Hernia

FOR UNDER GRADUATES OF PHYSIOTHERAPY

1. BY Dr.heta patel HERNIA

2. CONTENTS… What is hernia? Causes of hernia Types and prevalence Management Types of surgeries Physiotherapy management Complications

3. Hernias A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the wall of the containing cavity .

4. Contents of hernia Sac – pouch of peritoneum which comes out through the abdominal muscles. divided in 4 part. Mouth N eck B ody F undus .

5. Covering of sac : skin and muscles of the abdomen. Derives from layers of abdominal wall through which sac passes. After long time becomes stretched and atrophied. Contents of the sac : Fluid, O mentum , Loop of intestine, bladder, ovaries.

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7. Causes… 1 . Weakness of the abdominal wall Congenital – incomplete obliteration of umbilical may lead to infantile inguinal hernia. Acquired – excessive fat in abdomen, repeated pregnancy, surgical incision leads to cutting of nerve followed by muscle weakness.

8. 2 . raised intra abdominal pressure lifting heavy weight Strenuous exercises Whooping cough in childhood Urethral obstruction straining in micturition Vomiting constipation

9. 9 TYPES OF HERNIA Inguinal hernia Femoral hernia Incisional hernia Umbilical hernia Paraumbilical hernia Hiatus hernia Spigelian hernia Strangulated hernia Obturator hernia Epigastric hernia

10. INGUINAL HERNIA Commonly males. Most common form of hernia Abnormal protrusion of abdominal organ into inguinal canal through deep inguinal ring.

11. INDIRECT When herniation through deep inguinal ring. Occures at any age. Young adult, children. Descends in any direction. Piriform – complete, oval – incomplete

12. Causes increased intra abdominal pressure activities

13. Direct When content of hernia enter the inguinal ring and passes through posterior wall through hesselbach’s triangle. Elderly people Females not affected >1/2 cases bilateral Incomplete- spherical shape Causes: same

14. Femoral hernia The femoral canal is the way that the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh . Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) into the canal .

15. This hernia causes a bulge below the inguinal crease in roughly the middle of the thigh. Rare and usually occurring in women, these hernias are particularly at risk of becoming irreducible and strangulated.

16. Incisional hernia Abdominal surgery causes a flaw in the abdominal wall that must heal on its own . This flaw can create an area of weakness where a hernia may develop . This occurs after 2-10% of all abdominal surgeries, although some people are more at risk . After surgical repair, these hernias have a high rate of returning (20-45%).

17. Umbilical hernia 10-30%. often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn’t close completely . Even if the area is closed at birth, these hernias can appear later in life because this spot remains a weaker place in the abdominal wall. They most often appear later in elderly people and middle-aged women who have had children.

18. Para umbilical hernia Protrusion of linea alba just above / below umbilicus In obesity. Sac also consist of greater omentum , small intestine, and portion of transverse colon.

19. Hiatus hernia A hiatus hernia occurs when the upper part of the stomach, which is joined to the esophagus , moves up into the chest through the hole (called a hiatus) in the diaphragm. It is common and occurs in about 10 per cent of people. It is most common in overweight middle-aged women and elderly people .

20. It can occur during pregnancy. The diagnosis is confirmed by barium meal X-rays or by passing a tube with a camera on the end into the stomach ( gastroscopy ).

21. Symptoms : Heartburn Sudden regurgitation Belching Pain on swallowing hot fluids Feeling of food sticking in the oesophagus

22. Spigelian hernia This rare hernia occurs along the edge of the rectus abdominus muscle, which is several inches to the side of the middle of the abdomen . Reducible – goes off in supine Irreducible – due to adhesions in sac Obstructed – contains intestine Strangulated – blood supply to hernia is abscent

23. Strangulated hernia

24. Obturator hernia This extremely rare abdominal hernia happens mostly in women . This hernia protrudes from the pelvic cavity through an opening in your pelvic bone ( obturator foramen ). This will not show any bulge but can act like a bowel obstruction and cause nausea and vomiting

25. Epigastric hernia Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, these hernias are composed usually of fatty tissue and rarely contain intestine . Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

26. Treatment Conservative : indicated in a patient with severe ill health, short life expectancy, those who refuse for operation Operative : Herniotomy : neck of sac is transfixed, ligated and then the hernial sac is excised. Infant and children in whom there is congenitl hernia present. Young adult with very good inguinal muscles. Incision : ½ inch above and parallel to the medial of inguinal ring almost on inguinal canal .

27. HERNIORRAPHY : Consist of herniotomy and repair of posterior wall of the inguinal canal by apposing the conjoin tendon to the inguinal ligament. Indicated in – direct hernia Recurrent hernia Fascia transversalis is weak

28. Bassini repair After extraction of the hernia sac, we are taking spermatic duct on holders. Between the borders of transverse muscle, internal oblique muscle, transverse fascia and inguinal ligament interrupted sutures placed. Except that, couples sutures placed between border of abdominal rectus muscle sheath and pubic bone periosteum .

29. In such way, inguinal space closured and posterior wall strengthened. Spermatic duct placed on the new-formed posterior wall of the inguinal channel. Over the spermatic duct aponeurosis restored by interrupted sutures.

30. Hernioplasty Consist of herniotomy + repair of posterior wall of inguinal canal by filling the gap between conjoined tendon and inguinal ligament filled by fibrius tissue. Indication – all cases of direct hernia Recurrent hernia Indirect hernia with poor muscle tone

31. Assessment History – vomiting, intestinal obstruction, lump, abdominal distension. Past surgical history O/O: local : Redness + around hernia Swelling Skin chnages Lump Effect of coughing

32. O/P: Temperature Tenderness Swelling On percussion: Resonant : intestine Dull : omentum , extraperitoneal fatty tissue O/E: Pain ROM MMT ADL

33. Physiotherapy management AIM Increase strength of abdominal muscles Proper positioning Soft tissue healing- 3-4 weeks, muscles – 7-12 days Pre operative Chest physiotherapy Exercise tolerance test Improve muscle strength

34. POST-OPERATIVE MANAGEMENT Day 0 Assessment Operation notes Level of consciousness Level of pain Analgesia Wound site

35. Attachments Position of patient Auscultation Homan’s sign Treatment More emphasis on respiratory and circulatory functions. Patient should repeat exercise hourly.

36. Day 1 Mobility exercise: rolling to side lying, pushing up to sitting position. Deep breathing exercises every hourly. Supported coughing. Calf stretch and ankle pumps every quarter hourly.

37. Unilateral upper limb movements to improve chest expansion every hourly. Abdominal massage in the direction of large bowel helps to reduce abdominal pain due to ‘gas’.

38. Day 2 Encourage walking for short distance with assistance. Continuation of day 1 exercises. Add pelvic rocking and abdominal drawing in exercises.

39. Day 3 onwards Longer periods of sitting out and walking. Continuation of previous exercises. Pelvic floor exercises if there is no catheter in situ. 5 repetition of five sec hold. Posture and back care advises .

40. Femoral hernia… Lower limb mobility is more important. Wear inguinal belt Squatting, weight lifting after 3 months

41. Complications… DURING OPERATION Injury to vein or nerve Urinary bladder Inferior epigastric vessels Contents of sac EARLY POST OPERATIVE R etention of urine Inflammation of spermatic cord, scrotum Wound infection

42. LATE POST OPERATIVE Reccurance Neurologic pain due to involvement of ilioinguinal nerve in suture Painful scar Atrophy of testis due to testicular nerve due to compression of spermatic cord Epidermal cyst

43. Thank you