Approach to complicated Hernia

This is a detailed lecture about different complications of Hernia and their management. Including; Irreducible, obstructed, strangulated, incarcerated hernia.

1. Approach to complicated Hernia Dr. Jwan Ali AlSofi

2. Complications of Hernia :- Irreducible : if contents cannot be returned to the abdomen, and there is no other complications . Obstructed : if bowel in the hernia has a good blood supply but is obstructed (by stool for example). Strangulated : if blood supply of bowel is obstructed. Infarcted – when contents of the hernia have become gangrenous, high mortality Inflamed : if contents of the sac became inflamed. Incarcerated : includes all of the above, a broad term which is not commonly used.

3. Uncomplicated hernia No skin changes:- No redness, No ulceration. Impulse on coughing/straining Reducible Extent Bubonocele - within inguinal canal Funicular - exited superficial ring Complete inguinoscrotal - into scrotal sac Incarcerated Irreducible Relatively well No features of obstruction/strangulation Obstructed Features of intestinal obstruction Irreducible Strangulated Irreducible Tender , indurated, erythematous skin Sepsis Features of intestinal obstruction • Recurrent Evidence of prior repair Complicated hernia Clinical presentation

4. Complicated hernia UnComplicated hernia

5. Reducible & Irreducible hernias Reducible Hernia Irreducible Hernia The hernia either reduces itself when the patient lies down . Can be reduced by the patient or the surgeon. A reducible hernia imparts an expansile impulse on coughing . The intestine usually gurgles on reduction . The first portion is more difficult to reduce than the last. Omentum , in contrast, is described as doughy and the last portion is more difficult to reduce than the first . The contents cannot be returned to the abdomen It is usually due to adhesions between the sac and its contents or overcrowding within the sac . Irreducibility without other symptoms is almost diagnostic of an omentocele , especially in femoral and umbilical hernias . Note that any degree of irreducibility predisposes to strangulation . 6

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7. Obstructed & Incarcerated Hernia Obstructed Hernia Incarcerated Hernia This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel . The symptoms :- colicky abdominal pain and tenderness over the hernia site . Symptoms are less severe and the onset more gradual than in strangulated hernias, Usually there is no clear distinction clinically between obstruction and strangulation . The safe course is to assume that strangulation is imminent and treat accordingly . This term is correctly employed only when it is considered that portion of the colon occupying a hernial sac is blocked with faeces . The contents of the bowel should be capable of being indented with the finger, like putty. 8

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9. Differential diagnosis of irreducible Hernia:- a lymph node groin mass an abdominal mass. Such cases require urgent investigation by either ultrasound or CT scan 10

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11. Strangulated hernia A hernia becomes strangulated when the blood supply of its contents is seriously impaired . Gangrene may occur as early as 5–6 hours after the onset of the first symptoms. Femoral hernia is more likely to strangulate because of the narrowness of the neck and its rigid surrounding . 12

12. Strangulation of an inguinal hernia occurs at any time during life and in both sexes . Indirect inguinal hernias strangulate more commonly. The direct variety not so often because of the wide neck of the sac. Sometimes a hernia strangulates on the first occasion that it descends ; more often strangulation occurs in patients who have worn a truss for a long time and in those with a partially reducible or an irreducible hernia. In order of frequency, the constricting agent is : the neck of the sac; the external inguinal ring in children; Adhesions within the sac (rarely). 13

13. Contents In order of frequency:- Usually the small intestine is involved in the strangulation the next most frequent being the omentum ; sometimes both are involved . It is rare for the large intestine to become strangulated in an inguinal hernia, even when the hernia is of the sliding variety . 14

14. Strangulation during infancy:- The incidence of strangulation in infancy is 4% . The ratio of girls to boys is 5:1. More frequently, the hernia is irreducible but not strangulated. In most cases of strangulated inguinal hernia occurring in female infants, the content of the sac is an ovary or an ovary plus its fallopian tube . 15

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16. Pathology of Strangulated Hernia Initially, only the venous return is impeded . The wall of the intestine becomes congested and bright red with the transudation of serous fluid into the sac. The intestinal pressure increases , distending the intestinal loop and impairing venous return further. As venous stasis increases, the arterial supply becomes more and more impaired . Blood is extravasated under the serosa and is effused into the lumen . At this stage the walls of the intestine have lost their tone and become friable . Bacterial transudation occurs secondary and the sac fluid becomes infected. Gangrene appears at the rings of constriction . The colour varying from black to green depending on the decomposition of blood in the subserosa . The mesentery involved by the strangulation also becomes gangrenous. Perforation of the wall of the intestine occurs, either at the convexity of the loop or at the seat of constriction. Peritonitis spreads from the sac to the peritoneal cavity . 17

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18. Symptoms of strangulated hernia Sudden pain, situated over the hernia . Generalised abdominal pain, colicky in character and often located mainly at the umbilicus. Nausea and subsequently vomiting ensue. The patient may complain of an increase in hernia size. Spontaneous cessation of pain must be viewed with caution, as this may be a sign of perforation 19

19. Signs of Strangulated Hernia On examination the hernia is tense. Extremely tender and irreducible . There is no expansile cough impulse. The spasms of pain continue until peristaltic contractions cease with the onset of ischaemia . Paralytic ileus , peritonitis , and septicaemia develop. Spontaneous cessation of pain may be a sign of perforation . 20

20. Richter’s hernia Is a hernia in which the sac contains only a portion of the circumference of the intestine (usually small intestine). It usually complicates femoral hernia . Rarely, obturator hernias. 21

21. Types of Strangulated Hernia Strangulated Richter’s hernia . Strangulated omentocele . Inflamed hernia . 22

22. Inflamed Hernia 23

23. Investigations of complicated Hernia :- FBC - leukocytosis BUSEC - electrolyte derangements, AKI ABG - acid-base imbalance PT/PTT - sepsis with coagulopathy Blood C+S - sepsis GSH 24

24. Treatment of strangulated inguinal hernia:- The treatment of strangulated hernia is by emergency operation . Non-operative treatment of hernias  Only indicated in children. 25

25. Preoperative treatment of complicated inguinal hernias:- Resuscitate with adequate fluids Empty stomach with nasogastric tube Give antibiotics to contain infection Catheterise to monitor haemodynamic state ** operation should not be unduly delayed in moribund patients 26

26. Non-operative treatment of complicated hernias :- These are indicated only in infants . The child is given analgesics The child is Placed in gallow’s traction ( the judgement of Solomon position). In 75% of cases reduction is effected and there appears to be no danger of gangrenous intestine being reduced (Irvine Smith ). Taxis manoeuvre (forcible reduction) – is contraindicated in strangulated hernia. 27

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28. Note that vigorous manipulation ( taxis ) has no place in modern surgery and is mentioned only to be condemned. Its dangers include: contusion or rupture of the intestinal wall reduction- en -masse : ‘The sac together with its contents is pushed forcibly back into the abdomen; as the bowel will still be strangulated by the neck of the sac, the symptoms are in no way relieved ’. reduction into the a loculus of the sac the sac may rupture at its neck and the contents are reduced, not into the peritoneal cavity but extraperitoneally . 29

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30. The End