External_Hernias_Presentation pptx presentation 50 slides

External hernias

1. External Hernias of Life Classification, Diagnosis, and Treatment Surgical Educational Presentation

2. Introduction Definition: Protrusion of a viscus or part of a viscus through an abnormal opening in the wall of the cavity. External hernias are those that protrude through the abdominal wall. Common in both genders and across all age groups.

3. Epidemiology Inguinal hernias constitute about 75% of all external hernias. Males are affected more commonly than females. Incidence increases with age due to weakening of abdominal wall.

4. Anatomy of the Abdominal Wall Layers: skin, subcutaneous tissue, fascia, muscle, transversalis fascia, peritoneum. Weak points predispose to hernia formation. Knowledge of anatomy is essential for surgical repair.

5. Etiology Congenital defects (e.g., patent processus vaginalis). Acquired weaknesses due to aging, trauma, surgery. Increased intra-abdominal pressure (chronic cough, constipation).

6. Predisposing Factors Obesity or extreme thinness. Heavy lifting. Pregnancy. Chronic respiratory or urinary obstruction.

7. Classification Overview Classified based on location, content, and etiology. Most common: inguinal, femoral, umbilical, incisional, epigastric, Spigelian, lumbar, obturator.

8. Inguinal Hernia Most common type of external hernia. Divided into indirect and direct types. Occurs in inguinal region above inguinal ligament.

9. Indirect Inguinal Hernia Congenital origin due to patent processus vaginalis. Sac passes through deep inguinal ring lateral to inferior epigastric vessels. Common in young males.

10. Direct Inguinal Hernia Acquired type due to weakness in posterior wall of inguinal canal. Sac bulges through Hesselbach’s triangle. Common in elderly men.

11. Femoral Hernia Protrudes through femoral canal below inguinal ligament. More common in females. High risk of strangulation due to narrow neck.

12. Umbilical Hernia Occurs through umbilical ring. Common in infants (congenital) and multiparous women (acquired). Usually painless and reducible.

13. Epigastric Hernia Protrusion through linea alba between xiphoid and umbilicus. Contains preperitoneal fat or omentum. Common in middle-aged men.

14. Spigelian Hernia Rare hernia through Spigelian fascia (semilunar line). Difficult to diagnose clinically. May present as swelling in lower abdomen.

15. Lumbar and Obturator Hernias Lumbar hernia: through superior or inferior lumbar triangles. Obturator hernia: through obturator canal, seen in elderly women. Both rare but clinically significant.

16. Clinical Features - General Visible or palpable swelling that increases with standing or coughing. Discomfort or dragging sensation. Cough impulse present in reducible hernia.

17. Complications Irreducibility. Obstruction. Strangulation – surgical emergency. Inflammation or rupture (rare).

18. Diagnosis - History Onset and duration of swelling. Relationship with exertion or posture. History of pain, constipation, or vomiting.

19. Diagnosis - Examination Inspection: visible swelling, cough impulse. Palpation: reducibility, tenderness, expansile impulse. Auscultation: bowel sounds over swelling may indicate intestinal content.

20. Differential Diagnosis Hydrocele. Lymphadenopathy. Lipoma of the cord. Femoral artery aneurysm.

21. Investigations Ultrasound abdomen and groin. CT or MRI for complex or recurrent hernias. Laboratory tests before surgery.

22. Principles of Treatment Definitive treatment is surgical repair. Avoid manual reduction in strangulated hernia. Supportive care includes analgesia and fluid resuscitation.

23. Non-Surgical Management Trusses may be used in unfit patients. Used only temporarily before surgery. Not recommended for long-term management.

24. Surgical Management - Overview Objective: reduce hernia and reinforce defect. Approaches: open repair or laparoscopic repair. Choice depends on type, size, and patient fitness.

25. Open Hernia Repair Techniques Herniotomy – excision of sac. Herniorrhaphy – repair of defect without mesh. Hernioplasty – repair with mesh reinforcement.

26. Laparoscopic Hernia Repair Advantages: less pain, faster recovery, bilateral repair possible. Techniques: TAPP (TransAbdominal PrePeritoneal) and TEP (Totally ExtraPeritoneal). Requires general anesthesia and expertise.

27. Mesh Repair Use of polypropylene or composite mesh. Tension-free repair reduces recurrence rate. Mesh infection is a possible complication.

28. Strangulated Hernia Management Immediate surgical intervention required. Resection of non-viable bowel and repair of defect. Postoperative antibiotics and monitoring.

29. Postoperative Care Early ambulation encouraged. Pain management and wound care. Avoid heavy lifting for 6–8 weeks.

30. Recurrence and Prevention Proper surgical technique reduces recurrence. Treat underlying causes like chronic cough. Maintain healthy weight and avoid straining.

31. Special Types of External Hernia Richter’s hernia – only part of bowel wall is involved. May not cause obstruction but risk of strangulation remains. Littre’s hernia – contains Meckel’s diverticulum.

32. Sliding Hernia Part of wall of hernia sac formed by a viscus (e.g., bladder, colon). Common in elderly men. Careful dissection required to avoid organ injury.

33. Pantaloon Hernia Presence of both direct and indirect sacs on same side. Named for resemblance to a pair of trousers. Managed with standard hernioplasty.

34. Congenital Hernias Result from failure of closure of embryonic canals or rings. Common in infants and children. Require early surgical correction.

35. Incisional Hernia Occurs through postoperative scar. Causes: wound infection, obesity, poor closure technique. Treated with mesh repair.

36. Obturator Hernia (Detailed) Often presents as intestinal obstruction. Howship–Romberg sign: medial thigh pain due to nerve compression. Diagnosed by CT; managed surgically.

37. Lumbar Hernia (Detailed) Through superior or inferior lumbar triangle. Post-traumatic or post-surgical etiology. Repaired with mesh reinforcement.

38. Spigelian Hernia (Detailed) Occurs along semilunar line. Difficult to detect clinically; ultrasound/CT useful. Repaired surgically, usually with mesh.

39. Complications of Surgery Wound infection. Seroma or hematoma. Recurrence. Chronic pain or nerve entrapment.

40. Laparoscopic vs. Open Repair Laparoscopic: less postoperative pain, faster return to work. Open: preferred for strangulated hernias or unfit patients. Both have comparable recurrence rates.

41. Anesthesia in Hernia Surgery Local anesthesia for small reducible hernias. Spinal or general anesthesia for large or laparoscopic repairs. Choice depends on patient’s condition and surgeon preference.

42. Pediatric Hernias Mostly indirect inguinal hernias. High risk of incarceration. Treated by herniotomy without mesh.

43. Giant Hernias Large hernias with loss of domain. Require preoperative preparation and staged repair. Risk of abdominal compartment syndrome post-repair.

44. Role of Imaging Ultrasound: first-line investigation. CT: identifies complex or recurrent hernias. MRI: used for soft tissue assessment.

45. Research and Advances Biologic meshes and minimally invasive techniques. Robotic-assisted hernia repair emerging. Focus on reducing recurrence and chronic pain.

46. Case Example Male, 60 years, right groin swelling for 3 years. Diagnosis: indirect inguinal hernia. Treated with Lichtenstein mesh repair – uneventful recovery.

47. Summary External hernias are common surgical conditions. Diagnosis is clinical, supported by imaging. Definitive management is surgical repair. Early recognition of complications is vital.

48. References Bailey & Love’s Short Practice of Surgery, 28th Edition. Schwartz’s Principles of Surgery, 11th Edition. Recent surgical journals and guidelines.