Hernia and physiotherapy management

Hernia and its physiotherapy management

1. Hernias By- Dr. K.K.Patel (M.PT)

2. Hernia is the protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity which contains it.

3. Common external hernia are Inguinal – about 73% Femoral – about 17% Umbilical – about 8.5% Incisional – its incidence is not included Other 1.5 % cases are rare hernia e.g. Epigastric Lumbar Spigelian Obturator Gluteal

4. Etiology A) Any condition which increase intra-abdominal pressure e.g. - Power full muscular effort or strain by lifting heavy weight - Whooping cough, chronic cough - Obesity, - Repeated pregnancy - Vomiting, constipation

5. B - weakness of the abdominal muscle - Congenital weakness - Acquired weakness

6. Pathology Hernia consists of three part.. The sac The contents of sac The covering of sac

7. The sac- It is a pouch of peritoneum which comes out through the abdominal musculature. The sac can be divided in three part - The mouth - The neck - The body The fundus

8. The contents of sac – Abdominal viscus (depended upon site) Fluid – peritoneal exudates The covering of sac- Depends upon the layers of abdominal through which the sac passes

9. Classification Reducible hernia Irreducible hernia Obstructed hernia Strangulated hernia

10. Reducible hernia – H ernia reduces itself as the patient lies down or can be reduced by the patient or by surgeon One of the 2 most characteristic features of hernia is its Reducibility and second feature is Impulses on coughing. Irreducible hernia - Here the content cannot be returned to abdomen because of the adhesion formed between sac and content

11. Obstructed hernia It is irreducible hernia containing intestine which obstructed from without or from within but doesn't interfere blood supply to distal Strangulated hernia It is irreducible and obstructed hernia ant there is arrest of blood supply to the contents

12. An external abdominal hernia is protrusion of abdominal viscus through a weak spot in the abdominal wall Common external hernia are Inguinal hernia Femoral hernia Umbilical hernia Incisional hernia

13. Inguinal hernia It is the protrusion of part of the contents of the abdomen through the inguinal region of the abdominal wall. It is reducible Expansible impulse on cough

14. There are two types of inguinal hernia Indirect inguinal hernia Direct inguinal hernia

15. 1. Indirect hernia In indirect hernia the content of abdomen enter the deep inguinal canal and traverse the whole canal to come out through the superficial inguinal ring, it is lateral to the inferior epigastric vessels

16. Much common than the direct hernia, Can occur at any age but more common in children and young adult It is more commonly seen on right side. only 1/3 of cases are involved bilateral Impulses on coughing When it is complete it is pyriform shape and when it is incomplete it is oval shape The hernia has to be reduced by the patient or the doctor and it dose not reduced by itself

17. There are three types of indirect hernia BUBONOCELE – hernia is limited to the inguinal canal FUNICULAR – the contents of hernia can be felt separately from the testis and the testis lie below the hernia COMPLETE OR SCROTAL HERNIA – the hernia descends down to the bottom of the scrotum lying in front and side of the testis

18. Direct inguinal hernia Direct inguinal hernias occur medial to the inferior epigastric vessels through the posterior wall of the inguinal canal Female are not affected More than ½ the case are bilateral. it is usually caused by poor abdominal muscle. It is always incomplete and spherical shape This hernia is appears as forward bulges

19. It is automatically reduces when the patient lies down If the impulses is felt on the middle finger it is a direct hernia

20. Invagination test – When the little finger enters the ring if it goes upward, backwards, and out wards it is an indirect hernia If the impulses is felt on the tip of the finger it is an indirect hernia When the little finger goes directly backwards, it is direct hernia If the impulses is felt on the pulp of the finger it is an direct hernia

21. Ring occlusion test The hernia must be reduced first A thumb is pressed on the deep inguinal ring then asked to cough A direct hernia will show bulge medial to the finger but an indirect hernia will not find assess, so no bulge

22. Treatment – Herniotomy - In this operation the neck of the sac is transfixed and ligated and then the hernial sac is excised It is indicated – In infants and children in whom there is preformed sac In case of young adults with very good inguinal musculature

23. Hernioraphy – It is consist of herniotomy + repair of posterior wall of the inguinal canal by opposing the conjoined tendon to the inguinal ligament Hernioplasty – Herniotomy + reinforced repair of the posterior wall of the inguinal canal by filling the gap between the conjoined tendon and ligament by Autogenous or heterogenous material

24. Femoral hernia Abdominal contents pass through the femoral ring, transverse the femoral canal and comes out through the saphenous opening. it is 3 rd most common hernia after the inguinal and incisional hernia. Common in female elderly and most liable to get strangulated

25. You may see a bulge in the upper thigh next to the groin. Most femoral hernias cause no symptoms. There may be some groin discomfort that is worse when you stand, lift heavy objects, or strain. Sometimes, the first symptoms are abdominal pain, nausea, and vomiting. This may mean that the intestine is blocked, which is an emergency.

26. Umbilical hernia This is due to failure of all part of mid gut return to the colon during early fetal life. So the abdominal organ remain protruded. Umbilical hernia in infants and children – This is hernia through a weak umbilical scar, The hernia is usually symptomless and increase in size during crying

27. If small, symptomless then conservative treatment. Operation is only justified when the hernia fails to disappear after 18 months – Herniorapphy Para- umbilical hernia of adult – In the adults the hernia does not protrude through the umbilical. But it is protrusion through the linea alba just above the umbilicus or occasionally below the umbilicus That is why its called para umbilical hernia

28. Women are by far the major victims, Obese patient are mainly involved. Treatment – operation is the treatment of choice MAYO’ S OPERATION

29. Incisional hernia An incisional hernia is one which occurs through an acquired scar in the abdominal wall caused by a previous surgical operation or an accidental trauma.

30. Etiology Defect with patient - Obese individual - Chronic cough - Abdominal distension in the early POD - Malnutrision

31. 2- Fault during operation - Injury to the motor nerve supplying the area. - Improper closer of wound - Tube drainage through the laparotomy wound - Haemostasis was not perfect - Certain incision are more liable to causes incisional hernia

32. 3-Postoperative causes - Infection - Postoperative cough and distension - Postoperative peritonitis due to more chance of wound infection. - To early removal of sutures

33. Hernia may occur through the small portion of scar at lower end Diffuse bulging of whole length of incision Gradually size become increased and irreducible Mostly asymptomatic and broad neck don’t need any treatment Treatment Conservative treatment – abdominal belt Operative management

34. Physiotherapy management – For the undergoing surgery for an inguinal hernia pulmonary complications may be a risk when there is a chronic chest condition Pre and post operative breathing exercise and chest physiotherapy are important DVT is possible complication after herniorraphy and so exercise for legs should be given before and after surgery

35. These patients likely to have weak abdominal muscles which should be strengthen after surgery A progressive scheme of exercise starting with static in middle to inner range and following with free active exercise should be implemented, care should be taken not to go beyond the ability of the patient and exercise in outer range of the abdomen should be avoided Patients should be instructed in correct lifting techniques.

36. Patient undergoing surgery for a femoral hernia should have similar physiotherapy The risk of pulmonary complications is smaller but there may be a greater risk of developing a DVT Correct lifting techniques should be taught so that the intra abdominal pressure is not abnormally high during lifting

37. Patients undergoing for the umbilical and insicional hernia surgery physiotherapy is as for abdominal surgery To prevent pulmonary and circulatory complication. Strengthen abdominal muscle Teach postural correction Scar management Advice on back care Advice on progression of activities to function

38. Thank you…..