Inguinal Hernia. Shohreh Toutounchi Reference: Schwartz Principles of Surgery 2010 Internship: 1391. Anatomy. The inguinal canal is 4-6 cm long.
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Reference: Schwartz Principles of Surgery 2010
Under one and above 40.
A) Congenital Hernia:
B) Acquired Hernia:
It seems that most cases of hernia come from an acquired defect in the abdominal wall and the reason for its formation is multifactorial:
1- Strenuous physical activity can be a factor but it is not known whether the hernia is just from physical activity or in the setting of a patent process vaginalis.
2- A positive family history which can increase its incidence 8 times.
3- COPD increases the direct hernia risk.
4- Collagen deficiency associated diseases like collagen type I deficiency relative to type III.
5- An association exists between aneurisms and hernias.
Being overweight is to some extent protective (maybe it is from the more difficult diagnosis of hernia)
The valsalva maneuver causes an unusual bulging and it is possible to realize if this bulging can be reduced or not.
The extent of bulging on the two sides can be a criteria for the diagnosis of hernia on one or both sides.
There are different techniques for differentiating a direct from an indirect hernia in physical exam.
- If the finger is inside the inguinal canal and the patient exerts pressure or coughs and the hernia comes in contact with the tip of the finger it is a direct hernia.
- If with closure of the internal ring with the finger while the patient strains (coughs) the hernial sac does not bulge out the hernia is an indirect one, and if the hernial sac bulges the hernia is a direct one.
Important Point: the examination of the femoral hernia is difficult. This hernia presents under the inguinal ligament and the presence of too much or too little fat in the inguinal region can cause an error in the diagnosis. (Femoral Psuedohernia)
Therefore even the presence of a smallest bulging under the inguinal ligament has to raise the suspicion for a femoral hernia.
1-Malignancy: Lypoma, metastasis, testicular tumory
2-Testeicular primary conditions : Varicocele, Epididimitis, Testicular torsion, Hydrocele, Ectopic testes, undescended testes
3- Aneurism or pseudoaneurism of the femoral artery
5- Sebacious cyst
7- Nuck canal cyst (in women)
Imaging in hernia:
1- Overwieght individuals
2- Recurrent hernia
3- Hernias that are not found in the physical exam
In these conditions imaging is important
1-Sonography: It is inexpensive and does not have radiation.
Important Point: In underweight individuals the movement of the posterior wall and spermatic cord toward the anterior wall of the abdomen can have false positive results (the false positive results of the sonography is more than in the phyisical exam and MRI)
2- CT scan: Although it gives more information but the routine use of it is not recommended.
Important Point: In one determined evaluation among the imaging techniques, MRI was more truthful, and an accurate physical exam was more truthful than sonography.
1- A previous surgery in the area (a surgery that the surgeon entered the abdomen such as prostatectomy)
2-Primary medical condition
Important Point: In recurrent cases, dissection in the scar tissue should not be made (due to inability in exactly differentiating the anatomic parts.
Important point: In the treatment of hernia surgery is necessary, since with a conservative method, the wall defect is not removed but has the tendency to enlarge and cause incarceration.
1-Bad coexisting medical condition
2-A small asymptomatic hernia
3-An elderly person who is asymptomatic
Important Point: Conservative treatment is not used in femoral hernia.
Three reasons for incarceration
1- Enlargement of the contents of the hernia
2- Adhesion of sac contents to the canal wall
3- Narrow neck of the sac
Important Point: Indication for urgent surgery is when the intestines are under pressure and the patient has symptoms of bowel obstruction either in incarceration or in a sliding hernia.
3- Hemodynamic instability
4- Tender and warm hernia contents
5- Erythema in hernial sac
Important Point: Before surgery Serum and electrolytes, IV Antibiotics, and NG Tube
1-Patient condition: Nutrient deficiency, Immune deficiency, Diabetes, Steroid use, Smoking
2-Surgical Technique: Inexperienced surgeon, Not fixing the mesh, a Small mesh
3-Tissue: Infection, Tension, Ischemia
To reduce recurrence use a mesh
3-Weakness of external oblique muscle
2-Spermatic Cord Damage and Ischemic Orchitis
3-Vas deferans cut
Due to repetitive movement in lower extremity such as skiing, hockey, or American football, usually hernia is not found in physical exam other than the time of surgery.
inguinal canal repair.
In premature neonates inguinal hernia repair before hospital discharge.