Complicated hernia

Describes the various clinical presentations of hernia complications, their pathophysiology and principles of management.

1. Complicated Hernia Chea Chan Hooi General Surgeon Sibu Hospital

2. Content Definition Epidemiology Classification Clinical presentation Investigations Treatment

3. Definition Hernia Abnormal exit of tissue/organ through the wall of the cavity in which it normally resides Complicated Obstructed Strangulated Incarcerated Recurrent

4. Epidemiology 5 - 10% in the US IH > FH > others Men 8x more likely to develop hernia and 20x more likely to need repair compared with women Women manifest groin hernias at a later age

5. Classification External Ventral Epigastric Spigelian Umbilical Umbilical per se Paraumbilical Groin Inguinal Femoral Obturator Incisional Dorsal Lumbar Sciatic Internal Cerebral Hiatal

6. Clinical presentation Uncomplicated Impulse on coughing/straining Reducible Extent Bubonocele - within inguinal canal Funicular - exited superficial ring Complete inguinoscrotal - into scrotal sac

7. Complicated Obstructed Features of intestinal obstruction Irreducible Strangulated Irreducible Tender, indurated, erythematous skin Sepsis Features of intestinal obstruction Incarcerated Irreducible Relatively well No features of obstruction/strangulation Recurrent Evidence of prior repair

8. Investigations

9. FBC - leukocytosis BUSEC - electrolyte derangements, AKI ABG - acid-base imbalance PT/PTT - sepsis with coagulopathy Blood C+S - sepsis GSH

10. Management of Complicated Inguinal Hernia Resuscitation Volume Perfusion Acid-base disturbance Electrolyte imbalance Symptomatic relief Ryle's tube Analgesics Antipyretic Antibiotics Closed loop obstruction Strangulation Bowel perforation

11. Manual reduction Rule out strangulation Cold pack for 30 mins Adequate analgesia and sedation Trendelenburg position Patient group Adults Pressure to fundus of the hernia while guiding the proximal portion into the abdomen through the fascial defect Only 1 - 2 attempts Controversial Children Ipsilateral frog leg position Deep ring in infants is more medial, i.e. the canal more vertical First choice treatment

12. Ultrasonography Identify the nature of hernia content Help s locate the deep ring Gives the operator a n inside 'view' on the forces & direction for reduction Possible complications Unrecognised strangulated hernia --> bowel perforation Reduction en masse Retroperitoneal haematoma

13. Reduction en-masse Migration of a hernial sac along with its entrapped content into the properitoneal space Usually due to forceful reduction of a hernia Although non-visible, the pathologic process is on-going Patient does not improve or continues to deteriorate after 'reduction'

14. Transferring to another hospital Resuscitation NG tube CBD Adequate analgesia Blood investigations Empirical antibiotics Trendelenburg position

15. Surgery Anticipate omental & bowel resection Mode depends on hernia content involved, degree of contamination, available equipments & expertise Modes Open Hernioplasty, herniorraphy, herniotomy Laparotomy Laparoscopic Minimal bowel dilatation No overt, generalised peritonitis Esp. if suspect complicated omentocele

16. Femoral hernia About 10% of groin hernias More commonly occur in females (gynecoid pelvis) More commonly present with complication s

17. Problems Signs not clear-cut Location of fundus tends to vary Variety of differential diagnoses - LN, pseudoaneurysm, saphena varix, psoas abscess pointing, soft tissue tumour/abscess Commonly present with complication

18. Management Identify complicated FH Resuscitate Empirical antiobiotics Investigations Abdominal x-ray Ultrasonography In ambiguous cases TRO other differentials Blood tests Surgery NO ROLE OF MANUAL REDUCTION

19. Surgery Anticipate bowel resection Modes Laparoscopic Open High approach B etter access & visualisation Trans-inguinal approach Infra-inguinal approach

20. Obturator hernia Typically an elderly, frail lady who had lost significant body fat thus opening up the obturator foramen Pain In medial thigh/region of greater trochanter Relieved by thigh flexion Worsened by lateral rotation & extension of ipsilateral hip (Howship-Romberg sign) Intestinal obstruction Sepsis from strangulated bowel +- perforation

21. Diagnosis Pre-op: high index of clinical suspicion, notorious to be miss ed on x-ray , confirmed on CT scan Intra-op: during exploratory laparotomy

22. Treatment NO ROLE FOR MANUAL REDUCTION Emergency laparotomy Bowel gangrene is common Elderly patient with multiple significant co-morbidities Effects of pneumoperitoneum Elective repair Laparoscopic or open

23. Conclusion Groin hernias are common --> patients presenting with complications therefore proportionately high Potentially life-threatening FH & OH might present with diagnostic dilemma Surgical exploration, resection of devitalised tissue and repair is the main-stay treatment Laparoscopic repair is feasible in well-selected emergency patients

24. Thank you! Questions?