Inguinal hernia ; Treatment & Pathophisiology presentation

Inguinal hernia presentation
by Shariatyfar MD
based on schwartz principles of surgery 11th edition
Qom university of medical sciences
winter 2017
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1. INGUINAL HERNIA A.Shariatyfar & M . Navab zadeh

2. INTRODUCTION

3. What is a hernia? The word “hernia” is derived from a Latin term meaning “a rupture.” A hernia is defined as an area of weakness or complete disruption of the fibromuscular tissues of the body wall. Structures arising from the cavity contained by the body wall can pass through, or herniate, through such a defect.* * Maingot’s abdominal operations . 12 th edition pg. 123

4. Approximately 75% of abdominal wall hernias occur in the groin . Inguinal hernia repair is the most commonly performed operation in the United States . The lifetime risk of inguinal hernia is 27% in men and 3% in women .

5. ANATOMY

6. The inguinal canal is an approximately 4-6 cm long cone shaped region situated in the anterior portion of the pelvic basin The canal begins on the posterior abdominal wall, where the spermatic cord passes through the deep (internal) inguinal ring, a hiatus in the transversalis fascia . The canal concludes medially at the superficial (external) inguinal ring, the point at which the spermatic cord crosses a defect in the external oblique aponeurosis

7. Inguinal hernias are generally classified as indirect , direct , and femoral based on the site of herniation relative to surrounding structures . Indirect hernias protrude lateral to the inferior epigastric vessels, through the deep inguinal ring. Direct hernias protrude medial to the inferior epigastric vessels, within Hesselbach’s triangle. Femoral hernias protrude through the small and inflexible femoral ring.

8. Hesselbach's triangle The borders of the triangle are: 1- the inguinal ligament inferiorly 2- the lateral edge of rectus sheath medially 3- the inferior epigastric vessels superolaterally

9. Femoral hernia Femoral hernias protrude through the small and inflexible femoral ring. The borders of the femoral ring include: 1- the iliopubic tract and inguinal ligament anteriorly 2- Cooper’s ligament posteriorly 3- the lacunar ligament medially 4- and the femoral vein laterally

10. Spermatic cord Cremasteric muscle fibers Vas deferens Testicular artery Testicular pampiliform venous plexus Genital branch of genitofemoral nerve

11. EMBRYOLOGY

12. The testis develops between the peritoneum and body wall. Testicular descent takes place in two phases : 1- Trans-abdominal phase (between 10-15 weeks of gestation) 2- Trans-inguinal phase (between 25-35 weeks of gestation)

13. Trans-abdominal phase Extending from the caudal pole of the testis is a mesenchymal condensation rich in extracellular matrices, the gubernaculum. Prior to descent of testis this band of mesenchyme terminates in the inguinal region between the differentiating internal and external oblique abdominal muscles. In trans-abdominal phase enlargement of abdominal cavity causes anchored testis to be drawn downward to mouth of the deep inguinal ring.

14. Trans-inguinal phase Later an extra-abdominal portion of the gubernaculum forms and grows from the inguinal region toward the scrotal swelling . In trans-inguinal phase a finger-like evagination of peritoneum called the processus vaginalis pushes it’s way to the tissues of the developing abdominal wall. This evagination follows the course of gubernaculum. Layers of abdominal wall follow the processus vaginalis and become the layers of spermatic cord.

15. The connection between abdominal cavity and the processus vaginalis in the scrotal sac normally closes in the first year after birth .if this passageway remains open, intestinal loops may descend into the scrotum causing a congenital indirect inguinal hernia. Sometimes obliteration of this passageway is irregular, leaving small cysts along it’s course. Later these cysts may secrete fluid forming a hydrocel of the testis or spermatic cord.* * langman’s medical embryology 12 th edition pg. 258

16. PATHOPHISIOLGY

17. Acquired vs Congenital Most adult inguinal hernias are considered acquired defects in the abdominal wall . The best-characterized risk factor is weakness in abdominal wall musculature . Congenital hernias can be considered an impedance of normal development

18. Between 36 and 40 weeks of gestation , the processus vaginalis closes and eliminates the peritoneal opening at the internal inguinal ring . Failure of the peritoneum to close results in PPV (patent processus vaginalis) This explains the high incidence of indirect inguinal hernia in preterm babies. Children with indirect inguinal hernia present with PPV. Not all PPVs result in indirect inguinal hernia.

19. A: closed PV B: minimally patent PV C: moderately patent PV D: inguinal hernia

20. Presumed causes of groin herniation Coughing COPD Obesity Straining (Constipation, Prostatism ) Pregnancy Ascites Birth weight< 1500 g Valsalva’s maneuver Congenital connective tissue disorders Defective collagen synthesis Physical exertion

21. CLASSIFICATION

22. NYHUS classification 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 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 Type IIIC Femoral hernia Type IV Recurrent hernia . A-D for indirect, direct , femoral and mixed

23. Incarcerated hernia : hernia which cannot be reduced. Strangulated hernia : incarcerated hernia with resulting ischemia. Two definitions

24. DIAGNOSIS

25. History Patients who present with a symptomatic groin hernia will frequently report groin pain. Change in bowel habits or urinary syndromes are less common; suggesting sliding hernia consisting of intestinal contents or involvement of bladder. Inguinal hernia may compress adjacent nerves leading to generalized pressure , localized sharp pain and referred pain . Pressure or heaviness is a common complaint.

26. Important considerations of the patient’s history include the duration and timing of the symptoms. Hernias will often increase in size and content over a protracted time. Much less commonly, a patient will present with a history of acute inguinal herniation following a strenuous activity. It is more likely that an asymptomatic inguinal hernia became evident once the patient experienced symptoms after an acute event.

27. Patients will often reduce the hernia by pushing the contents back into the abdomen, thereby providing temporary relief As the defect size increases and more intra-abdominal contents fill the hernia sac, the hernia may become harder to reduce.

28. Physical examination Ideally, the patient should be examined in a standing position to increase intra-abdominal pressure, with the groin and scrotum fully exposed. Inspection is performed first, with the goal of identifying an abnormal bulge along the groin or within the scrotum. If an obvious bulge is not detected, palpation is performed to confirm the presence of the hernia.

29. Palpation is performed by advancing the index finger through the scrotum toward the external inguinal ring. The patient is then asked to perform Valsalva’s maneuver to protrude the hernia contents. These maneuvers will reveal an abnormal bulge and allow the clinician to determine whether the hernia is reducible or not. Femoral hernias should be palpable below the inguinal ligament, lateral to the pubic tubercle

30. Imaging In the case of an ambiguous diagnosis, radiologic investigations may be used as an adjunct to history and physical examination. Imaging in obvious cases is unnecessary and costly. The most common radiologic modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). MRI is an effective diagnostic test, with a sensitivity of 95% and specificity of 96%. But its high cost and limited access remain obstacles to more routine use.

31. Differential diagnosis Malignancy: (Lymphoma, Retroperitoneal sarcoma, Metastasis and Testicular tumor) Primary testicular: (Varicocele, Epididymitis, Testicular torsion, Hydrocele, Ectopic testicle and Undescended testicle) Femoral artery aneurysm or pseudoaneurysm Lymph node Sebaceous cyst Hidradenitis Hematoma, psoas abscess, ascites and …

32. TREATMENT

33. Surgical repair is the definitive treatment of inguinal hernias. When the patient’s medical condition confers an unacceptable level of operative risk, elective surgery should be deferred until the condition resolves, and operations reserved for lifethreatening emergencies . Complication rates of immediate and delayed elective tension-free repair are equivalent . Nonoperative inguinal hernia treatment targets pain , pressure , and protrusion of abdominal contents in the symptomatic patient population.

34. The risks of incarceration and strangulation appear to decrease over the first year, likely because gradual enlargement of the abdominal wall defect facilitates spontaneous reduction of hernia contents. Femoral and symptomatic inguinal hernias carry higher complication risks, and so surgical repair is performed earlier. one study found the 3-month and 2-year cumulative incidences of strangulation were 2.8% and 4.5%, respectively, for inguinal hernias and 22% and 45%, respectively, for femoral hernias.

35. Data from the Swedish Hernia Registry demonstrate that emergent operation is associated with a sevenfold increase in all-cause mortality over that of elective surgery among 107,838 groin hernia repairs. For this reason, it is recommended that femoral hernias and symptomatic inguinal hernias be electively repaired, when possible. The indication for emergent inguinal hernia repair is impending compromise of intestinal contents. As such, strangulation of hernia contents is a surgical emergency. Clinical signs that indicate strangulation include fever , leukocytosis , and hemodynamic instability .

36. INGUINAL HERNIA IN ARTICLES

37. 1. Why do inguinal hernia patients have pain? Histology points to compression neuropathy* Patients completed pain questionnaires pertaining to preoperative pain and the quality of pain experienced. During routine inguinal hernia repair, nerve segments were sampled for histologic evaluation . quantified various histologic indicators including nerve diameter, fascicle count, myxoid content within the epineurium, perineurium and endoneurium. Increased preoperative patient pain scores correlate with increased nerve diameter, increased fascicle count and increased myxoid material both within the perineurium and endoneurium The American Journal of Surgery 213 (2017) 975-982

38. 2. Etiology of inguinal hernias : a comprehensive review* The aim was to summarize the evidence on hernia etiology, with focus on differences between lateral and medial hernias. Medial and lateral hernias both have common and different etiologies. Risk factors to develop both lateral and medial hernias are older age , a low BMI , and gene mutations . Even though connective tissue alteration is confirmed in both hernia subtypes, medial hernias appear to have a more profound alteration. Patent processus vaginalis and increased cumulative occupational mechanical exposure are risk factors to develop lateral hernias. *Frontiers in surgery, September 2017, volume 4, article 52

39. 3. Risk Factors for Inguinal Hernia among Adults in the US Population* The authors examined risk factors for incident inguinal hernia among US adults (5,316 men and 8,136 women) participating in the First National Health and Nutrition Examination Survey. hernia. Ninety-six percent of the baseline cohort was recontacted , with a median follow-up of 18.2 years. the cumulative incidence of inguinal hernia was higher among men (13.9%) than among women (2.1%). American journal of epidemiology, vol. 165, pages 1154-1161

40. Among men in multivariate analysis, a higher incidence (p < 0.05) of inguinal hernia was associated with an age of 40–59 years. an age of 60–74 years and hiatal hernia, while Black race being overweight and obesity were associated with a lower incidence. Among women, older age, rural residence, greater height, chronic cough, and umbilical hernia were associated with inguinal hernia. In the United States, inguinal hernias are common among men, especially with aging. The lower risk among heavier men was unexpected and bears further study.

41. ATTENTION!!! Thanks for your attention 