HERNIA. Done by D1 group. objectives. Definition Anatomy Precipitating factors Types Clinical features Preoperative assessment Management and repair. Definition.
Done by D1 group
A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity .
The inguinal canal is approximately 4 cm long and is directed obliquely
inferomedially through the inferior part of the anterolateral abdominal wall. The canal lies parallel and 2-4 cm superior to the medial half of the inguinal ligament.This ligament extends from the anterior superior iliac spine to the pubic tubercle.
The deep (internal) inguinal ring is the entrance to the inguinal canal. It is thesite of an outpouching of the transversalis fascia. This is approximately 1.25 cm superior to the middle of the inguinal ligament
The superficial, or external inguinal ring is the exit from the inguinal canal. It is a slitlke opening between the diagonal fibres of the aponeurosis of the external oblique
The Cord Itself.—The contents of the spermatic cord are
(a) the ductus (vas) deferens and its artery .
(b) the testicular artery and venous (pampiniform) plexus.
(c) the genital branch of the genitofemoral nerve.
(d) lymphatic vessels and sympathetic nerve fibers.
(e) fat and connective tissue surrounding the cord and its coverings in various amounts
The major feature of the femoral canal is the femoral sheath. This sheath is a condensation of the deep fascia (fascia lata) of the thigh and contains, from lateral to medial, the femoral artery, femoral vein, and femoral canal. The femoral canal is a space medial to the vein that allows for venous expansion and contains a lymph node (node of Cloquet). Other features of the femoral triangle include the femoral nerve, which lies lateral to the sheath,
anterior is the inguinal ligament
posterior is the iliopsoas, pectineal, and long adductor muscles (floor).
Medial is lacunar ligament
Lateral is femoral vessle
All hernias occur at the site of WEAKNESS OF THE ABDOMINAL WALL which are acted on by repeated INCREASE in abdominal pressure
Hernia through the inguinal canal
The sac passes through a weakness or defect of the transversalis fascia in the posterior wall of the inguinal canal
Hernia medial to femoral vessels under inguinal ligament
Hernia through the umbilical ring
A protrusion through the linea alba just above or sometimes just below the umbilicus
Protrusion of extraperitoneal fat through the linea alba anywhere between the xiphoid process and the umbilicus
Hernia through an incisional site
occur through the inferior lumber triangle of Petit
Indirect Versus Direct inguinal hernias
1 ) Femoral hernia
2 ) Vaginal hydrocele
3 ) Spermatocele
4 ) Encysted hydrocele of the cord
5 ) Un-descended testis
6 ) Lipoma of the cord
1 ) Hydrocele of the canal of nuck:
Is a fluid filled distal part of the sac of an indirct hernia with narrow proximal part it present with a smoth fluctuant swelling with out a cough impulse which will transilluminate
2 ) Femoral hernia
Note that examination using finger and thumb across the neck of the scrotum will help to distinguish a swelling of inguinal origin and one that is entirely intrascrotal
Small femoral hernia may be unnoticed by the patient or disregarded for years perhaps until the day it strangulates. Adherence of the greater omentum sometimes causes a dragging pain. Rarely a large sac is present .
1) Inguinal hernia
2 ) saphenavarix: a saccularenlargment of the termination of the long saphenous vein The swelling disappears completely when the patient lies flat there is impulse in
coughing and fluid thrill and sometimes venous hum can be heard over a
3 ) Enlarge lymph node: fever + other lymph node enlargment
4 ) Lipoma
5 ) Femoral aneurysm: expansile pulsation
6 ) Psoas abscess:
There is often a fluctuating swelling and examination of the spine and a radiograph
will confirm the diagnosis
7 ) A distended psoas bursa:
The swelling diminishes when the hip is flexed and osteoarthritis of the hip is present
1. Lab :
* CBC : to check hemoglobin level anemia and WBCs infections
* U&E : to check for any electrolyte imbalance
* LFTs : indicated in jaundiced patients and suspected hepatitis or any clotting problems
* PT & PTT
* grouping and cross matching
2. Imaging :
* Chest X ray : for all patients
3. ECG : for any patient who is more than 40 years of age
Inguinal Hernia Repair
May be appropriate for pt with asymptomatic hernia or elderly pt with minimal symptoms or easily reduced inguinal hernia.
Routine F/U with health care professional
A Randomized trial concluded that this is an acceptable option for men with minimally symptomatic inguinal hernia and that delaying repair until symptoms increase is safe due to low rate ofincarceration. 23% of pt initially treated with watchful waiting crossed over to surgical ttt due to increase in symptoms (most often hernia-related pain) , only 1 pt (0.3%) experienced acute hernia incarceration without strangulation within 2years, a second had acute incarceration with
Bowel obstruction at 4 years, corresponding to frequency of acute intervention of 1.8/1000 pt-years (JAMA 2006,295:285)
Femoral hernia repair
Femoral hernias should be repaired very soon after the diagnosis has been made because of the high risk of strangulation.
There is no place for a truss for a femoral hernia.
Different approaches :
Open VS Laparoscopic
Three approaches have been described for open surgery :
Each technique has the principle of dissection of the sac with reduction of its contents, followed by ligation of the sac and closure between the inguinal and pectineal ligaments.