Inguinal Hernia.pptx

Lecture notes for MBBS

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2. Learning Objectives At the end of this session the learner will be able to describe- Aetiology Pathophysiology Clinical Features Management Of Inguinal Hernia

3. Learning Objectives Introduction & History Relevant Anatomy, Physiology Aetiology Pathophysiology Pathology Classification Clinical Features Investigations Management Controversies Prevention Guidelines Take home messages

4. Hernia: Definition

5. Hernia: Definition An abnormal protrusion of a viscus or its part through a normal or abnormal opening in the walls of its containing cavity.

6. Relevant Anatomy

7. Pathophysiology Anatomy Hesselbach's triangle- Lateral border of the rectus abdominis  Inguinal ligament  Inferior epigastric vessels.

8. Anatomy Hesselbach's triangle-

9. Anatomy Inguinal Canal Anterior- . Posterior- Inferior- Superior- Lateral /Entry- Medial/Exit- Content-

10. Anatomy Inguinal Canal Anterior- Ext. Obl. Aponeurosis . Posterior- Fascia Transversalis Conjoint tendon medially Inferior- Inguinal ligament. Superior- Conjoint tendon. Lateral /Entry- Internal/deep ring Medial/Exit- External/ Supf . ring Content- Spermatic cord

11. Anatomy The spermatic cord- Vas deferens Processus vaginalis. C remasteric muscle fibers ,  Testicular artery and accompanying veins Genital branch of the genitofemoral nerve  Cremasteric vessels, Lymphatics, 

12. Anatomy Inguinal Ligament The lacunar ligament

13. Anatomy Inguinal Ligament: ( Poupart’s ligament) is the inferior edge of the external oblique aponeurosis and extends from the anterior superior iliac spine to the pubic tubercle, turning posteriorly to form a shelving edge. The lacunar ligament is the fan-shaped medial expansion of the inguinal ligament, which inserts into the pubis and forms the medial border of the femoral space

14. Anatomy The external (superficial) inguinal ring: The Internal (Deep ) ring

15. Anatomy The external (superficial) inguinal  ring: is an ovoid opening of the external oblique aponeurosis that is positioned superiorly and slightly laterally to the pubic tubercle. The Internal (Deep ) ring : Opening in Fascia transversalis at mid inguinal point. 1.25 cm above the inguinal ligament, midway between the symphysis pubis and the anterior superior iliac spine

16. Anatomy Important sensory nerves- Iliohypogastric n. Ilioinguinal n. Genital branch of the genitofemoral nerve  

17. Anatomy The inferior epigastric artery and vein .

18. Anatomy  The inferior epigastric artery and vein  .  Defines the type of inguinal hernia. Indirect inguinal hernias occur lateral to the inferior epigastric vessels, whereas direct hernias occur medial to these vessels.

19. Anatomy Cremaster muscle-

20. Anatomy Cremaster muscle- arise from the internal oblique, encompass the spermatic cord, and attach to the tunica vaginalis of the testis.

21. Anatomy Parts of Hernia- Sac Coverings of the sac Contents of the sac. Neck of sac is at internal ring where sac communicates with peritoneal cavity.

22. Anatomy Types of Hernia- Bubonocele . The hernia is limited to the inguinal canal. Funicular. The processus vaginalis is closed just above the epididymis . Complete (synonym: scrotal).

23. Relevant Physiology

24. Defense of inguinal canal Shutter mechanism Obliquity of inguinal canal Ball valve mechanism of cremaster Contraction of cremaster helps the spermatic cord to plug superficial inguinal ring.  The pinchcock action of the internal ring musculature Flap valve mechanism The superficial inguinal ring is guarded from behind by the conjoint tendon and by the reflected part of the inguinal canal.  The anterior wall opposite the deep ring is reinforced laterally by the internal oblique muscles.  Slit valve mechanism Contraction of the external oblique results in approximation of the two crura of the superficial inguinal ring 

25. Aetiology Idiopathic Traumatic Infections /Infestation Neoplastic (Benign/Malignant) Congenital/ Genetic Nutritional Deficiency/excess Autoimmune Degenerative / lifestyle Iatrogenic Psychosomatic Poisoning/ Toxins/ Drug induced

26. Inguinal hernia: Etiology Idiopathic Congenital Traumatic Infections /Infestation Autoimmune Neoplastic (Benign/Malignant) Degenerative

27. Inguinal hernia: Etiology Risk factors Elevated intra-abdominal pressure is associated with chronic cough, ascites, increased peritoneal fluid from biliary atresia, peritoneal dialysis or ventriculoperitoneal shunts, intraperitoneal masses or organomegaly, and obstipation. Premature infants Exstrophy of bladder, neonatal intraventricular hemorrhage, myelomeningocele, and undescended testes. 

28. Inguinal hernia: Etiology Molecular Risk factors The rectus sheath adjacent to groin hernias is thinner than normal. The rate of fibroblast proliferation is less than normal, and the rate of collagenolysis appears increased. Sailors who developed scurvy had an increased incidence of hernia Aberrant collagen states ( eg , Ehlers-Danlos, fetal hydantoin, Freeman-Sheldon, Hunter-Hurler, Kniest , Marfan , and Morquio syndromes), have increased rates of hernia formation, as do osteogenesis imperfecta, pseudo-Hurler polydystrophy , and Scheie syndrome.

29. Inguinal hernia: Etiology Molecular Risk factors Acquired elastase deficiency Heavy smokers The contribution of biochemical or metabolic factors to the creation of inguinal hernias is unclear.

30. Pathophysiology

31. Pathophysiology An indirect inguinal hernia follows the tract through the inguinal canal. It results from a persistent processus vaginalis. The processus fails to close adequately at birth in 40-50% of boys.  A familial tendency exists, with 11.5% of patients having a family history.  Direct hernia is caused by weakness of posterior wall – abdominal wall and thinning of fascia.

32. Pathophysiology Increased intra-abdominal pressure: Marked obesity Heavy lifting Coughing Straining with defecation or urination Ascites Peritoneal dialysis Ventriculoperitoneal shunt Chronic obstructive pulmonary disease (COPD) Family history of hernias

33. Classification

34. Classification Indirect Inguinal hernia. Direct Inguinal hernia. Congenital Inguinal hernia. A sliding hernia :a portion of the sac is composed of visceral peritoneum covering part of a retroperitoneal organ, usually the colon or bladder

35. Clinical Features

36. Clinical Features Demography Symptoms Signs Prognosis Complications

37. Demography

38. Demography Incidence & Prevalence Geographical distribution. Race Age Sex Socioeconomic status Temporal behaviour

39. Demography Incidence 5-10 % Geographical distribution : none Age- increases with age. Sex -25 times more common in males. Even in females most common groin hernia is inguinal hernia. Side-More common on right side.

40. Symptoms

41. Symptoms Swelling in inguinoscrotal region. Painless unless complicated.

42. Signs

43. Signs Male Complaint painless inguinoscrotal swelling on and off. Skin over swelling –normal. Visible peristalsis. O/E local temperature normal Non tender Testis palpable separately Getting above swelling not possible Reducible. Impulse on coughing present Resonant on percussion Opaque Three finger test Invagination test Ring Occlussion test.

44. Prognosis

45. Prognosis Morbidity Mortality rate 5 year survival in Malignancy

46. Prognosis Congenital and indirect hernias have high risk of strangulation .

47. Complications

48. Complications Irreducible / Incarcerated Obstruction Strangulation Inflammed hernia.

49. Investigations Laboratory Studies Routine Special Imaging Studies Tissue diagnosis Cytology FNAC Histology Germ line Testing and Molecular Analysis Diagnostic Laparotomy.

50. Diagnostic Studies Imaging Studies X-Ray USG CT Angiography MRI Endoscopy Nuclear scan

51. Diagnostic Studies Imaging Studies X-Ray USG CT Angiography MRI Endoscopy Nuclear scan

52. Differential Diagnosis

53. Differential Diagnosis Hydrocele Encysted hydrocele of the cord Varicocele Ectopic testis Epididymitis Testicular torsion Lipoma Hematoma Sebaceous cyst Hidradenitis Inguinal  lymphadenopathy Lymphoma Metastatic neoplasm Femoral hernia Femoral lymphadenopathy Femoral artery aneurysm or pseudoaneurysm

54. Management

55. Non Operative Therapy

56. Non Operative Therapy Elderly with direct hernia .

57. Operative Therapy

58. Operative Therapy Herniotomy Herniorrhaphy . Hernioplasty using mesh.

59. Minimally invasive Therapy

60. Minimally invasive Therapy TAPP TEP

61. Controversies

62. Controversies

63. Futuristic

64. Futuristic

65. Guidelines

66. MCQ Hernia with highest rate of strangulation is? (A) Direct inguinal hernia (B) Indirect inguinal hernia (C) Femoral hernia (D) Incisional hernia

67. MCQ Hernia with highest rate of strangulation is? (A) Direct inguinal hernia (B) Indirect inguinal hernia (C) Femoral hernia (D) Incisional hernia

68. MCQ The following are the risk factors for inguinal hernia except : a) Family history of inguinal hernia b) Weight lifter c) COPD d) Female e) Obesity

69. MCQ The following are the risk factors for inguinal hernia except : a) Family history of inguinal hernia b) Weight lifter c) COPD d) Female e) Obesity

70. MCQ Hernia that is least likely to strangulate is a) Femoral hernia b) Direct inguinal hernia c) Indirect inguinal hernia d) Umbilical hernia

71. MCQ Hernia that is least likely to strangulate is a) Femoral hernia b) Direct inguinal hernia c) Indirect inguinal hernia d) Umbilical hernia

72. MCQ Which of these would you like to do for a case of strangulated hernia - a) X-ray abdomen b) USG abdomen c) Aspiration of contents of sac d) Correction of hypovolemia e) Prepare OT for urgent surgery

73. MCQ Which of these would you like to do for a case of strangulated hernia - a) X-ray abdomen b) USG abdomen c) Aspiration of contents of sac d) Correction of hypovolemia e) Prepare OT for urgent surgery

74. MCQ Viscera forms wall of which hernia- Lumbar hernia Sliding hernia Epigastric hernia Femoral hernia

75. MCQ Viscera forms wall of which hernia- Lumbar hernia Sliding hernia Epigastric hernia Femoral hernia

76. MCQ All of the following statements are true about repair of groin hernias except - Lichtenstein tension free repair has a low recurrence rate TEP repair is an extraperitoneal approach to laparoscopic repair of groin hernia In Shouldice repair, non- abosorbable mesh is used The surgery can be done under local

77. MCQ All of the following statements are true about repair of groin hernias except - Lichtenstein tension free repair has a low recurrence rate TEP repair is an extraperitoneal approach to laparoscopic repair of groin hernia In Shouldice repair, non- abosorbable mesh is used The surgery can be done under local

78. MCQ Sliding constituent of a large direct hernia is - Bladder Sigmoid colon Caecum Appendix

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