Types-of-Hernia-and-Its-Management.pptxfhhgjj

Hernia

1. Dr. Omongo TYPES OF HERNIA AND ITS MANAGEMENT

2. DEFINITION TYPES & CLASSIFICATION INGUINAL HERNIAS FEMORAL HERNIA PARAUMBILICAL HERNIA INCISIONAL HERNIA EPIGASTRIC HERNIA OTHER RARE HERNIAS OVERVIEW

3. A HERNIA IS A PROTRUSION OF A VISCUS OR PART OF A VISCUS THROUGH AN ABNORMAL OPENING IN THE WALLS OF ITS CONTAINING CAVITY. DEFINITION

4. GROIN HERNIA -Inguinal hernia Direct inguinal hernia Indirect inguinal hernia -Femoral hernia PELVIC HERNIA - obturator hernia -sciatic hernia -gluteal hernia TYPES OF HERNIA

5. ANTERIOR ABDOMINAL WALL HERNIAS -Umbilical hernia - paraumbilical hernia - epigastric hernia - Spigelian hernia POSTERIOR ABDOMINAL WALL HERNIAS -superior lumbar hernia -inferior lumbar hernia

6. Reducible – if contents can be returned to abdomen Irreducible – if contents cannot be returned but there are no other complications Obstructed – if bowel in the hernia has good blood supply but bowel is obstructed. Strangulated – if blood supply of bowel is obstructed. Inflamed – if contents of sac have become inflammed Incarcerated – if the portion of the colon occupying a hernial sac is blocked with faeces CLASSIFICATION

7. Inguinal hernia

8. Protrusion of peritoneal sac through an abnormal opening in the inguinal region. Broadly classified as indirect and direct. Inguinal hernias

9. Congenital Patent processus vaginalis Passes through the inguinal canal Higher risk of strangulation than direct INDIRECT INGUINAL HERNIA

10. INDIRECT INGUINAL HERNIA

11. Indirect inguinal hernia

12. Indirect inguinal hernia

13. Direct Inguinal hernia Within the floor of hesselbach’s triangle Acquired defect Do not descend to scrotum Less chances of strangulation

14. Direct inguinal hernia

15. Multifactorial Increased abdominal pressure Cough Constipation Urinary trouble Acsites Intraabdominal malignancies pregnancy ETIOLOGIES

16. 2) Weakness of abdominal wall Congenital Patent processus vaginalis Patent canal of nuck in female b) Acquired Obesity Surgical incision Connective tissue disorder ( Marfan’s syndrome)

17. A hernia consists of three parts : The sac Coverings of sac Contents of sac The sac is a diverticulum of peritoneum, consists : Mouth Neck Body fundus COMPOSITION OF HERNIA

18. Omentum = omentocoele Intestine = enterocele A portion of the circumference of the intestine= Richter’s hernia A portion of the bladder A Merkel’s diverticulum = a Littre’s hernia Fluid, as part of ascites or peritoneal fluid. Contents

19. Skin & subcutaneous fat. Campers fascia. Scarpa’s fascia. External oblique fascia. Cremaster muscle. Spermatic cord (male) or Round ligament (female). Internal oblique & Transversus abdominis . Transversalis fascia. Preperitoneal tissues. Peritoneum. layers

20. 4cm in length. Extends between superficial and deep rings. Deep/ internal ring is ‘U’ shaped in the fascia transversalis which lies 1.25cm above the mid inguinal point Superficial/ External ring is in the external oblique aponeurosis situated just above and lateral to the pubic crest. Anatomy of inguinal canal

21. Inguinal canal

22. Boundaries of inguinal canal

23. Ilioinguinal nerve Spermatic cord (in males) Round ligament (in females ) Contents of the inguinal canal

24. SPERMATIC CORD coverings External spermatic fascia derived from external oblique aponeurosis and attached to the margins of the superficial inguinal ring Cremasteric fascia derived from the internal oblique muscle Internal spermatic fascia derived from fascia transversalis and attached to the margins of the deep inguinal ring

25. 3 arteries Testicular artery Ductus deferens artery Cremasteric artery 3 nerves Cremasteric nerve Genital branch of genitofemoral nerve Ilioinguinal nerve 3 other things Ductus deferens Pampiniform plexus Lymphatics Spermatic cord contents

26. Major nerves in the region are ilioinguinal , iliohypogastric & genitofemoral nerves. Ilioinguinal nerve provides sensory to pubic region, upper labia, scrotum. Most commonly injured especially during appedicectomy . Iliohypogastric nerve provides sensory to skin superior to the pubis. Genitofemoral nerve provides sensory to scrotum and thigh. Nerve Innervation in Groin

27. Boundaries of Hesselbach Triangle

28. TYPE I: Indirect hernia, normal internal ring, (children or young adults). TYPE II: Indirect hernia, dilated internal ring. TYPE III: posterior wall defects, A : Direct hernia, B : Indirect hernia, dilated internal ring, massive scrotal swelling, Sliding hernia. C: Femoral hernia. TYPE IV: Recurrent herniae (post-hernia repair). Nyhus Classification of hernia

29. A “bulge” or expansile swelling in groin Pain or dull dragging sensation. Extrainguinal symptoms Change in bowel habit Urinary symptoms Pressure on nerves -local sharp pains -referred pain to scrotum, testis or inner thigh Precipitating factors HISTORY

30. INSPECTION Best done in standing postion Site Size Surface Margin Shape Extension Visible cough impulse PHYSICAL EXAMINATION

31. PALPATION Tenderness Warmth Site – relation to pubic tubercle Size Shape Extension Consistency Can get above swelling? Palpation of spermatic cord and testis Cough impulse on palpation

32. REDUCIBILITY TEST DEEP RING OCCLUSION TEST

33. SEARCH FOR PREDISPOSING FACTORS : 1) ABDOMEN EXAMINATION -ABDOMINAL MASS 2)PER RECTAL EXAMINATION -BPH -PROSTATIC CARCINOMA -CONSTIPATION

34. Femoral hernia Lipoma Femoral aneurysm Saphena varix Inguinal lymphadenopathy Psoas abscess Ectopic testis Spermatocoele Vaginal hydrocoele DIFFERENTIAL DIAGNOSIS

35. Imaging modalities Ultrasound CT scan MRI Indications for imaging in inguinal hernia: Vague groin swelling and diagnostic uncertainty Poor localization of swelling (hidden in thick fat) Intermittent swelling which is not present at the time of examination Other groin complaints without swelling. Imaging for inguinal hernia

36. Ultrasound Imaging

37. CT abdomen and pelvis is a good imaging modality to assess for abdominal hernia, especially when there is concern for acute incarceration or strangulation.   CT findings include a “zone of transition” depicting a change in diameter of small bowel from dilated to a normal or decreased diameter such as the “pinch point ” seen in the case image.    Signs concerning for strangulation include engorged vessels within incarcerated hernia, fat stranding and thickened bowel wall (Strange). Computed tomography ( ct scan)

38. HERNIOTOMY -Usually done in children HERNIORRHAPHY - Bassini repair - Shouldice repair - Mc Vay repair HERNIOPLASTY Lichtenstein repair Plug and patch repair Laparoscopic repair TEP (total extra peritoneal) TAPP (trans abdominal preperitoneal ) SURGICAL TREATMENT

39. 1. INCARCERATION : A reducible hernia becomes irreducible . No intestinal obstruction or strangulation. 2. OBSTRUCTION Clinicalfeatures of Small or Large bowel obstruction. 3. STRANGULATION -S/S of Intestinal obstruction, with severe abdominal pain & constitutional symptoms - if gut is strangulated. COMPLICATIONS

40. Sliding hernia: large bowel “slides” through internal ring, lateral to cord. Richter’s hernia: portion of wall of small bowel inside hernia sac. Littre’s hernia: Meckel’s diverticulum in hernia sac. Maydl’s hernia: W shaped hernia Amyand’s hernia: hernia containing appendix Other Groin Hernias

41. Femoral hernia

42. Herniation of intra abdominal contents through femoral canal. Sex: common in females Side: right side 2x more common than left side FEMORAL HERNIA

43. It’s a triangular hollow in the upper 1/3 rd of the anterior thigh. Boundaries : - Superior : inguinal ligament - Lateral : medial border of sartorius - Medial : lateral border of adductor longus - Roof : fascia lata - Floor : adductor brevis muscle ANATOMY OF FEMORAL TRIANGLE

44. Femoral nerve Femoral artery Femoral vein Femoral sheath Femoral canal Deep inguinal lymph nodes Fat tissue Contents of femoral triangle

45. It is a funnel shaped sheath that surrounds upper 1/3 rd of the femoral vessels The anterior wall is the downward prolongation of the fascia transversalis of the anterior abdominal wall. The posterior wall is the downward prolongation of the fascia iliac of the posterior abdominal wall. ANATOMY OF FEMORAL SHEATH

46. Contents of femoral sheath : Femoral artery Femoral vein Femoral branch of genitofemoral nerve Femoral canal

47. It is conical in shape and 1 ½ cm in length. Extends from the femoral ring to the saphenous ring. About 1 ½ inches below and lateral to the pubic tubercle. Innermost compartment of femoral sheath Boundaries of femoral ring : Anterior : inguinal ligament Posterior : ligament of Cooper, iliopectineal ligament Medial : lacunar ligament Lateral : femoral vein Anatomy of femoral canal & femoral ring

48. Fat Facsia Lymphatics : lymph node of Cloquet Contents of femoral canal :

49. Causes of femoral hernia - Pregnancy : increased intraabdominal pressure Wide femoral canal Coverings of femoral hernia : Skin Superficial fascia Cribriform fascia Transversalis fascia Fat and lymphoid tissue Sac

50. Local symptoms : 1) Pain if adhered to greater omentum 2) Swelling: apparent on standing and straining, disappear upon lying down. Situated below and lateral to the pubic tubercle. General symptoms : If obstructed, colicky abdominal pain, vomiting, abdominal distention. If strangulated, sudden pain at local side which then spreads to whole abdomen. Clinical features

51. Specific examination: Swelling below and lateral to pubic tubercle Reducible Expansile cough impulse often not present due to narrow inguinal canal Consistency : firm and doughy ( omentum or extraperitoneal fat)

52. Inguinal hernia Saphena varix Femoral aneurysm Enlarged femoral lymph node Lipoma Psoas abscess DIFFERENTIAL DIAGNOSIS

53. Surgery is a must in all cases due to high risk of strangulation. Basic principle : approximation of inguinal ligament with Cooper’s ligament. MANAGEMENT

54. 3 surgical approaches : Lotheissen’s operation Incision in made through the inguinal canal b) High approach of Mc Evedy Incision is made over femoral canal and continued above inguinal canal. Useful in strangulated and irreducible hernias c) Low operation of Lockwood Incision made below the inguinal ligament via groin crease incision. Indicated in uncomplicated cases Does not prevent inguinal hernia

55. Paraumbilical hernia

56. Hernia occurs either above or below the umbilicus, through linea alba Common in females Causes: Obesity Repeated pregnancy Ascites PARAUMBILICAL HERNIA

57. Swelling over the umbilical region which increases in size on coughing and straining. Positive expansile cough impulse Reducibility can be present Dragging pain if adhered to omentum . Consistency : firm or granular mass Clinical features

58. Mayo’s repair -a curvilinear incision made below the umbilicus -skin flaps are raised -sac is dissected all around and the defect in the linea alba is identified -contents are reduced -defect in the linea alba is extended laterally and then upper and lower aponeurotic flaps are sutured together by using double breasting technique. MANAGEMENT

59. Mayo’s repair

60. Incisional hernia

61. Hernia which occurs through an acquired scar in the abdominal wall usually caused by previous surgical operation or an accidental trauma. Also called ventral hernia or post operative hernia. Etiology : Infection Incision wrongly placed Improper suture material Increased intra-abdominal pressure. INCISIONAL HERNIA

62. Incisional hernia

63. There are various operations for treatment of incisional hernias depending upon the size of the defect, anatomical location of incision and the presence of precipitating factors. 1) laparoscopic mesh repair MANAGEMENT

64. Epigastric hernia

65. Hernia which occurs in the epigastrium through linea alba which extends between the xiphoid process and umbilicus. Precipitated by sudden straining or heavy exercises resulting in the tear of few fibres of linea alba. Treatment : Small incision made over the swelling. If hernial sac is present, it is opened, the contents are reduced and the defect is closed using non- absorbable sutures. EPIGASTRIC HERNIA

66. Epigastric hernia

67. Rare external hernias

68. An interstitial hernia which occurs through the Spingelian fascia. This is a thin strip of fascia which runs parallel to the outer border of rectus sheath from the tip of the 9 th costal cartilage to the pubic tubercle. A reducible swelling located just below and lateral to the umbilicus. Precipitated by pregnancies, advancing age, obesity, sudden straining due to cough or weight lifting. Treatment : sac is excised after reducing the content and the defect is repaired . Spingelian hernia

69. Spingelian hernia

70. It is the herniation either through superior or inferior lumbar triangle. Treatment: -small defects can be closed with simple sutures. -large defects need to be closed with or without mesh . Lumbar hernia

71. Lumbar hernia

72. Hernia which occurs through the obturator canal. Common in females Precipitated by repeated pregnancies and older women who have recently loss lots of weight. Common presentation is acute intestinal obstruction with strangulation. Pain is referred along the obturator nerve to the knee. Treatment : - Closure if the obturator opening is done by stitching the broad ligament over the opening or by using the monofilament nylon with or without mesh. Obturator hernia

73. Obturator hernia

74. MANIPAL MANUAL OF SURGERY ( 3 rd EDITION) DOCTRINE PERPETUA GOOGLE IMAGES REFERENCES