Strangulated hernia

defination of hernia,epidemiology,etiology,parts of hernia,classification,clinical features,pathophysiology,predisposing factors and surgical management of strangulated hernia,

1. Strangulated hernia By DR BADAL KHAN PGR SU4 25-8-2015 1

2. HERNIA DEFINATION IT IS AN ABNORMAL PROTRUSION OF A VISCOUS OR A PART OF A VISCOUS THROUGH AN OPENING ARTIFICIAL OR NATUERAL WITH A SAC COVERING IT. 25-8-2015 2

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4. AETIOLOGY OF HERNIA STRAINING LIFTING OF HEAVY WEIGHT CHRONIC COUGH (TB,CH BRONCHITIS,ASTHMA) CHRONIC CONSTIPATION URINARY CAUSES OLD AGE; BPH CA PROSTATE YOUNG AGE;STRICTURE URETHRA VERY YOUNG AGE ;PHIMOSIS,METAL STENOSIS OBESITY PREGNENCY SMOKING ASCITES APPENDICECTOMY FAMILIAL COLLEGEN DISORDER 25-8-2015 4

5. PARTS OF HERNIA COVERING 2. SAC 3.CONTENTS 25-8-2015 5

6. 1.COVERING COVERING OF THE SAC ARE THE LAYERS OF THE ABDOMINAL WALL THROUGH WHICH THE SAC PASESS 25-8-2015 6

7. 2.SAC OF HERNIA IT IS A DIVERTICULAM OF PERITONEUM WITH .MOUTH .NECK .BODY .FUNDUS NECK IS NARROW IN INDIRECT BUT WIDE IN DIREC HERNIA BODY IS THIN IN INFANTS, CHILDREN AND IN INDIRECT BUT IS THICK IN DIRECT AND LONG STADING HERNIA 25-8-2015 7

8. 3.CONTENTS OF HERNIA OMENTUM-OMENTOCELE INTESTINE-ENTEROCELE COMMONLY SMALL BOWEL PORTTION OF CIRCUMFERENCE OF BOWEL URINARY BLADDER-CYSTOCELE MECKLE,S DIVERTICULAM-LITTRE,S HERNIA OVARY FALLOPIAN TUBE 25-8-2015 8

9. CLASSIFICATION OF HERNIA CLASSIFICATION NO 1 CONGENITAL ACQUIRED 25-8-2015 9

10. CLASSIFICATION (CONT….. CLASSIFICATION NO 2 ACCORDING TO CONTENTS OMENTUM-OMENTOCELE ENTEROCELE-INTESTINE CYSTOCELE-URINARRY BLADDER LITTRE,S HERNIA-MECKLE,S DIV.. SLIDING HERNIA PART OF BOWEL-RICHTER,S HERNIA 25-8-2015 10

11. CLASSIFICATION CONT…. CLASSIFICATION NO 3 ACCORDING TO SITES INGUINAL FEMORAL OBTURATOR DIAPHRAGMATIC LUMBAR UMBLICAL EPIGASTRIC 25-8-2015 11

12. CLASSIFICATION CONT….. CLASSIFICATION NO 4 CLINICAL CLASSIFICATION REDUCIBLE HERNIA IRREDUCIBLE HERNIA OBSTRUCTED HERNIA INFLAMED HERNIA STRANGULATED HERNIA 25-8-2015 12

13. STRANGULATED HERNIA 25-8-2015 13

14. DEFINATION A HERNIA IN WHICH BLOOD SUPPLY OF THE HERNIATED VISCUS IS SO CONSTRICTED BY SWELLING AND CONG- -STION AS TO ARREST ITS CIRCULATION 25-8-2015 14

15. STRANGULATED HERNIA CONT …. STRANGULATION COMMONLY OCCURS IN SMALL BOWEL AND ALSO OCCURE IN LARGE BOWEL . OCCASIONALLY STRANGULATED OMENTOCELE CAN ALSO OCCURE WITHOUT ANY INTESTINAL OBSTRUCTION 25-8-2015 15

16. STRANGULATED HERNIA CONT…. STRANGULATION CAN OCCUR IN INGUINAL FEMORAL OBTURATOR UMBLICAL ANY OTHER HERNIA 25-8-2015 16

17. STRANGULATED HERNIA CONT…. BUT INDIRECT INGUINAL HERNIA IS MORE PRONE FOR STRANGULATION BECAUSE OF CONSTRICTING AGENTS NECK OF SAC SUP ING RING IN CHILDREN ADHESIONS WITHIN SAC 25-8-2015 17

18. SO NOW WE WILL DISCUSS Strangulated inguinal hernia 25-8-2015 18

19. EPIDEMIOLOGY INCIDENCE RATE OF STRANGULATED INGUINAL HERNIA VARIES BETWEEN 0.29% AND 2.9% MORTALITY RATE RANGES BETWEEN 2.6% TO 9% BUT A DELAY OF 12 H INCREASE CHANCE OF INTESTINAL RESECTION RATE . ABOUT 95% OF INGUINAL HERNIA PATIENT PRESENT AT CLINICS AND ONLY 5% PRESENT AS AN EMERGENCY WITH IRREDUCIBLE HERNIA WHICH PROGRESS TO STRANGULATION 25-8-2015 19

20. EPIDEMIOLOGY CONT…. MORTALITY RISK IS SEVEN TIME HIGHER IN CASES AFTER EMERGENCY STRANGULTED INGUINAL HERNIA SURGERY AND 20 TIME HIGHER IF BOWEL RESECTION WAS UNDERTAKEN DURING INFANCY INCIDENCE IS 4% FEMALE TO MALE RATIO IS 5;1 IN FEMALE INFANTS THE CONTENTS MAY BE OVARY WITH OR WITHOUT FALLOPIAN TUBE 25-8-2015 20

21. EPIDEMIOLOGY CONT….. STRANGULATED HERNIAS ARE MORE FREQUENTLY SEEN IN ELDERLY PATIENTS,AND THEIR PREVELANCE IN THE 60 YEAR OLD POPULATION HAS BEEN REPORTED TO BE 9.8% COMPARED WITH 1.8% FOR YOUNGER PATIENTS 25-8-2015 21

22. PATHOLOGY OF STRANGULATED HERNIA OBSTRUCTION VENOUS RETURN IMPAIRED CONGESTION OF THE BOWEL FURTHER DILATATION OF THE BOWEL WHICH BECOMES PURPLE COLOURED CONT … 25-8-2015 22

23. PATHOLOGY CONT…... FLUID COLLECT IN THE SAC EVEVTUALLY ARTERIAL SUPPLY IS IMPAIRED BOWEL BECOMES DARK, BROWNISH BLACK COLOURED WITH FLABBY AND FRIABLE WALL 25-8-2015 23

24. PATHOLOGY CONT…... BACTERIA MIGRATE TRAN SEROSALLY AND MULTIPLY IN FLUIDE OF THE SAC PERFORATION OCCURE AT THE SITE OF CONSTRICTION RING PERITONITIS OCCURE 25-8-2015 24

25. COMMON BACTERIA IN STRANGULATED HERNIA E.COLI ANAEROBIC STREPTOCOCCI ANEROBIC BACTERIA KLEBSELLA 25-8-2015 25

26. PREDISPOSING FACTORS OBLIQUE INGUINAL HERNIA TRUSS WORN FOR LONG TIME PARTIALLY REDUCIBLE HERNIA LARGE HERNIA IN ELDERLY 25-8-2015 26

27. CAUSES OF STRANGULATION NARROW NECK ADHESIONS IRREDUCIBILITY LONG TIME HERNIA 25-8-2015 27

28. CONTENTS SMALL INTESTINE ( USUALLY ) LARGE INTESTINE (RARELYY) BOTH SMALL INTESTINE AND OMENTUM (SOMETIME) 25-8-2015 28

29. DIAGNOSIS OF STRANGULATED HERNIA HISTORY TAKING EXAMINATION INVESTIGATION 25-8-2015 29

30. 1.HISTORY TAKING SEVERE PAIN INITIALLY AT HERNIAL SITE THEN BECOME GENERALISED PERSISTENT VOMITING ABDOMINAL DISTENSION CONSTIPATION RECENT SUDDEN INC IN SIZE OF LUMP 25-8-2015 30

31. 2.EXAMINATION INSPECTION PALPATION SITE SIZE SHAPE COLOUR TEMP EXTREMELY TENDER ( MAYDLE,S HERNIA TENDERNESS ABSENT ) REBOUND TENDERNESS IS DIAGNOSTIC COUGH IMPULSE ABSENT IRREDUCIBLE 25-8-2015 31

32. EXAMINATION CONT…... PERCUSSION AUSCULTATION NOT POSSIBLE DUE TO TENDERNESS IF DONE THEN…. DULL IN CASE OF OMENTUM RESONENT IN CASE OF GUT GUT SOUNDS MAY BE AUDIBLE IN CASE OF ENTEROCELE SILENT ABDOMEN IN CASE OF PERITONITIS ( PARALYTIC PARALYSIS ) 25-8-2015 32

33. 3.INVESTIGATIONS BLOOD TESTS IMAGING CBC (TOTAL COUNT BLOOD SUGAR SERUM ELECTROLYTES BLOOD UREA SERUM CRITININE PLAIN XRAY ABDOMEN IN ERECT POSITION IN CASE OF OBS MULTIPLE AIR FLUIDE LEVELS U/S ABDOMEN 25-8-2015 33

34. Treatment 25-8-2015 34

35. TREATMENT CONT….. OFTEN IN IRREDUCIBLE HERNIA, REDUCTION OF HERNIA IS TRIED BY ELEVATION SEDATION TAXIS 25-8-2015 35

36. WHAT IS TAXIS? IT IS A TRIAL TO REDUCE PARTIALLY REDUCED OR IRREDUCIBLE HERNIA WHILE FLEXING AND MEDIALLY ROTATING THE HIP IT IS DANGEROUS IN OBS AND MAYDLES HERNIA 25-8-2015 36

37. SURGICAL TREATMENT PREOPERATIVE MEASURES OPERATION HERNIOTOMY (SHAMIM) BASSINI,S (SRB) LIGHT WEIGHT SYNTHETIC MESH (BAILEY &LOVE) 25-8-2015 37

38. TREATMENT CONT….. PREOP TREATMENT PT ADMITTED IV CANULA RYLE,S TUBE (NG) ASPIRATION IV FLUIDS TO CORRECT DEHYDRATION AND ELECTROLYTE IMBALANCE ANTIBIOTICS CATHETERISATION SHIFT PT FOR EMERGENCY SURGERY 25-8-2015 38

39. TREATMENT CONT….. OPERATION – NO 1. INGUINAL HERNIOTOMY INCISION INCISION IS MADE OVER THE MOST PROMINENT PART OF THE SWELLING 25-8-2015 39

40. OPERATION ( HERNIOTOMY ) CONT….. 2.DELIVERING & OPENING OF SAC SAC IS EXPOSED CONSTRICTION RING AND SUP RING IS RELEASED DELIVER BODY AND FUNDUS OF SAC WITH COVERING ONTO SURFACE SAC IS OPENED WITHOUT SPILLAGE OF FLUIDE FLUID IS SUCKED AND MOPPED 25-8-2015 40

41. OPERATION ( HERNIOTOMY ) CONT…. 3.EXCISION OF STRANGULATED CONTENTS IN CASE OF OMENTUM DEVITSLISED OMENTUM IS EXCISED AFTER BEING SECURELY LIGATED 25-8-2015 41

42. OPERATION ( HERNIOTOMY ) CONT….. 2.IN CASE OF INTESTINE BOWEL IS HELD WITH FINGERS SO AS TO PREVENT IT FROM GETTING REDUCED VIABILITY OF THE BOWEL IS CHECKED BY COLOUR PERISTALSIS PULSATION BLEEDING VIABLE INTESTINE IS RETURNED TO PERITONEAL CAVITY WHEN GANGRENOUS RESECTION AND ANASTOMOSIS IS DONE AND DRAIN IS PLACED 25-8-2015 42

43. OPERATION ( HERNIOTOMY ) CONT….. 4.EXCISION OF SAC MODERATE SIZED HERNIAL SAC CAN BE EXCISED AND CLOSED BY A PURSE STRING SUTURES 2. LARGE SIZED &ADHERENT HERNIAL SAC IS CUT ACROSS AND NECK OF SAC IS TIED AND SUTURED 6.WOUND CLOSER WOUND CLOSE LAYER BY LAYER 25-8-2015 43

44. TREATMENT CONT….. NO.2 BASSINI,S REPAIR IT IS DONE BY PLACING INTERUPTED NON- -ABSORBABLE SUTURES NO.3 LIGHTWEIGHT MESH SOME SURGOENS STILL USE A LIGHWEIGHT SYNTHETIC MESH COVERED BY APPROPRIATE ANTIBIOTIC 25-8-2015 44

45. POST OP COMPLICATION ANESTHESIA COMPLICATIONS BLEEDING URINARY RETENTION SEROMA WOUND INFECTION SEPTICEMIA LEAK WITH FISTULA CHRONIC PAIN 25-8-2015 45

46. REFRENCES BAILEY,S AND LOVE SRB,S MANUAL OF SURGERY ESSENTIALS OF SURGERY BY DR SHAMIM WIKIPEDIA TOPIC UPON HERNIA FROM UNIVERSITY OF COLORADO HOSPITAL 25-8-2015 46

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