Inguinal Hernia- Groin Swellings

Inguinal Hernia is the commonest problem in General surgery. All medical students should know everything about this common problem. In this ppt presentation I have covered all the details regarding Inguinal hernia thoroughly.

1. Dr.B.Selvaraj MS;MCh;FICS Professor of Surgery Melaka Manipal Medical college Melaka Malaysia 75150 GROIN SWELLINGS INGUINAL HERNIA

2. Inguinal Hernia- Overview Causes of groin swellings Classical C linical Vignette of Inguinal Hernia Inguinal Hernia in detail- one pathology in each episode Mind map of Inguinal Hernia Algorithm to clinch the correct diagnosis Tabular column of differential diagnosis depicting their characteristic features to differentiate them from Inguinal Hernia

3. Causes of Groin swellings Inguinal hernia- Indirect & direct Femoral hernia Undescended testis Inguinal lymphadenitis Lipoma of spermatic cord Encysted hydrocele Saphena varix Femoral artery aneurysm Psoas abscess Femoral nerve neuroma

4. Classical Clinical Vignette 40 years old male patient, a manual labourer by occupation, presented with a swelling in his right groin and scrotum for last 2 years and pain over the swelling for last 6 months . The swelling appeared insidiously, initially in the right groin and gradually increased in size for last 2 years and descended into the right scrotum . The swelling disappears completely when the patient lies down , but the swelling reappears on standing and increases in size as the patient walks & coughs Bladder and bowel habits are normal. No history of chronic constipation , or difficulty in micturition .

5. Classical Clinical Vignette Patient complains of chronic cough and breathlessness for last 3 years, which particularly aggravates during the winter season. O/E: The swelling is pyriform in shape and there is visible peristalsis and expansile impulse over the swelling . It is not possible to get above the swelling and there is palpable expansile impulse. The swelling lies above and medial to the pubic tubercle . The content of the swelling reduces with a gurgling sound. The deep ring occlusion test is positive. Bowel sounds are audible over the swelling . Lt inguinoscrotal region is normal Inguinal Hernia

6. Inguinal Hernia Hernia is an abnormal protrusion of the whole or a part of a viscus through an opening in the wall of the cavity which contains it Inguinal hernia occurs either through the deep inguinal ring (indirect) or through the posterior wall of inguinal canal ( direct hernia). The hernia sac consists of mouth, neck, body, and fundus

7. Inguinal Hernia- Etiology Pediatric congenital hernias  due to patent PV Indirect inguinal hernia due to increased intra abdominal pressure Direct inguinal hernia due to weakness of posterior wall of inguinal canal Classification: The European Hernia Society has recently suggested a simplified system of classification P rimary or recurrent (P or R); L ateral , medial or femoral (L, M or F); D efect size in finger breadths assumed to be 1.5 cm . A primary, indirect, inguinal hernia with a 3-cm defect size would be PL2.

8. Inguinal Hernia- Indirect Indirect inguinal hernia is a herniation of abdominal contents through the deep inguinal ring into the inguinal canal. As it traverses the inguinal canal, it is invested by the following coverings from outside within 1. Skin 2. Superficial fascia/ dartos muscle in scrotum. 3. External spermatic fascia derived from external oblique muscle. 4. Cremasteric fascia derived from the internal oblique muscle. 5. Internal spermatic fascia derived from fascia transversalis and 6. The peritoneum which forms the sac.

9. Inguinal Hernia- Indirect Types Bubonocele : Hernial sac stops within inguinal canal after entering internal ring Funicular: Hernial sac after emerging out of external ring stops just above the testis Complete Scrotal: P rocessus vaginalis is patent throughout being continuous with tunica vaginalis of the testis. It is a congenital hernia, commonly seen in children but it may appear in adult or adolescent life.

10. Inguinal Hernia- Clinical Features Swelling in the inguinal region, this is gradually increasing in size . History of dragging pain indicates pull on mesentry in enterocele and pull on omentum in omentocele Age—It occurs in all ages from birth to elderly . Direct hernia is more common in elderly people while indirect hernia is more common in younger and adult life . Expansile impulse on coughing is present . Indirect  Pyriform shape; Direct Globular shape Direct hernia pops out as soon as patient stands. Presence of a scar indicates recurrent hernia

11. Inguinal Hernia- Clinical Features Swelling is soft and gurgles if it is enterocele . It may be firm or granular if omentocele An expansile impulse is felt at the root of scrotum. Getting above the swelling is not possible Reducibility : The direct hernia usually reduces immediately and spontaneously but indirect hernia may require manipulation Internal or deep ring occlusion test: swelling does not reappear in case of indirect hernia; swelling reappears immediately in case of direct hernia

12. Inguinal Hernia- Clinical Features Ziemann’s Test: (Three fingers test ): Index finger is kept at the deep ring, Middle finger, at the superficial ring and Ring finger, at fossa ovalis . Depending on the type of hernia, indirect, direct and femoral, impulse is felt by the index, middle and ring fingers respectively. Examination of respiratory system is done to rule out chronic bronchitis/ COPD Leg raising test (Head raising test): Weakness of the oblique muscles is manifested by Malgaigne’s bulging- the precursor of a direct inguinal hernia.

13. Inguinal Hernia- Clinical Features

14. Inguinal Hernia- Clinical Features

15. Indirect Vs Direct Inguinal Hernia

16. Indirect Vs Direct Inguinal Hernia

17. Inguinal Hernia-Special Types Dual/ Pantaloon /Saddle Hernia: Both direct and indirect sacs + Sliding Hernia: (Hernia- en -glissade) Retroperitoneal organ is part of hernial sac Richter’s Hernia: only part of circumference of the small gut is obstructed Maydl’s Hernia: “W” shaped hernia Littre’s Hernia: Meckel’s diverticulum Amyand’s Hernia: Appendix

18. Inguinal Hernia- Complications Irreducible: Hernia is no more reducible Obstructed: Lumen of hollow viscera is blocked. Can not happen in omentocele . Strangulated: The blood supply to the content of hernial sac is cut off  Gangrene Perforation Peritonitis Incarcerated: The block of the lumen of hollow viscera is due to thick fecal matter/ adhesions Reduction- en -mass: Taxis is normal maneuver to reduce; If you forcibly reduce this complication can occur

19. Inguinal Hernia- Complications

20. Inguinal Hernia- Treatment Pediatric congenital: High ligation of sac/ Herniotomy Young adults: Herniorraphy - suturing together patient’s tissues 1. Bassini’s repair 2. S houldice repair 3. Maloney’s repair  Darning of posterior wall 4. Desarda repair Strip of external oblique aponeurosis is used to strengthen posterior wall

21. Inguinal Hernia- Treatment Old people: Hernioplasty  Litchtenstein’s tension free mesh repair Prolene Hernia System: PHS- Gilbert’s open suture less repair Open pre-peritoneal repair- Stoppa’s Laparoscopic repair: TAPP & TEP Indications: 1.Recurrent Hernias 2.Bilateral inguinal hernias

22. Inguinal Hernia-Complications Of Surgery Seroma/ Hematoma Urinary retention Wound infection Recurrence Chronic neuralgic pain due to nerve injury or entrapment Testicular atrophy due to testicular artery injury

23. Inguinal Hernia- Mindmap

24. Algorithm for Groin Swellings

25. D/D for Groin Swellings Compare & Contrast; Vertical reading