Inguinal hernia

inguinal hernia ; anatomy, pathophysiology, and management.

1. Inguinal hernia by : Dr Karrar Adil

2. What is an inguinal hernia ? It is a protrusion of a peritoneal sac through a musculoaponeurotic barrier in the inguinal area .

3. Incidence : About 27% of males and 2% of females develop inguinal hernias. is the most common hernia in males and females. Indirect inguinal hernias are the most common hernias in both men and women. a right-sided predominance exists.

4. ANATOMY

5. Abdominal Wall L ayers : Skin Subcutaneous fat Scarpa’s fascia External oblique muscle Internal oblique muscle Transversus abdominis Transveralis fascia Preperitoneal fat Peritoneum

6. The Inguinal Canal : is a short passage that extends inferiorly and medially through the inferior part of the abdominal wall. It is superior and parallel to the inguinal ligament . serves as a pathway by which structures can pass from the abdominal wall to the external genitalia . It is a potential weakness in the abdominal wall, and thus a common site of herniation.

7. Mid-inguinal point : the point halfway between anterior superior iliac spine (ASIS) and pubic symphysis . It is a landmark for the femoral artery . Midpoint of the inguinal ligament : the point halfway between ASIS and the pubic tubercle . It is the landmark for the deep inguinal ring .

8. The Inguinal Rings : The deep (internal) ring : oval in shape is found above the midpoint of the inguinal ligament. which is lateral to the epigastric vessels. is created by the transversalis fascia, which invaginates to form a covering of the contents of the inguinal canal.

9. The Inguinal Rings : The superficial (external) ring : triangular in shape marks the end of the inguinal canal, and lies just superior to the pubic tubercle . formed by the evagination of the external oblique, which forms another covering of the inguinal canal contents.

10. Inguinal C anal Boundaries : Anterior wall : external oblique aponeurosis Posterior wall : transversalis fascia Roof : arched fibers of internal oblique, and transversus abdominis . Floor : inguinal ligament and lacunar ligament .

11. Contents : In females : Round ligament of uterus ilioinguinal nerve iliohypogastric nerve Genital branch of genitofemoral nerve In males : Spermatic cord and its contents:

12. The classical description of the spermatic cord contents : 3 structures : vas deferens , pampiniform plexus, and testicular lymphatics . 3 arteries : artery to vas deferens, testicular artery, and cremasteric artery. 3 fascial layers : external spermatic , cremasteric , and internal spermatic fascia. 3 nerves : genital branch of genitofemoral nerve , sympathetic and visceral afferent fibers , and ilioinguinal nerve (outside spermatic cord but travels next to it).

13. CLASSIFICATION Inguinal Hernia

14. Anatomical Classification : based on their relationship to inferior epigastric vessels : DIRECT Inguinal Hernia INDIRECT Inguinal Hernia

15. DIRECT Inguinal Hernia : occur medial to the inferior epigastric vessels within the floor of Hesselbach’s triangle. occur when abdominal contents herniate through a weak spot in the fascia of the posterior wall of the inguinal canal, which is formed by the transversalis fascia.

16. Hesselbach’s triangle : is located within the inferomedial aspect of the abdominal wall. It has the following boundaries: Medial – lateral border of the rectus abdominis muscle. Lateral – inferior epigastric vessels. Inferior – inguinal ligament

17. INDIRECT Inguinal Hernia : occur when abdominal contents protrude through the deep inguinal ring , lateral to the inferior epigastric vessels . due to patent processus vaginalis . The most common type of all hernias. Higher risk of strangulation than direct.

18. Indirect Direct Can occur at any age from childhood to adults Occurs in pre-existing sac Protrusion through deep ring Narrow neck lateral to inf epigastric artery Obstruction/strangulation is common Sac should be opened during surgery Common in elderly Always acquired Herniation through posterior wall Wide neck medial to inf epigastric artery Obstruction/strangulation is rare Sac is not necessarily opened unless obstruction is present

19. Clinical Classification : Reducible : c an be reduced by the patient , surgeon or by it self . Irreducible hernia: cannot be pushed back into the abdomen by applying manual pressure. Irreducible hernias are further classified into : Obstructed hernia : is one in which the lumen of the herniated part of intestine is obstructed but the blood supply to the hernial sac is intact. Incarcerated hernia : is one in which adhesions develop between the wall of hernial sac and the wall of intestine . Strangulated hernia : is one in which the blood supply of the sac is cut off, thus, leading to ischemia.

20. Pantaloon Hernia (Double ,Saddle, Romberg hernia) : Both direct and indirect inguinal sacs are present. During surgery , indirect sac may be missed and so leads to recurrent hernia through retained or unidentified indirect sac. Here both medial and lateral sacs straddle the inferior epigastric artery.

21. Etiology : Increased pressure within the abdomen A pre-existing weak spot in the abdominal wall Straining during bowel movements or urination Heavy lifting Ascites Pregnancy Excess weight Chronic coughing or sneezing Peritoneal dialysis

22. Symptoms and Signs : A bulge in the area on either side of the pubic bone. Pain or burning or discomfort in the bulge , especially when bending over, coughing or lifting. Occasionally, in men, pain and swelling in the scrotum around the testicles when the protruding intestine descends into the scrotum. In Pediatrics : Sometimes the hernia may be visible only when an infant is crying, coughing or straining during a bowel movement. In an older child, a hernia is likely to be more apparent when the child coughs, strains during a bowel movement or stands for a long period of time .

23. Examination : Proper exposure from umbilicus to mid thigh . Inspection : Standing / lying Palpation : Can you get above the swelling? Reducibility Cough impulse Head or leg raise to look for abdominal muscle tone

24. Internal ring occlusion test : Lie the patient Reduce the content Occlude the internal ring using thumb Ask patient to cough Direct hernia: swelling medial to thumb Indirect hernia: swelling doesn’t appear

25. Zieman’s test : Place index finger on deep inguinal ring and middle finger on superficial inguinal ring and ring finger above saphenous opening Ask patient to cough Indirect hernia: impulse felt on index finger. Direct hernia: no impulse.

26. Ring invagination test : Reduce the hernia. Invaginate little finger from bottom of scrotum. gradually push up and rotate to enter the superficial ring. Ask patient to cough. i mpulse is felt at the tip of the invaginated finger.

27. Systemic examination must be done to find out precipitating factors like chronic bronchitis or ascitis .

28. Differential Diagnosis : Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumor Varicocele Epididymitis Testicular torsion Hydrocele Ectopic or Undescended testicle Femoral artery aneurysm or pseudoaneurysm Psoas abscess Hematoma Ascites

29. MANAGEMENT

30. Conservative Management Hernias that or not strangulated or incarcerated can be mechanically reduced. A truss can be placed over the hernia after it has been reduced & left in place to prevent the hernia from recurring .

31. Taxis : The patient is sedated and placed in a Trendelenburg position. The hernial sac is grasped with both hands, elongated, and then milked back through the hernia defect. Taxis should not be applied to strangulated hernias as a potentially gangrenous portion of bowel may be reduced into the abdomen without being addressed .

32. Operative Management : Pre-operative investigations : ECG CXR CBP Coagulation study Biochemistry U/S : to assess the content of the hernial sac

33. Principles of S urgical Repair : Reduction of the hernia content into the abdominal cavity. Excision and closure of peritoneal sac. Reapproximation of the walls of the neck of the hernia. Permanent reinforcement of the abdominal wall defect with sutures or mesh.

34. Surgical Options : Herniotomy : excision of hernia sac in children. Herniorrhaphy : strengthening of posterior wall of inguinal canal. Hernioplasty : placement of mesh.

35. Surgical Approaches : Open hernia repair : Open non-mesh repairs : include ( Shouldice , Bassini , McVay techniques) Open mesh repairs: most commonly performed are Lichtenstein technique,and plug and patch technique. Laparoscopic repair : Transabdominal Preperitoneal Procedure (TAPP) Totally Extraperitoneal (TEP) Repair

36. The Lichtenstein tension-free repair : has persisted as one of the most prefered and commonly performed procedures in the world. i nitial part of surgery is same as Bassini repair. Once hernia has been removed and any medial defect closed, a piece of mesh is placed over posterior wall, behind the spermatic cord and is split to wrap around the spermatic cord at deep inguinal ring. Loose sutures with Prolene hold mesh to inguinal ligament and conjoint tendon.

37. Laparoscopic Repair : Transabdominal Preperitoneal Procedure (TAPP) Totally Extraperitoneal (TEP) Repair Indications include : bilateral inguinal hernia, recurrent hernia, need for early recovery

38. Recurrence : Causes: Patient factors : malnutrition , immunosuppression, diabetes, steroid use , and smoking. Technical factors : mesh size, prosthesis fixation, and causes related to the surgeon. Tissue factors : wound infection, tissue ischemia, and increased tension within the surgical repair.

39. Complications : Common Complications Early : pain, bleeding, urinary retention, anesthesia related. Intermediate : seroma , wound infection. Late : chronic pain, testicular atrophy, recurrence.

40. THANK YOU …