Groin hernias

inguinal- indirect and direct and femoral hernias

1. Groin hernias Include- Indirect inguinal hernia Direct inguinal hernia Femoral hernia Dr. G S Randhawa Associate professor of surgery Punjab institute of medical scienc e s , Jalandhar,punjab,India .

2. Indirect inguinal hernia Definition - hernia, of which sac passes through deep inguinal ring to superficial inguinal ring. Mostly preformed sac due to defect in development of processes vaginalis . Most common type(65%) Common in younger age group. More common on right side in first decade of life. Equal incidence in second decade.

3. Indirect... Bilateral in 30% of cases Neck is thin hence more prone to strangulation. Neck lies lateral to deep inferior epigastric vessels. In children sometimes sac is so narrow in the middle that it admits only peritoneal fluid behaves like hourglass. Often associated with undescended testis

4. Indirect ... Types – Bubonocele -when the hernia is limited to inguinal canal. Funicular - processes closes just above the epididymis . Hernia and testicle can be felt separately. Complete( inguinoscrotal )- here testicle appears lying in hernial sac. Occurs in completely open processes.

5. Indirect... Clinical features- Prevalent 25% in males and 2% in females. Often present since birth Or appeared during adolescence Swelling increases in standing position while reduces in lying down position. Impulse on coughing. Ring occlusion test positive.

6. Indirect .... Differential diagnosis- Hydrocele Undescended testis Femoral hernia Lipoma of the cord Hydrocele of the canal of Nuck in females Inguinal lymphadenopathy Inguinal abscess

7. Indirect.... Investigations- Routines X-ray chest u/s abdomen Tests relevant for precipitating causes like-chronic cough,contipation,urinary obstruction, ascites , intra-abdominal mass cyst etc., Herniography ( Gullmo )

8. Indirect .... Treatment- In children- simple herniotomy In adults- herniotomy + reinforcement of posterior wall by- Bassini’s repair. Lichtenstein tensionfree mesh repair Kugel’s repair(open or laparoscopic) Surgery can be done under local anaesthesia as outpatient daycare procedure.

9. Indirect..treatment Read-Rives repair-mesh sutured directly over peritoneum after herniotomy and invasion of stump. Stoppa repair- mesh placed between peritoneum and transversalis fascia. TEP TAPP

10. Indirect... Related/special conditions Hernia-en- glisade - non- mesentry content Richter’s hernia- partial strangulation of gut Littre’s hernia- meckel’s diverticulum as content Pantaloon hernia- two sacs saddled over inferior epigastric vessels Maydl’s hernia- double loop(hernia-en-W)

11. Conservative treatment Truss

12. Direct hernia Hesselbach’s triangle

13. Direct .... 10-15% hernias are direct. 35% inguinal hernias are direct. 50% direct h.are bilateral. Rare in females and children. Always acquired, due to weakness of posterior wall of inguinal canal. Medial to inferior epigastric vessels; wide neck and thick walled sac.

14. Direct..... Occurs through Hesselbach’s triangle . Medial or lateral according to the position of neck vis a vis position of medial umbilical ligament ( obliterated umbilical artery )

15. Direct.... Coverings - from inside out Extra-peritoneal tissue Fascia transversalis Conjoint tendon External spermatic fascia skin

16. Direct..... Predisposing factors- Chronic cough, smoking Straining at stool or urine Heavy weight lifting Appendicectomy (on right side) Malgaigne bulgings - soft supple bulges near external ring on raising legs show weak musculature of inguinal region.

17. Direct.... Rarely descends into scrotum. When descends usually massive. Strangulation may occur. Treatment- Mesh repair without herniotomy in most cases. Herniotomy needed only when inguinoscrotal . Sac dissected and invaginated and a prolene mesh fixed over it. Bilateral problem can be dealt with single suprapubic incision( pfennsteil’s )

18. Complications of hernias Most common esp. In indirect hernia is strangulation Obstruction Incarcenation Intestinal obsruction

19. Complications of surgery Injury to- ilioinguinal n.,spermatic artery leading to testicular atrophy, vas deferens, inferior epigastric vessels, femoral vessels, external illiac vessels (in cases of endoscopic repair), urinary bladder esp. In children. Haematoma formation Infection . Recurrence (10%) within 3yrs early ;after 3yrs late. Chronic groin-pain syndrome. Infertility due to entrappement of vas in cases with single functioning testicle.

20. Femoral hernia Surgical anatomy of femoral canal Medial most compartment of the femoral sheath Extends from femoral ring to saphenous ring Lower end covered with cribriform fascia Contents - fat,lymphatics and lymph node of Cloquet . 1.25cm long and 1.25cm wide at the base which is upper end. Boundries of femoral ring- anteriorly inguinal ligament, posteriorly iliopecteneal ligament of Cooper,pubic bone and fascia covering the pectineus muscle. Medially free sharp border of lacunar ligament. Laterally thin septum separating it from femoral vein.

21. Surgical Anatomy of femoral canal

22. Surgical anatomy.....

23. Femoral... Surgical pathology Femoral canal> vercally descends upto saphenous ring>escapes out in loose areolar tissue to expand and assumes the shape of a retort. Due to arduos path and narrow neck more prone to obsruction and strangulation During surgery utmost precaution should be taken to prevent injury to femoral vein and pubic branch of obturator artery. An alarming haemorrage takes place otherwise.

24. Femoral hernia Clinical features Common in females 2:1 Most patients multiparous females Rare before puberty, 20% bilateral; common on right side Presents as a swelling below and lateral to the pubic tubercle in contrast to inguinal hernia, which is above and medial to pubic tubercle. Swelling, impulse on coughing, reducibility and gurgling sound while being reduced. Dragging pain.

25. Femoral hernia

26. Femoral hernia

27. Femoral hernia Signs of obsruction /strangulation Pain, markedly tender. No impulse on coughing. Ireducible . Redness over swelling. Abdominal distension. Vomiting. Sighns of toxicity- fever, tachycardia,low BP,dehydration , confusion etc. Often present along with inguinal hernia. 40% present as intestinal obstruction.

28. Femoral hernia Differential diagnosis Inguinal hernia Enlarged cloquet’s lymph node Psoas abscess. Lipoma . Femoral artery aneurism. Distended psoas bursa. Saphena varix . Haematoma Haemangioma of adductor muscle

29. Femoral hernia Related conditions Hydrocele of femoral hernia Laugier’s femoral hernia- through a rent in lacunar ligament Narath;s femoral hernia- hernia behind femoral vessels in congenital dislocation of hip Cloquet’s hernia- when sac lies under pectineal fascia. Sliding hernia –urinary bladder

30. Femoral hernia- treatment Treament includes various surgical repair techniques Lockwood low operation- approached from below. Inguinal ligament sutured to Cooper’s ligament(ideal and common) Mc’Evedy high operation- vertical incision across inguinal ligament over swelling. Good exposure. Ideal for strangulated hernia Lutheissen’s operation- conjoint tendon to iliopectineal ligament AK Henery’s operation- repair of b/l hernia through pfennsteil incision. Laparoscopic mesh repair-TEP/TAPP

31. Femoral hernia Complications- Of hernia- obsruction , strangulation, intestinal obstruction. Of surgery- injury to femoral vein or artery, urinary bladder, obturator artery Sequele -recurrence, ch groin-pain syndrome,restricted hip flexion.

32. THANK ....YOU