Hernia

1. Hernia 4th stage Lecture -5- D.H. Zaini Kufa university

2. Direct Hernia . occur between 10-15% of inguinal hernia , half of them bilateral. . Always acquired. . The sac passes through weakness or defect of transversalis fascia in post . wall of canal . . Often pt. has poor abdominal musculature as shown by presence of elongated bulging called “malgaigne’sbulgings . . Woman never develop direct hernia practically (by brown). . Predisposing factors . Chronic cough . Heavy work (heavy lifting) . Damage to ileoinguinal N. mainly in previous appendicectomy (motor branch) lead to weakness of conjoined tendon .

3. . Rarely large enough to descend to scrotum , not attain a large size. . The hernia mass consist mainly of extra peritoneal fat & neck of sac wide & so rarely get strangulation , the sac is smaller than hernia mass. . Prevesical hernia , funicular direct hernia pass through small defect in conjoined tendon (apponeurosis of 2 muscles int. oblique & tansversus ) . . Dual or saddle bag or pantaloon hernia means there is both direct & indirect hernia & usually seen intra operatively .

4. The most medial to inf. epigastric A. is direct & most lat. to A. is indirect hernia. • This is most common cause of true or false recurrence. . Direct inguinal hernia lies behind the spermatic cord. . Direct ing. H. once treated, it usually not need removal of sac & only retained it ‘s content & herniorrhaphy & no herniotomy . . But sometime in very large sac that it’s returned into peritoneal cavity difficult so may need herniotomy. . Strangulation occur rarely because of wide neck but occur especially in pt. wearing a truss that are unfit for anesthesia or refuse surgery.

5. . Constricting agents in strangulation:- - neck of sac. - external ring in children. - Rarely adhesion within the sac. . Rx. Should be urgently (of strangulated hernia) because strangulation within short time may develop septicemia. • IV. Fluid. • Analgesia & sedation & AB. • NG tube for gastric decompression to prevent vomiting & inhalation pneumonia. • Urethral catheterization due to full bladder from volume over load.

6. .Recurrence a)) true recurrence - within 1st 2 yrs. - same hernia return on b)) false recurrence • there is other type of hernia that is over looked . Exp:- direct & indirect, femoral with inguinal. . To prevent recurrence remove spermatic cord as it is barrier & called complete excision of cord & testes & complete closure of canal. . Operation ... motioned above . Complication... (for herniorrhaphy mainly )

7. * General . Retention . Respiratory . Cardiovascular & thromboembolic * Local 1- wound sepsis mainly due to poor & septic technique or towel may not so aseptic. 2- hematoma, bruising 3- lymphocele specially after repair of femoral hernia 4- wound sinus when foreign mesh T. used for repair that continually discharging. 5- division of spermatic cord especially in infancy because it is very thin &small 0.2,mn

8. 6- testicular ischemia especially after large or recurrent repair 7- testicular atrophy because of ischemia & pressure effect 8- hydrocele 9- nerve genito femoral branch (sensory) entrapment pain, numbness or parasthesia 10- recurrence especially after large hernia

9. Strangulated Inguinal Hernia . Occur at any time & both sex . Commonly occur in case of indirect , rarely direct . Commonly following hernia for long time especially in those wearing truss or in irreducible . Constrictive agents as mentioned above • Strangulation during infancy - incidence 4% - F\M 5\1 contain ovary or ovary with fallopian tubes • Should be treated urgently • May Rx conservatively by Iv fluid , AB, analgesia, sedation & NG tube with elevation of pelvis or buttock & manual reduction without vigorous manipulation.

10. Note conservative Rx & manual reduction used with caution in adult * Vigorous manipulation 1- contusion or rupture of intestinal wall 2- reduction en masse this mean that mass with obstructing agents &sac become intraperitonealy complain continue not relieve 3- reduction into a loculus of a sac 4- ruptured of sac & passed into extra peritoneal space

11. Sliding Hernia ... (Hernia-en-glissade) . Is a result of slipping of post. parietal peritoneum on underlying retro peritoneal structure . Post . wall of sac is not formed of peritonium alone but by:- L. Sigmoid colon & it’s mesentry R. Cecum either side portion of bladder & rarely small intestine (1-2000) . Occur mainly (almost always) in male & 5\6 on L side . Bilateral sliding hernia is rare . Age > 40 years . Is very large & globular descending well into the scrotum . Should not be treated by truss because part of sac is part of intestine &should be operated by excision of sac &marsupelization . Cecum . appendix or portion of colon wholly in the sac is not a sliding hernia.

12. Femoral Hernia . Third most common type [ incisional is 2nd most common] . 20% of H. in woman 5% in men FIM 2\1 . More liable for strangulation it is the initial presentation in 40% of cases because of narrowness of neck & rigidity of canal . Femoral canal is most medial compartment of femoral sheath extend from femoral ring above into saphenous opening below -1.25 cm 1.25 cm wide at the base which is directed upward .

13. . The space contain fat, lymph v., L.N. of cloquet. . It can not be controlled by truss . The canal is closed above by septum crurale , a condensation of extraperitonel tissue pierced by lymphatic vessels and below by cribriform fascia. * boundaries Ant. Inguinal lig. post. . ileopectineallig. (Astley cooper’s lig) . Pubic bone . Fascia over pectinus m . Med. Lacunarlig. Gumbernat ‘s lig. Lat. Femoral vein separated by thin septum. F\M 2\1 female are usually elderly while male from 30-45 years.

14. Rare before puberty & R. side twice the L. 2:1 . 20% bilateral . Usually passed unnoticed or may presented with obstruction or strangulation because it is small & it’s under underwear . Fully distended femoral H. has the shape of retort and it’s bulbous extremity may be above the inguinal ligament , usually irreducible ape to strangulate.

15. DDx .... 1- inguinal hernia the neck above and medial to inguinal ligament. 2- saphenavarix has pulse on cough saccular enlargement of large saphenous v with other signs of varix vein, disappear when pt. lie. 3- enlargement of femoral L.N. with infected wound or abrasion 4- lipoma 5- femoral aneurysm 6- psoas abscess fluctuating swelling 7-rupture of adductor longus with hematoma by history 8- distended psoas bursa the swelling decrease when the hip is flexed and there is osteoarthritis of the hip . . Truss C.I in femoral hernia .

16. * Rx ..... Also there is a laparoscopic approach • Operations of 3 types 1)) High type opening above inguinal lig (Mc Evedy) 2)) low type opening below inguinal lig. (Lockwood) 3)) inguinal approach opening through inguinal canal ( Lotheissen) • in all cases the bladder must be emptied by catheterization. N .B. Funicular hernia * narrow necked hernia * operation is usually advised * contain prevesical fat and portion of bladder * occurs through a small oval defect in the medial part of conjoined tendon just above the pubic tubercule * occur principally in elderly men, occasionally strangulated .

17. N.B. Dual hernia . Two sacs that straddle the inf. epigastric A. . The condition is not rare . One of the sacs have been overlooked during operation N.B. Repair of direct hernia is as the indirect except 1- hernial sac can usually be simply inverted after free dissection 2- transversalis fascia is simply reconstructed in front of it * The reconstruction should be done by shouldice repair or mesh implant according to Lichtenstein technique. * Bassini is not acceptable because of high recurrence rate and slow rehabilitation.