Hernia examination by Dr Min Oo

1. Examination of Hernia DR MIN OO Surgery

2. Outline Definition Types Predisposing factors Basic features of a hernia Inguinal hernia Applied anatomy Examination of inguinal hernia Differences b/t direct and indirect inguinal hernia Some definitions Video click for inguinal hernia examination 6/27/2012 2

3. Learning out come To understand the basic principle for examination of hernia. To know the various types of herniae . Able to understand the applied anatomy for the inguinal region. Able to demonstrate the examination of inguinal hernia. Comprehend the differences between direct and indirect inguinal hernia. To appreciate the some confused definitions . To be able to develop the skill for the examination of a herniae 6/27/2012 3

4. What is hernia? 6/27/2012 4

5. Hernia – protrusion of a viscous or part of viscous through an abnormal opening in the walls of its containing activity. 6/27/2012 5 25 th edition,Bailey`s & Love`s Short practice of surgery

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7. Predisposing factors ??? 6/27/2012 7

8. Composition of hernia 6/27/2012 8

9. Classification 6/27/2012 9

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11. Basic features of hernia??? Occur at weak point (Congenital or acquired) Reducible on lying down or with direct pressure Have an expansile cough impulse (Visible & palpable) 6/27/2012 11 Note: last 2 signs may be absent if constricted at the neck

12. Causes of abdominal Herniae Anatomical weakness Structures passing through the abdominal wall Muscle fail to develop Scar tissue Acquired weakness Trauma High intra-abdominal pressure Coughing Straining Abdominal distension 6/27/2012 12

13. Various types of Herniae ? (common ) Inguinal Umblical Incisional Femoral Epigastric 6/27/2012 13

14. Spigelian Obturator Lumbar Gluteal 6/27/2012 14 Other rare herniae

15. Inguinal Hernia 6/27/2012 15

16. Surface anatomy ????? 6/27/2012 16

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18. Relation to the surrounding structures 1.Anterior wall Medially-external obliqueaponeurosis Lateral- internal oblique muscle 2.Posterior wall Medially – strong conjoint tendon Lateral- fascia transversalis 3.Floor Medial- Lacunar ligament Lateral- inguinal ligament 4.Roof Arching of fibers of int oblique and transverse muscles. 6/27/2012 18

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21. Examination of the hernia Ask permission Exposure Position Third party Privacy Manner 6/27/2012 21

22. Ask the patient to stand up Lying position …..why not? Not possible to see the true size. proper examination even not detect at all. If suspect since early,start with standing position If found during routine abdominal exam, complete abd exam first and ask the patient to stand up to examine properly. NOTE: examine both inguinal regions 6/27/2012 22

23. Look at the swelling from the front Exact size and shape Visible expansile cough impulse Distinguish from femoral hernia Extend of lump…down into the scrotum ?? Other scrotal swelling …. Any other swelling on the “normal side” 6/27/2012 23

24. Feel from the front Exam the scrotum and content First whether inguino -scrotal or true scrotal by getting above the upper edge ( get above ) Don’t exam the external ring or canal as it is painful 6/27/2012 24

25. Feel from the side Having exam the scrotal content & can’t get above the lump – assuming the inguinal hernia – proceed to examination of the lump…….??? Inguinal Hernia examination Stand at the side of the patient –same side of hernia Place on hand at the back of to support the patient Examinating hand and fingers parallel to the inguinal ligament . 6/27/2012 25

26. Expansile cough impulse Firmly compress the lump with fingers Ask the patient to turn head toward to opposite side & to cough If Tense and expansile = cough impulse (+) Note: Localized swelling in the spermatic cord and undescended testis come out during cough but not bigger nor tense . (+) is diagnostic for hernia (-) can not exclude diagnosis ( e.g adhesion …) 6/27/2012 26

27. Is the swelling is reducible? Position ???? Can control at internal ring =indirect Can not control = direct Note: Reduction point to pubic tubercle above and medial … inguinal Below and lateral …….femoral Only for reducible one 6/27/2012 27

28. Remove the finger and watch the reappearance Direction and the way reappearance help to deduct the origin of hernia Obliquely downward = indirect Directly project forward = direct NOTE: Difficult in obese patient 6/27/2012 28

29. Percuss and auscultate Intestine = resonant and audible bowel sound 6/27/2012 29

30. Feel the other side Move the other side and exam the inguinal region Commonly bilateral particularly in direct inguinal hernia Ask the patient to cough to make obvious small bulge 6/27/2012 30

31. Examine the abdomen Any possible increased intra-abdominal pressure e.g ..???? 6/27/2012 31

32. Cardiovascular & respiratory assessment Fitness Any chronic respiratory problem.. Increased intraabdominal pressure 6/27/2012 32

33. Differences b/t direct and indirect inguinal hernia 6/27/2012 33

34. Indirect inguinal hernia Direct inguinal hernia Any age but common in young Elderly Via deep inguinal ring and long the inguinal canal Via transversalis fascia ( hasselbach’s triangle) Patent or reopen processus vaginalis Weak abdominal wall/muscle Unilateral in 2/3 case (right side more common) Bilateral in > ½ case Enter scrotum (complete) Does not enter scrotum (incomplete) Reduced by patient/doctor (manually) Reduced on lying down (automatically) Narrow neck- more liable to strangulate Broad neck Zieman technique- impulse on index finger Impulse on middle finger Deep ring occlusion test- control Bulge out Little finger invagination test- impulse on finger tip Impulse on pulp 6/27/2012 34

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36. D/ Dx of inguinal hernia??? Femoral hernia Vaginal hydrocele Hydrocele of cord or canal of nuck Undescended testis Lipoma of cord 6/27/2012 36

37. Some definition ????? Strangulated hernia ? Richter`s hernia? Maydl`s hernia? Sliding hernia? Incarceration ? 6/27/2012 37

38. Video for inguinal hernia examination 6/27/2012 38

39. THANK YOU HAVE A NICE DAY 6/27/2012 39