Inguinal Hernia.pptx kist general surgery

Preoperative Measures:

High carbohydrate drink given 90-120 minutes before surgery to maintain bowel function.
Preoperative medications to improve postoperative comfort.
Intraoperative Strategies:

Careful monitoring of intravenous fluids to avoid fluid overload and intestinal edema.
Long-lasting anesthetics administered via abdominal wall or spine to reduce postoperative pain.
Postoperative Protocol:

Early mobilization: Encouraging patients to get out of bed and walk shortly after surgery.
Early resumption of food intake: Patients are allowed to eat regular foods as tolerated.
Diversified pain management: Use of non-opioid medications to promote normal bowel function recovery.

1. INGUINAL HERNIA Mentor :Dr Sushil Dhungel Prepared By: Shikhar Shrestha Resident general surgery(1 st year)

2. objectives To know and understand Anatomy Causes of inguinal hernia Types of hernia and classifications Clinical history and examination findings in hernia Non-surgical and surgical management of hernia including mesh Complications of hernia surgery

3. Introduction Defined as an area of weakness or complete disruption of fibromuscular tissues of the body wall Inguinal hernias are among the oldest known afflictions of humankind Surgical repair of inguinal hernia is the most common general surgery procedure performed today

4. Epidemiology Approximately 75% hernia occurs in groin Life time risk of inguinal hernia is 27% in male and 3 % in female M/C of all hernias in both male and female is indirect inguinal hernia Inguinal hernia is more common in right side Approximately 70% of femoral hernia repairs are performed in females Highest rate of strangulation – femoral hernia(15-20%) Most strangulated Hernias are – indirect inguinal hernia(because of its high incidence)

5. ANatomy

6. Etiology Presumed causes of inguinal hernia : Coughing , COPD Obesity Straining , coughing, constipation Pregnency Family history of hernia Valsva maneouver Ascities

7. Congenital connective tissue disorder Defective collagen synthesis Previous incision Cigarettee smoking Heavy weight lifting Strenous physical exertion

8. Classification On the basis of site of herniation relative to the surrounding structures 1.Direct 2.Indirect One the basis of origin 1 congenital 2 Acquired

9. Indirect hernia protrude lateral to the inferior epigastric vessels,through deep inguinal ring Direct hernia protrude media to the inferior epigastric vessels,within Hesselbach’s triangle Femoral hernia protrude through the small and inflexible femoral ring

10. The borders of the hesselbach’s triangle -inguinal ligament inferiorly -lateral border of rectus sheath medially -inferior epigastric vessels superolaterally

11. The borders of femoral ring - Illopubic tract and and inguinal ligament anteriorly -cooper’s ligament posteriorly -lacunar ligament medially -Femoral vein laterally

12. European Hernia Society(EHS) Primary or Recurrent (P or R) Lateral Medial or Femoral (L,M or F) Defect Size in Finger breadths ,assumed to be 1.5 cm A primary, indirect inguinal hernia with defect of 3 cm would be PL2

13. Nyhus Classification Type 1 : indirect inguinal herna;Internal inguinal ring normal Type 2 : indirect inguinal hernia;internal inguinal ring dilated but posterior wall intact doesnot extend to scrotum ,inferior epigastric vessels are not displaced Type 3 : posterior wall defect Type 3A : Direct inguinal hernia,Size is not taken into account Type 3B : indirect inguinal hernia that has enlarged enough to encroached upon posterior inguinal wall,indirect sliding or scrotal hernia ;includes pantaloon hernia Type 3c : femoral hernia Type 4 : Recurrent hernia;Indirect ,direct ,femoral and mixed

14. Gilbert classification Based on : 1.Presence or absence of peritoneal sac 2.Size of the deep inguinal ring 3.Integrity of the posterior wall Type 1 : Peritoneal sac passing through ,deep inguinal ring less than 1 finger breadth and intact posterior wall – indirect hernia Type 2 : Peritoneal sac passing through ,deep inguinal ring 1 finger breadth and intact posterior wall – indirect hernia Type 3 : Peritoneal sac passing through ,deep inguinal ring 2 finger breadths or wider,part of posterior wall has broken down– indirect hernia

15. Type 4 : No Peritoneal sac passing through ,deep inguinal ring intact and full breakdown of the posterior wall –Direct hernia Type 5 : No Peritoneal sac passing through ,deep inguinal ring intact, diverticular defect of posterior wall Rutkow and Robbins added Type 6 : Double inguinal hernia ,pantaloon Type 7 : femoral

16. checks Reducibility Cough impulse Tenderness Overlying skin color changes Multiple defect/contralateral side Signs of previous repair Scrotal content for groin hernia Associated pathology

17. Differntial diagnosis Hydrocele Lymphnode Sebaceous cyst Varicocele Epididymitis Ectopic testicle , Undescended testicle Psoas abscess , Ascites , Hematoma Femoral artery aneurysm Testicular tumor

18. Diagnosis History Physical Examinataion Imaging

19. History Work up for inguinal hernia begins with a detailed history Most common symptom is groin mass that protrudes while standing , straining , coughing Important consideration in history includes duration and timing of symptoms Sudden onset of symptoms are more concerning Predisposing factors should be identified if possible

20. Physical Examination Should be properly examined with the patient in the standing position Silk glove sign Inguinal occlusion test : -Block the internal inguinal ring and patient advised for cough -A controlled impulse suggests indirect inguinal hernia -A persistent hernia suggests direct inguinal hernia

21. Examination of femoral hernia involves : Palpation of femoral canal just below the inguinal ligament in the upper thigh Most easily palpable landmark is femoral artery located lateral in the canal Medial to artery is femoral vein Femoral empty space is just medial to vein This area palpated with two fingers, and examined closely while patient cough or strains

22. IMaging In case of ambiguious diagnosis Imaging used as adjunct to history and physical examination Most common radiologic modalities include USG,CT,MRI Because there are few bones in the inguinal canal Inferior epigastric vessels are used define groin anatomy Positive intra abdominal pressure is used to elicit herniation of abdominal contents

23. USG detects inguinal hernia with a sensitivity of 86 % and specificity of 77% CT detects inguinal hernia with a sensitivity of 80 % and specificity of 65% In cases , physical examination detects a groin bulge but USG is inconclusive,MRI is used MRI has sensitivity of 95% and specificity of 96 %

24. Management principles Not all hernias require surgical repair Small hernias can be more dangerous than large Pain, tenderness and skin colour changes imply high risk of strangulation Femoral hernia should always be repaired

25. TREATMENT Surgical repair is the definitive treatment of inguinal hernia Open, laparoscopic or with robotic assistance M/c reason for the repair is pain Incarcerated and strangulation,primary indications of urgent repair Asymptomatic should undergo watchful waiting

26. Data from Swedish hernia registry demonstrated (Done in 1,07,838 groin hernia repair) Immediate emergent operation is associated with seven fold increase In all cause of morbidity and mortality over that of elective process Femoral and symptomatic inguinal hernia be electively repair ,when possible

27. Surgical approach 1 . R eduction of the hernia content into the abdominal cavity with removal of any non-viable tissue and bowel repair if necessary; 2. E xcision and closure of a peritoneal sac if present or replacing it deep to the muscles; 3. R eapproximation of the walls of the neck of the hernia if possible; 4 . P ermanent reinforcement of the abdominal wall defect with sutures or mesh.

28. herniotomy In children , who have lateral hernias with a persistent processus , it is sufficient just to remove and close the sac. This is called a herniotomy.

29. Classic Open Tissue repairs Bassini repair Mc vay repair Shouldice repair Marcy repair Pott’s repair Desarda operation

30. Bassini Conjoint tendon and Transversalis fascia are attached to Poupart’s ligament

31. Mcvay Conjoint tendon and transversalis fascia are attached to cooper’s ligament

32. Shouldice Four layer suture repair of inguinal hernia with double breasting of posterior wall of inguinal canal

33. desarda Suture repair of inguinal hernia employing external oblique aponeurosis

34. Open tension free mesh repairs Lichtenstein operation Plug and patch technique Stoppa operation

35. Lichtenstein Allows tension for the tension free repairing of the inguinal floor by buttressing the floor with a prosthetic mesh

36. Plug and patch technique Modification of the Lichtenstein repair Prior to placing the prosthetic mesh patch A 3D prosthetic plug is placed in the area previously occupied by hernia sac Indirect hernia : plug is placed alongside the spermatic cord through the internal ring Direct hernia : plug is sutred with cooper’s ligament, Inguinal ligament and internal oblique

37. Stoppa An open preperitoneal operation placing a large mesh over the posterior aspect of inguino femoral canal area

38. Mesh in hernia repair - B ridge a defect - Plug a defect - A ugment a repair: the defect is closed with sutures and the mesh added for reinforcement.

39. MESH characteristics Woven, knitted or sheet Synthetic or biological Light, medium or heavyweight Large pore, small pore Non-absorbable or absorbable

40. Laparoscopic approach Transabdominal preperitoneal repair(TAPP) Totally extraperitoneal repair (TEP) Intraperitoneal onlay mesh repair(IPOM)

41. A im of surgery T o reduce the hernia and hernia sac within the abdomen, A nd then place a 10 × 15 cm mesh just deep to the abdominal wall, Ex tending across the midline into the retropubic space and 5 cm lateral to the deep inguinal ring M esh covers Hasselbach’s triangle, DIR and the femoral canal.

42. TEP : C reate a space just deep to the abdominal muscles without entering the perotineal cavity TAPP : Enters peritoneal cavity then incises the peritoneum above the hernia defects, R eflects it away from the muscles Once the hernia has been reduced M esh is inserted and the peritoneum closed over the mesh

43. Emergency inguinal Hernia surgery Out of all 95 % presents in opd , 5 % present in Emergency As such,strangulation of hernia content is surgical emergencyPainful Hernia bulge is warm and tender, skin overlying erythematous Clinical signs includes tenderness , fevr,leukocytosis Surgery needs to be performed rapidly after well resuscitation Principles of surgery are same as in elective Light weight synthetic mesh repair with appropriate coverage of antibiotics

44. Complications of hernia repair Early : Pain Bleeding Urinary retention Anesthetic complications Medium : seroma , wound infection Chronic : testicular atrophy ,chronic pain(63%) Postherniorahhapphy inguinodynia

45. References Bailey and love’s Short practice of surgery 27 th edition Sabiston A text book of surgery 21th edition Schwartz 11th edition Maingots Abdominal operations13th edition