Direct and indirect inguinal hernia final for website

the lecture is being prepared and delivered to 2nd year mbbs class in King Edward Medical university, Lahore

1. Direct and Indirect inguinal Hernia Dr. Ahmad Uzair Qureshi FCPS ( SURGERY) / MCPS ( SURGERY) MRCS ( ENGLAND) / Dip Med Edu (Cardiff) Colorectal Fellow Yonsei University, South Korea Assistant Professor of Surgery, King Edward Medical University, Lahore

2. Objectives The students will be able to Define hernia Different sites and types of hernia Enlist clinical features of groin hernia Enumerate differences in direct and indirect hernia Describe contents of hernia sac and their origin Enlist complications which may arise from hernia Describe the steps of open Hernia repair

3. ABDOMINAL REGIONS WHERE HERNIAS OCCUR

4. What is a Hernia? It is an abnormal protrusion of a viscus or part of a viscus through a potential weak space of its containing cavity.

5. CLINICAL FEATURES Lump at an appropriate anatomical site Increases in size on coughing or straining. It reduces in size or disappears when relaxed or supine position. Examination may show it to have a cough impulse and to be reducible

6. Rt. INDIRECT ING. HERNIA

7. FACTORS PREVENTING HERNIATION 1- Oblique coarse of the inguinal canal . 2- Contraction of conjoint tendon during coughing or straining (shutter mechanism) . 3- Contraction of cremasteric muscle : Plugging of inguinal canal

8. Groin hernia Inguinal Femoral Obturator

9. Two (2) types Acquired Congenital

10. Groin hernia Inguinal Direct Indirect Depending on the site of origin of sac. And per operatively by relation to the deep epigastric vessels

11. Layers of anterior abdominal wall

12. What is an Direct/ Indirect Hernia?

13. What is an Indirect Hernia? Congenital or acquired weaknesses in TF Location: lateral to deep epigastric vessels Protrude through deep inguinal ring; may descend into the scrotum Men Deep ring

14. DIRECT INGUINAL HERNIA Acquired weaknesses in TF Location: Hesselbach’s Emerge between the deep epig. artery and rectus abd. muscle and protrude into the ingu. canal but not into the SC. More difficult to repair?! Men

15. CLINICAL FEATURES I rreducible hernias have either a narrow neck or the contents adhere to the sac wall Obstructed hernias contain obstructed but viable intestine Strangulated hernias when the venous drainage from the sac contents is compromised

16. A HERNIA CONSISTS OF : A sac   Its coverings Its contents ( all abdominal viscera except liver and pancreas).

17. QUESTIONS MUST BE ANSWERED AT THE END OF GENERAL AND LOCAL EXAMINATION 1- Hernia or not ? 2- Rt or Lt ? 3- Is it inguinal or femoral ? 4- Is it direct or oblique ? 5- What is the content ? 6- Recurrent or not ? 7- Complicated or not ? 8- what is the predisposing factors ?

18. HERNIAS… COMPLICATIONS Reducible Irreducible Obstructed or incarcerated Strangulated

19. D.DIAGNOSIS of OIH 1- Other hernia direct inguinal hernia femoral hernia 2- Hydrocele congenital & infantile encysted hydrocele of the cord 3- Ectopic or undescended testicle 4- Psoas abscess 5- Inguinal adenitis 6- Endemic funiculitis 7- Lipoma of the cord

20. COMPLICATIONS O bstruction Irreducible abdominal pain, distension and vomiting may occur The hernia will be tense tender and irreducible Strangulation become red and tender, Irreducible No impulse on cough. If contains bowel  signs of obstruction.

21. Ex. Ring Test?

22. INGUINAL HERNIA REPAIR RATIONALE TENTION FREE REPAIR MESH REPAIR

23. HERNIA…PRINCIPLES OF REPAIR Irrespective of approach used the following will be achieved Dissection of the sac Reduction / inspection of the contents Ligation of the sac Approximation of the inguinal and pectineal ligaments

24. INGUINAL HERNIA. TYPES OF REPAIR Bassini repair : Suturing conjoined tendon to inguinal ligament behind the cord . Lytle repair : Plication of the fascia transversals . Shouldice repair : incision of the fascia & double breasting of it . Halsted ‘s repair Bassini repair plus reinforced by suturing the 2 leaflets of external oblique together behind the cord

25. INGUINAL HERNIA. TYPES OF REPAIR Shouldice or Liechtenstein Laparoscopic hernia repair:

26. Surgical Anatomy – land marks Ant Sup Iliac Spine Pubic tubercle

27. Incision

28. Ext Oblique Muscle

29. Ext Oblique Muscle - Incised

30. Ext Oblique reflected Conjoined Muscle Inguinal ligament

31. Spermatic Cord + Indirect Hernia Sac

32. Pearly white Hernia Sac

33. Herniotomy (opening of sac) Spermatic Cord Vas/ pampiniform plexus

34. Extraperitoneal fat ( extend of dissection)

35. Transfixation of the hernia sac near the base after twisting the sac , using catgut

36. Division of sac

37. Lax porterior wall of inguinal canal

38. Plication of posterior inguinal canal wall

39. Darn / Mesh placement using prolene suture

40. Closure of External oblique

41. Closure of Skin