinal canal. Bulge from the posterior wall of the inguinal canal
Can descend into the scrotum. Cannot descent into the scrotum.
Lateral to inferior epigastric vessels. Medial to inferior epigastric vessels.
Reduced: upward, then laterally and backward. Reduced: upward, then straight backward.
Controlled: after reduction by pressure over the internal (deep)
inguinal ring.
Not controlled: after reduction by pressure over the internal (deep)
inguinal ring.
The defect is not palpable (it is behind the fibers of the external
oblique muscle).
The defect may be felt in the abdominal wall above the pubic
tubercle.
After reduction: the bulge appears in the middle of inguinal
region and then flows medially before turning down to the
scrotum.
After reduction: the bulge reappears exactly where it was before.
Common in children and young adults. Common in old age.
Note that examination using finger and thumb across the
neck of the scrotum will help to distinguish a swelling of
inguinal origin and one that is entirely intrascrotal
Femoral hernia

Small femoral hernia may be unnoticed
by the patient or disregarded for years
perhaps until the day it strangulates.
Adherence of the greater omentum
sometimes causes a dragging pain.
Rarely a large sac is present .


Femoral hernia
History
Age ; uncommon in children , most
common in old age female .
Sex; women > men (but still commonest
hernia in women the inguinal hernia )
The patient came with local symptoms
1- discomfort and pain
2- swelling in the groin
General ; femoral hernia is more likely to
be strangulated than the inguinal hernia
Multiplicity ; often bilateral



Femoral hernia versus inguinal hernia
Inguinal hernia Femoral hernia
1- more common in male 1- more common in females
2- pass through the inguinal canal 2- pass through the femoral canal
3- neck of the sac is above and medial the pubic tubercle 3- neck of the sac is below and lateral the pubic tubercle
4- less common to be strangulated 4- more common to be strangulated
5- can be treated without surgery 5- must be treated surgically
6- the two diagnostic signs of hernia + 6- the two diagnostic signs of hernia -
7- the sac mainly contain ; bowel 7- the sac mainly contains ; omentum
Umbilical hernia
Signs and symptoms
Age ; doesnt appear until the umbilical
cord has separated and healed .
No specific symptoms
Have wide neck and reduce easily ,
rarely give intestinal obstruction.
Nature history ; 90 % disappear
spontaneously during the first year.
Examination
Inspection
Site ; in the center of the umbilicus
Size and shape ; size can vary from vary small
to very large . Shape is usually hemispherical.
Palpation
Composition ; contain bowel , which makes it
resonant to percussion . They reduce
spontaneously when the child lies down .
Reducibility ; easy
Cough impulse; invariably present .
Acquired umbilical hernia

Hernia through the umbilical scar , so it is
a true umbilical hernia.
Not common and is usually secondary to
increase intra abdominal pressure.
The most common causes
1- pregnancy
2- ascitis
3- ovarian cyst
4- fibrodis
5- bowel distention


Incision hernia

Signs and symptoms
Previous operation or accidental trauma
Age ; all ages , but more common in old age.
Symptom ; lump ,pain ,intestinal obstruction ( distention ,colic,
vomiting ,constipation , sever pain in the lump )
Examination
1- reducible lump
2- expansile cough impulse
3- if the lump dose not reduse and dose not have cough
impulse , than it may be not a hernia
Ddx
Tumor
Chronic abscess
Hematoma
Foreign body granuloma
Preoperative assessment

proper history and examination
identify high risk patients
prepare the preoperative notes :
consent..
pre op Dx
procedure planned
surgeons
Anasthesia anticipated (general , local,
spinal)
Preoperative assessment

Investigation data ( pre operative tests ) :
1. Lab :
* CBC : to check hemoglobin level anemia and WBCs
infections
* U&E : to check for any electrolyte imbalance
* LFTs : indicated in jaundiced patients and suspected
hepatitis or any clotting problems
* PT & PTT
* ABG
* grouping and cross matching
2. Imaging :
* Chest X ray : for all patients
3. ECG : for any patient who is more than 40 years of age


Preoperative assessment


current medications or allergies
any major (chronic) illness
pre op orders :
1. skin preparation
2. diet (NPO)
3. GIT preparation
4. Sedation
5. Preanesthetic medications
6. Other medications
7. Antibiotics
8. Blood transfusion ( if needed )
9. Bladder preparation



Inguinal Hernia Repair
Reduction
Surgical
TTT
Pre op
Evaluation
&
preparation
Surgical TTT
Choice of
Anesthetic
TTT of hernial sac
Inguinal floor
reconstruction
Pre op evaluation &preparation
Watchful Waiting
Surgical TTT
May be appropriate for pt with asymptomatic hernia or elderly
pt with minimal symptoms or easily reduced inguinal hernia.
Routine F/U with health care professional
A Randomized trial concluded that this is an acceptable option for men with minimally symptomatic inguinal hernia and that delaying repair until symptoms increase is safe
due to low rate of incarceration. 23% of pt initially treated with watchful waiting crossed over to surgical ttt due to increase in symptoms (most often hernia-related pain) ,
only 1 pt (0.3%) experienced acute hernia incarceration without strangulation within 2years, a second had acute incarceration with
Bowel obstruction at 4 years, corresponding to frequency of acute intervention of 1.8/1000 pt-years (JAMA 2006,295:285)
Pre op preparation
Most pt are treated surgically
Increase IAP abnormalities (Chronic cough,
Constipation, Bladder outlet obstruction)
should be evaluated and remedied to extent
possible before elective herniorrhaphy.
In case of intestinal obstruction and
possible strangulation, Broad spectrum
AB,NG suction may be indicated, correction
of volume status& elctroyles.
Reduction
Uncomplicated:
Manual Gentle pressure over hernia
Gentle traction over the mass sedation
and trendelenburg position.

Complicated (strangulated):
no attempt should be made to reduce the
hernia because of potential reduction of
gangrenous segment of bowel with the
hernial sac.
Surgical TTT
1.choice of anesthetic:
elective open repair : Local is
preferred
Laproscopic hernia repair: more
commonly under GA.


2.TTT OF HERNIAL SAC
INDIRECT: sac is dissected free from the
cord structures and creamsteric fibers. Sac
should be open away from any herniated
contents. Contents are then reduced, and
the sac is ligated deep to inguinal ring with
an absorbable suture

DIRECT:
Too broadly based for ligation and should
not be opened, simple freed from
transversalis fibers and inverted.
3.Inguinal Floor
Reconstruction
Some method of
reconstruction of the
inguinal floor is
necessary in all adult
hernia repairs to
prevent recurrence.
3.Inguinal
Floor
Reconstruction
Primary tissue repair
Open tension free
repair
Laproscopic &
preperitoneal repairs
1.Primary tissue repair

Bassini repair: inferior arch of
transversalis fascia (TF) or conjoint
tendon is approximated to shelving
portion of inguinal ligament.

McVay: TF is sutured to cooper
ligament.

Shouldice: TF is incised and
reapproximated.
2.Open tension free
repair
Lichtenstein repair &Patch and Plug
technique: Mesh is used to reconstruct
inguinal floor

Mesh plug technique : place mesh in
the hernial defect

Laproscopic &
preperitoneal repairs

TAPP (transabdominal prepeitoneal procedure): peritoneal
space entered by conventional lap at umbilicus and
peritoneum overlaying inguinal floor is dissected away as flap.

TEP (Total extraperitoneal repair): preperitoneal space is
developed with a balloon inserted between posterior rectus
sheath and peritoneum balloon inflated to dissect the
peritoneal flaps awau from posterior abdomianl wall and the
direct and indirect spaces, other ports inserted into this
preperitoneal space without entering peritoneal cavity.

After lap. Dissection and reduction of hernia sac , a large
piece of mesh is placed over inguinal floor
Femoral hernia repair
Femoral hernias should be repaired very soon after the
diagnosis has been made because of the high risk of
strangulation.
There is no place for a truss for a femoral hernia.
Different approaches :
Open VS Laparoscopic

Open surgery
Three approaches have been described for
open surgery :
1.Infra-inguinal approach (Lookwood)
2.Supra-inguinal approach ( McEvedy)
3.Trans-inguinal approach ( Lotheissen)
Each technique has the principle of
dissection of the sac with reduction of its
contents, followed by ligation of the sac
and closure between the inguinal and
pectineal ligaments.
Lockwoods infra-inguinal
approach
The sac is dissected out below the
inguinal ligament via groin crease
incision.
Then the sac is opened and the
contents are inspected and reduced
into the abdomen.
Then the neck of the sac is pulled
down , ligated and allowed to retract
through femoral canal.
Then close the femoral canal by mesh
plug or non absorbable sutures.
McEvedys high approach
Vertical incision is made over the femoral
canal and continued upwards above the
inguinal ligament.
This incision provides good access to the
preperitoneal space and then to the
peritoneum itself.
Use finger dissection to sweep
peritoneum from anterior abdominal wall
, so the neck of the sac can be
identified.
Dissect the sac , reduce the contents
and repair the defect by mesh or sutures.
Lotheissens trans-inguinal
approach
The incision is made superior and
parallel to inguinal ligament extending
from pubic tubercle to mid inguinal
point.
Thank
You