Inguinal hernia ppt

Covers most aspects with mostly in descriptive pictures

1. Inguinal Hernia Dr.P. Viswakumar .,M.S Assistant professor, Dept of General surgery, PSGIMSR.

2. The term “ hernia ” is derived from the Greek word  hernios , which means “ budding .” Hernia – Protrusion of visceral contents through the Abdominal wall. Two key components Defect Hernial Sac

3. Natural factors for Hernia Erect Human posture – Vulnerability between abdominal muscle wall & hard pelvic bones. Passage of various structure from trunk to extremities (Femoral nerve,Iliac vessels and Spermatic cord). So Adult hernia is in part results from weakness of inner envelope of Abdominal wall ( Transversalis fascia). Weakest points – Inguinal, Femoral and Umblical .

4. Anatomy of Inguinal region Why ? “ No disease of human body belonging to the province of the surgeon requires in its treatment a better combination of accurate knowledge with surgical skill than hernia in all its varities ” - Sir Astley paston cooper ;1804

5. Anatomy of Inguinal region Layers of Abdominal wall ?? - 9 layers 1) Skin 2) Camper’s fascia 3) Scarpa’s fascia 4) External oblique muscle & aponeurosis . 5) Internal oblique muscle & aponeurosis . 6) Transverse abdominus & aponeurosis . 7) Transversalis fascia 8) Preperitoneal fat. 9) Peritoneum.

6. Certain important structures Ligament of henle / Falx inguinalis : Lateral vertical expansion of the rectus sheath that inserts on the pecten of the pubis. In one-third to one-half of patients and is fused with the transversus aponeurosis and fascia

7. Conjoint tendon: By definition, the fusion of lower fibers of the internal oblique aponeurosis with similar fibers from the aponeurosis of the transversus abdominis where they insert on the pubic tubercle and superior ramus of the pubis . The trouble is that the anatomic configuration thus described is extremely rare (3 – 5%). The distinction between falx inguinalis and conjoined tendon is one of anatomic nicety and admittedly of little practical significance in the operating room provided that the distinction is understood . The term conjoined area can be applied correctly to that region that contains the ligament of Henle

8. Ligament of Gimbernat (Lacunar Ligament ): Triangular extension of the inguinal ligament before its insertion upon the pubic tubercle.

9. Cooper’s or Pectineal ligament: The periosteum of the superior ramus of the pubis, strongly reinforced by endoabdominal fascia ( transversalis fascia), with more reinforcement by the transversus abdominis aponeurosis and the iliopubic tract medially Iliopubic tract : Aponeurotic band formed by transversus abdominis muscle and aponeurosis and the transversalis fascia. Begins near the anterior superior iliac spine extends medially to attach to Cooper's ligament

10. Inguinal canal The inguinal canal is formed in relation to the relocation of the testis during fetal development . The inguinal canal in adults is an oblique passage approximately 4 cm long directed inferomedially . The main occupant is the spermatic cord in males and the round ligament of the uterus in females . The deep (internal) inguinal ring defect in fascia transversalis . The superficial ring is a split that occurs in the diagonal, otherwise parallel fibers of the external oblique aponeurosis . The lateral crus attaches to the pubic tubercle, and the medial crus attaches to the pubic crest.

11. Inguinal canal Anterior wall : external oblique aponeurosis throughout the length of the canal; its lateral part is reinforced by muscle fibers of the internal oblique. Posterior wall : transversalis fascia; its medial part is reinforced by pubic attachments of the internal oblique and transversus abdominis aponeuroses that frequently merge to variable extents into a common tendon—the inguinal falx (conjoint tendon)—and the reflected inguinal ligament. Roof: laterally by the transversalis fascia, centrally by musculoaponeurotic arches of the internal oblique and transversus abdominis , and medially by the medial crus of the external oblique aponeurosis . Floor: laterally by the iliopubic tract, centrally by gutter formed by the infolded inguinal ligament, and medially by the lacunar ligament.

12. Nerves of Inguinal Region

13. Vessels of Inguinal Region

14. Laparoscopic anatomy The laparoscopic anatomy of the inguinal area based on M yopectineal orifice of Fruchaud . Superior: Arch of internal oblique muscle and transversus abdominis muscle Lateral: Iliopsoas muscle Medial: Lateral border of rectus muscle and its anterior lamina Inferior: Pubic pecten

15. Preperitoneal space: Space of Retzius - Retropubic space Space of Bogros – Lateral extension of space of retzius Contains inferior epigastric artery

16. Clinicals of Inguinal hernia Types : Anatomical types: According to Extent i ) Bubonocele ii) Incomplete iii) Complete

17. According to its site of Exit : i ) Indirect hernia. ii) Direct hernia. Indirect(oblique) Hernia : 80 % of cases Almost all pediatric and women cases comprise this group Often a complete variety Two forms Congenital and Acquired Congenital 1) Congenital vaginal(complete) 2) congenital funicular Acquired Differentiated from above by as it wont form complete hernia

18. According to its contents: 1) Enterocele 2) Epiplocele or Omentocele 3) Cystocele Clinical types: i ) Reducible ii) Irreducible iii) Obstructed or Incarcerated (irreducibility + obstruction) iv) Strangulated v) Inflammed

19. Rare varieties of Hernia : Hernia-en-glissade or Sliding hernia . Extraperitoneal bowel Part of sac wall

20. Richter’s hernia

21. Littre’s hernia

22. Maydl’s hernia ( Hernia-en-W) Strangulated intraabdominal part Bowel within sac

23. Femoral Hernia

24. Causes of Herniation Coughing Chronic obstructive pulmonary disease Obesity Straining Constipation Prostatism Pregnancy Birthweight <1500 g Family history of a hernia Valsalva's maneuvers

25. Causes of Herniation Ascites Upright position Congenital connective tissue disorders Defective collagen synthesis Previous right lower quadrant incision Arterial aneurysms Cigarette smoking Heavy lifting Physical exertion (?)

26. Classification Gilbert Classification : Type 1 : Small , indirect Type 2 : Medium , indirect Type 3 : Large , indirect Type 4 : Entire floor, direct Type 5 : Diverticular , direct Type 6 : Combined ( pantaloon ) Type 7 : Femoral

27. Nyhus classification : Type I : Indirect hernia; internal abdominal ring normal; typically in infants, children, small adults Type II : Indirect hernia; internal ring enlarged without impingement on the floor of the inguinal canal; does not extend to the scrotum Type IIIA :Direct hernia; size is not taken into account Type IIIB :Indirect hernia that has enlarged enough to encroach upon the posterior inguinal wall; indirect sliding or scrotal hernias are usually placed in this category because they are commonly associated with extension to the direct space; also includes pantaloon hernias Type IIIC : Femoral hernia Type IV : Recurrent hernia; modifiers A–D are sometimes added, which correspond to indirect, direct, femoral, and mixed, respectively

28. Diagnosis History Physical examination Imaging Differential diagnosis : Malignancy Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumor

29. Primary testicular Varicocele Epididymitis Testicular torsion Hydrocele Ectopic testicle Undescended testicle Femoral artery aneurysm or pseudoaneurysm Lymph node Sebaceous cyst Hidradenitis Cyst of the canal of Nuck (female) Saphenous varix Psoas abscess Hematoma Ascites

30. Treatment Open Repair Anterior Repairs, Nonprosthetic i ) Bassini’s repair ii) Shouldice Repair iii) McVay Repair iv) Moloney darn Anterior Repairs, Prosthetic i ) Lichtenstein tension free Hernioplasty ii) Mesh plug and patch iii) Read-Rives iv) Kugel v) Nyhus -Condon vi) Wantz , Stoppa , and Rives

31. Bassini’s Repair

32. Shouldice H ospital R epair

33. Lichtenstein Tension-Free Repair

34. Complications Recurrence Chronic groin pain Nociceptive Neuropathic Cord and testicular Hematoma Ischemic orchitis Testicular atrophy Injury to vas deferens Hydrocele Testicular descent Bowel and bladder injury

35. Osteitis pubis Prosthetic complications Contraction Erosion Infection Rejection Fracture Miscellaneous complications Seroma Hematoma Wound infection General complications

36. Laparoscopic repair TAPP ( Transabdominal preperitoneal repair) TEP ( Total extraperitoneal repair)

37. TAPP Video