CHARACTERISTIC OF INCARSERATED INGUINAL HERNIA PATIENTS AT DR HASAN SADIKIN HOSPITAL PERIOD JANUARY 2013- FEBRUARY 2015

CHAPTER I

INTRODUCTION

hernia repair is one of the cornerstones of a general surgery practice and is one of the most commonly performed procedures in the United States, owing to a significant lifetime incidence and variety of successful treatment modalities. Although there are no exact figures totaling the number of inguinal hernia repairs performed annually, it has been estimated that approximately 800,000 cases were performed in 2003, not including recurrent or bilateral hernias.1 A vast majority of these procedures were performed on an outpatient basis. Advancements in perioperative anesthesia and the increase in proportion of laparoscopic treatment of inguinal hernias have combined to increase the percentage of ambulatory inguinal

hernias1 The lifetime risk of inguinal hernia is 27% in men and 3% in women.2 Of inguinal hernia

repairs, 90% are performedin men and 10% in women. The incidence of inguinal hernias in males has a bimodal distribution, with peaks before the first year of age and after age 40. The agedependence of inguinal hernias in 1978. Those age 25 to 34 years had a lifetime prevalence rate of 15%, whereas those age75 years and over had a rate of 47%2. Generally hernia is a protrusion (protrusion) fill a cavity through a defect or weak parts of the abdominal wall in question. Abdominal hernia, abdominal contents protrude through a defect or weak parts of the musculo-aponeurotik layers of the abdominal wall. Called hernia incarcerated hernia or Strangulated when it sandwiched by hernia ring so that the bag is trapped and can not get back into the abdominal cavity. As a result, frequent disturbances passage or vascularization. Clinically hernia incarcerated hernia is intended to ireponibel with passage disorder, whereas vascularization disorder called hernia Strangulated . The incidence of inguinal hernias in infants and children between between one and two percent. There may be a hernia on the right side of 60%, 20-25% left side and 15% bilaterally2. Children who have undergone hernia surgery in infancy have the possibility of a 16% gain contralateral hernia in adulthood. Incidence of inguinal hernia in adults is approximately 2%. Hernia incidence increased with increasing age may be due to increased intra-abdominal pressure elevating disease and reduced the strength of the supporting network 2

CHAPTER II

LITERATURE REVIEW

A. Definition

Hernia is a protrusion protusi or fill a cavity through a defect or weak parts of the wall cavity concerned. A hernia is a protrusion of the coil or segment cavity or tissue through an abnormal opening. Ireponibel incarcerated hernia is a hernia that has been followed with signs of mechanical ileu3s.

B. Anatomy and Physiology

The muscles of the abdominal wall which divided four rectus abdominis muscle, m. Obliqus internus abdominis, m. Transfersus abdominis. Inguinal canal arising from descensus testiculorum, where the testicles do not penetrate the abdominal wall ventral abdominal wall but pushed forward. These channels run from kranio-lateral to the mid-caudal, parallel to the inguinal ligament, length: ± 4 cm3.

Ingunalis canal bordered on kraniolateral by the internal inguinal ring, which is an open part of the fascia transversalis and m.transversus abdominis aponeurosis in the medial bottom, above the pubic tubercle. This canal is limited by the external annulus. The upper limit is aponeurosis m.obliqus eksternus and there based on inguinal ligament. Channel contains sperm and sensibility leather strap inguinal region, scrotum and a small portion of skin, upper limb portion proksimedia3.

In the state of the abdominal wall muscle relaxation, which limits the portion of the internal annulus also sagging. In the circumstances it is not a high intra-abdominal pressure and inguinal canal runs vertically. Conversely when the abdominal wall muscles contract runs transverse inguinal canal and inguinal ring sealed so as to prevent the entry of the intestine into the inguinal canal. In a healthy person, there are three mechanisms that can prevent an inguinal hernia is the inguinal canal that runs sideways, the structure m.obliqus internus

abdominis which closes the internal inguinal ring when the contract and the fascia transversalis strong covering Hasselbach triangle which generally hardly muscular so disturbance in this mechanism may lead to the occurrence of inguinal hernia3.

C. Risk Factor Hernia

The causes of hernias among others3:

1. Congenital hernias

a. Congenital hernias Perfect

In this situation the baby is suffering from hernia since birth due to a defect in certain places.

b. Congenital hernias imperfectly

Babies are born normal but have a defect in certain places, and a few months after life through the defect would undergo hernia.

2. Hernia Aquisita

b. High intra-abdominal pressure

Many occur in patients who are often either at the time straining to urinate or defecate as in patients with BPH, urethral stones, constipation and chronic cough.

b. Constitutional body

Thin people tend to be susceptible to hernias, because the connective tissue backers tend to be less so at the weak spots (locus minoris resistant) backers little connective tissue. While in obese people may also be susceptible to hernias because a lot of fat in the body tissue and fat tissue may increase the workload of connective tissue LMR backers.

c. Distended abdominal wall

Therefore, various causes are ascites, obstruction or ileus. This situation will lead to an increase in intra-abdominal pressure.

d. sikatrik

Scars caused by laparotomy. If you do laporotomy cut off more than one n.interkostalis then in place sikatrik LMR will happen and can be a hernia.

D. Factors that affect hernia

Factors that affect the hernia, among others2:

Coughing Chronic obstructive pulmonary disease Obesity Straining Constipation Prostatism Pregnancy Family history of a hernia Valsalva’s maneuver Ascites Upright position Congenital connective tissue disorders Defective collagen synthesis Previous right lower quadrant incision Cigarette smoking Heavy lifting Physical exertion

E. Various hernia2

1. Clinically divided becoming:

a. Reducible Hernia

If the organ is experiencing hernia hernia sac can be in and out of actively or passively. The contents do not necessarily emerge spontaneously, but occurs when seconded gravity or increased intra-abdominal pressure. Intestines out when standing or straining and enter again if lying or pushed into the stomach, no pain or symptoms of intestinal obstruction.

b. Irreducible Hernia

If the organ into the hernia sac can not get out except with the help of surgery. If this is due to adhesions on the organ called the hernia sac of hernia accreta.

c. Obstructed Hernia

A irreducible hernia which has occurred in the vascularization disorders viscera trapped in the hernia sac or pinched hernia ring.

d. Incarcerated hernia

Irreducible hernia is already followed by signs of mechanical obstruction.

Type Reponibel Painful Obstruction Looks sick Toxic Reducible / free

Irreducible / accreta

Incarcerated

Disturbance

+

-

-

-

-

-

+

++

-

-

+

+

-

-

+

+

-

-

-

++

2. Under the direction of herniation

b. External Hernia

A hernia that penonjolannya can be seen from the outside because of hernia protrusion outwards.

1). Medial inguinal hernia (direct) and lateral (indirect)

The medial inguinal hernia due to factors of chronic elevation of intra-abdominal pressure and muscular weakness in the wall of Hesselbach triangle, round shape. Lateral inguinal hernia due to protrude from the abdomen in the lateral inferior epigastric arteries. Called indirect because through two doors, namely channel annulus and inguinal canal oval.

2). Femoral Hernia

Elevation of intra-abdominal pressure will push the fat preperitonial into the femoral canal that would be opening the hernia. Women suffer more because of the factors causing this hernia multiparous pregnancy, obesity, and connective tissue degeneration due to old age. The entrance hernia is a hernia femoral ring would then fill in the femoral canal entrance.

3). Hernia epigastrica

Hernia comes out through a defect in the linea alba between the umbilicus and processes xiphoideus.

4). Obturator hernia

Is a hernia through the obturator canal. Canalis obturator is a channel formed by the obturator membrane does not cover the obturator foramen, overall is a defect in the obturator sulcus.

5). Hernia semilunaris

Hernias that occur along the linea semilunaris abdomen. Linea semilunaris is the image contained in the lateral line. Rectus abdominis, linea 3 is formed by the union of the abdominal muscle aponeurosis is m.obliqus eksternus, m.obliqus internus, m.transversus abdominis.

6). Perineal hernia

Perineal hernia is a protrusion of perineal hernia through a defect in the pelvic floor may occur as a primer.

7). Hernia ischiadica

Meruupakan hernia through the foramen and foramen ischiadikum ischiadikum major minus.

b. Hernia interna

Called external hernia because the hernia contents into the cavity of another example of the thorax cavity or exchanges omentalis or into the recess in the abdominal cavity.

1). In the abdominal cavity

a. epiploic hernia winslowi

hernia abdominal viscera through the epiploic foramen winslowi.

b. Hernia exchanges omentalis

Continued from epiploic hernia where the viscera are not only in the epiploic foramen but has entered into exchange omentalis.

c. Hernia mesenterica

Retroperitoneal organ or tissue herniation into the mesentery.

d. Retroperitoneal hernia

This is called retroperitoneal hernia because the abdominal viscera into the pockets formed by the folds of the parietal peritoneum covering the retroperitoneal organs.

2). In the thoracic cavity

Herniation that occurs from the abdominal cavity into the thoracic cavity due to pass through the diaphragmatic structure known as a diaphragmatic hernia. Diaphragmatic hernia occurs due to an abnormal hole or defect in the diaphragm which causes the abdominal viscera can through the hole into the cavity of the thorax.

a. Hernia diafragmatica traumatica

Defects arise because of gunfire, beatings, stabbings, or the destruction of the diaphragm.

b. Hernia diafragmatica non traumaticum

1). Congenital

Because of the growth process diaphragm

2). Acquisital

The hernia will pass through the hole on the already existing diafragmatica as esophageal hiatus.

F. Pathophysiology

Hernia develops when intra-abdominal pressure as the pressure increased when lifting something heavy, at the time of defecation or a strong cough or sneeze and displacement stricken parts of the intestine abdominal muscles, excessive pressure on the abdominal region of course will lead to a possible weakness due to the abdominal wall is thin or not sufficiently strong in the area where the conditions existed or occurred on a fairly long development process, abdominal surgery and obesity. First of all damage is very small in the abdominal wall, then going hernia because organs are always doing heavy work and takes place in a long time, so there was protrusion and cause severe damage. Thus eventually causing the bag contained in the stomach into or experiencing weakness if the blood supply is disrupted dangerous and can lead to gangrene2.

G. Clinical manifestations

The groin hernia can present in a variety of ways, from the asymptomatic hernia to frank peritonitis in a strangulated hernia. Many hernias are found on routine physical examination or on a focused examination for an unrelated complaint. These groin hernias are usually fully reducible and chronic in nature. Such hernias are still referred for repair since they invariably develop symptoms, and asymptomatic hernias still have an inherent risk of incarceration and strangulation. The most common presenting symptomatology for a groin hernia is a dull feeling of discomfort or heaviness in the groin region that is exacerbated by straining the abdominal musculature, lifting heavy objects, or defecating. These maneuvers worsen the feeling of discomfort by increasing the intra-abdominal pressure and forcing the hernia contents through the hernia defect. Pain develops as a tight ring of fascia outlining the hernia defect compresses intra-abdominal structures with a visceral neuronal supply. With a reducible hernia, the feeling of discomfort resolves as the pressure is released when the patient stops

straining the abdominal muscles. The pain is often worse at the end of the day, and patients in physically active professions may experience the pain more often that those who lead a sedentary lifestyle3.

Overwhelming or focal pain from a groin hernia is unusual and should raise the suspicion of hernia incarceration or strangulation. An incarcerated hernia occurs when the hernia contents are trapped in the hernia defect so that the contents cannot be reduced back into the abdominal cavity. The tight circumferential pressure applied by the hernia defect serves to impede the venous outflow from the hernia contents, resulting in congestion, edema, and tissue ischemia. Ultimately, the arterial inflow to the hernia contents is compromised as well, resulting in tissue loss and necrosis, termed strangulation of the hernia. All types of groin hernias are at risk for incarceration and strangulation, although the femoral hernia seems to be predisposed to this complication. Incarceration and strangulation of a groin hernia may present as a bowel obstruction when the tight hernia defect constricts the lumen of the viscus. Hence, all patients presenting with bowel obstruction require a thorough physical examination of the groin region for inguinal and femoral hernias. If there is no bowel in the hernia sac, an incarcerated groin hernia may alternatively present as a hard, painful mass that is tender to palpation3,4.

H. Complication

hernia can cause complications as follows1,3,4:

1. Adhesions occur between the bag with the contents of the hernia hernia known as hernia accreta

2. Hernia occurs ireponibel 3. Clasps happen blood vessels which results in ischemia organ 4. Infection and eventually necrosis 5. Incarcerated or strangulated hernia

J. Management Incarcerated inguinal hernia

There is no conservative therapy and surgery should be performed as soon as possible (speed operation) to eliminate ileus because ileus including emergencies. Operations carried

out without the patient's general condition wapaupun see operations that can be done only palliative surgery if the patient in the bad condition

Therapy Type Traditional techniques

Traditional surgical repairs, like Bassini and Shouldice techniques are not used very commonn elective inguinal hernia repair. However, in an emergency surgery, as in cases of strangulated inguinal hernias, these techniques are preferred from contemporary tension-free techniques, due to high possibility of mesh infection, in tension free techniques. Regardlessthe choice between traditional and tension-free techniques, the operation begins with anoblique skin incision (or along the Langer lines) approximately 2 centimeter superior to and parallel to the thigh crease, and then the incision is being extended 5 cm toward the anterior superior iliac spine, starting from just lateral to the pubic tubercle. In thin patients, the external ring can actually be palpated just lateral and slightly above the pubic tubercle and should be Strangulated Inguinal Hernia the medial starting point of incision3,4,6. Then the dissection is going deeper through the subcutaneous tissue until the aponeurosis of the external oblique is identified. In strangulated hernia the tissues maybe inflamed and edematous, therefore careful dissection of the anatomic structures is mandatory. Along with external oblique aponeurosis, the apex of the inguinal canal and also the external inguinal ring must be identified, before incising the external obliquemuscle. The inguinal canal should be entered at its apex. For a correct identification of the apex of the canal, the lower wall of the canal, which is where the external oblique aponeurosis disappears into the fat of the thigh, should be pointed out. Approximately one finger breadth above this point is a good entry site into the canal3,4. The external inguinal ring is also important because the external ring is ultimately the end point of the division to be made in the external oblique aponeurosis and defines the orientation of this cut. Once the external oblique aponeurosis is identified, is thoroughly exposed and a gentle stab incision in its mid-portion along the orientation of its fibers is made. This incision is extended superiorly, and medially downward, through the superficial ring, thus exposing the inguinal canal and the cord structures3,4. Afterwards comes the circumferentially mobilization of the cord structures off the floor of the canal by working on the pubic tubercle as a fulcrum. With blunt dissection of the index finger in a sweeping and medially encircling fashion, the cord is sufficiently freed, so that the cord structures can be surrounded by a Penrose drain for convenient retraction. This allows exposure of the inguinal floor and protects the cord structures. Then, an examination of the anteromedial aspect of the cord should be made, foran indirect component of the hernia. Separating the cremasteric muscle along its fibers oftenfacilitates this. The cremasteric muscle fibers must be dissected carefully with slow electrocautery coagulation, as the cut muscle fibers tend to bleed. If an indirect hernia is

present, the sac is dissected off the cord structures, down toward its base at the internal inguinal ring, until it is comfortably invaginated into the preperitoneal space. This is preferably achieved without division of the sac. However, if necessary, as with certain large hernias, the sac can be entered carefully and examined for visceral contents, and then divided with a high ligation. The peritoneal fluid within the sac should be sucked and sent for culture. If there is ischemic bowel inside the sac it should be resected promptly and anastomosed with an end-to-end manner. Occasionally there may be only strangulation of a portion of the greater omentum or strangulation of a portion of the sac itself, which maybe the cause of local discomfort and pain Direct hernias, which protrude through the inguinal floor at the Hesselbach triangle, aresimilarly dissected away from the cord structures toward their base and then are invertedbelow the transversalis fascia. Closure of the defect and buttressing of the inguinal canal floor can now be performed. The Bassini technique is widely used, but the Shouldice technique is considered to be better, in terms of recurrence, is not usually used, because of the more extensive dissection, and a belief that the skill of surgeons is important as well. The Bassini repair is a technique in which thesurgeon sutures the conjoined tendon to the inguinal ligament, which slides the patient’s ownmuscles together to cover the hole in the abdominal wall and repair the hernia. The spermatic cord remains in its normal anatomic position under the external oblique aponeurosis. Thesurgeon closes the incision with a stitch known as the simple interrupted suture pattern, an Inguinal Hernia speedy stitch that allows for surgery to be complete in approximately one hour2,3,4,6.

Bassini'soriginal technique yielded outstanding results for a pure tissue technique; however, problemsoccurred when surgeons failed to open the posterior wall. So, a new operation, known as the"modified" or "North American" Bassini was introduced. By not opening the posterior wall,the wall tissue was damaged in its most medial portion by sutures placed under tension, andrecurrences resulted, primarily in the pubic tubercle area. Thus, the failure of this operationin its first year was more likely due to an overlooked second hernia or to poor surgicaltechnique, rather than a metabolic or tissue defect that might predispose to recurrent hernia4.

The Shouldice technique (it is also known as ilio-inguinal incision) begins with the ligation ofsuperficial veins. Afterwards, comes the same procedure as described above. The reconstruction in Schouldice technique is achieved by continuous suturing using 2.0 or 3.0 polypropropylene sutures; starting medially, not through the periosteum of the pubic tubercle. Suturation of the inferior edge of the fascia transversalis (Thomson’s ligament) to a fold of the anteriorside of the conjoined tendon (‘white line’) is being made, until the internal ring is constricted in order to allow passage for the spermatic cord and point of tweezers). Then comes the secondlayer after including cremaster stump with the same thread to the iliopubic tract (inferior edge of the inguinal ligament). The third layer begins laterally, with the closure of

the conjoined tendon to inguinal ligament. Original Shouldice has a fourth layer in the same plane4,6.

Finally,After opening of the subcutaneous tissue, a gangrenous portion of the sac and the adjacent preperitoneal tissue was revealed, which was resected, the reapproximation of the external oblique aponeurosis is achieved with a running 3-0polyglactin suture; at that stage the surgeon must be careful for the underlying ilioinguinalnerve. Reapproximation of the Scarpa fascia is followed with interrupted 3-0 polyglactin suture and then a running subcuticular closure of the skin with 3-0 poliglecaprone suture. The operative site is cleaned and sterile dressings are applied

Tension-free techniquesThe Lichtenstein repair is widely accepted as the tension-free technique of choice.

Theoperation starts again with medial incision as possible, for good exposure of the tubercle ofpubic bone and rectus sheath. The superficial veins are ligated and the external oblique is cleaved, just like the traditional operation (with caution of the ilioinguinal nerve). The spermatic cord is surrounded and the posterior wall is assesed. Cremaster does not need to be excised unless hypertrophic, thus, leaving an unacceptably wide internal ring. The hernia sac is dissected until inside the internal ring, and then it can be reduced (which is the preferable option), transected, or resected. If necessary, the surgeon sutures a large direct hernia tensionfree with continuous soluble sutures until a flat posterior wall has been created with a normal internal ring. All nerves should be preserved in principle, but it is advised that if a nerve is damaged or interfers with the palcemnet of mesh it should be resected. Special attention to the iliohypogastric nerve should be paid; this nerve may lie under the mesh, but preferably notagainst a sharp edge. In that case the prosthesis is cut to the size it needs to be, because it isobvious that dividing a nerve is better than causing neuralgic pain. Polypropylene mesh 7x9x14 cm is applied (trimming is often necessary) with a 2-cm overlap at the pubic tubercle4,6.

Then the prosthesis is sutured continuously with polypropylene sutures 3.0 starting 2 cm mediocranially from the pubic tubercule on the lateral rectus edge and then on the inguinalligament to the internal ring. An incision in the mesh is made on 1/3 of the lower side until just medial to the spermatic cord. And both flaps of the prosthesis are sutured, overlapping on the lateral side to the inguinal ligament with one polypropylene suture; upper flap over the lower flap. The cranial edge of the mesh is also stabilized with one or more sutures (which may be soluble) to the aponeurosis of the internal oblique, avoiding muscle in order to avoid injury to the intramuscular segment of the iliohypogastric nerve. Again particular attention should be paid in order not to entrap nerves by suturing. Mesh must lie tension-free (domed) after removal of the wound spreader. The closure procedure is the same as in the Shouldice technique. In women, it is important to preserve the round ligament and the ilioinguinal nerve

(like the spermatic cord). If both structures are cut, it is not necessary to create flaps in themesh4,6.

Endoscopic techniqueEndoscopic technique has been used rarely in the management of strangulated inguinal

hernias, but lately, even more surgeons prefer that technique. In the endoscopic repair (or extra peritoneal approach TEP) the bladder must be empty before the operation. An incision (2 cm) is made just under and next to the umbilicus until inside the anterior rectus sheath. The preperitoneal space is opened with the finger and, if needs be, a balloon (optional) is inserted, 10 Inguinal Herniaup to the pubic bone. The surgeon insufflates with gas, under camera control, and replaces the balloon with blunt balloon or Hasson trocar. The patient is during the procedure in Trendelenburg position. Then, identification of os pubis, Cooper’s ligament, epigastric vessels and internal ring takes place. Next, the surgeon dissects with a second trocar (5 or 10 mm in medial line) the lateral space until ASIS and inserts a third trocar (5 mm). The lateral hernia sac is dissected from the spermatic cord which is put aside over 5–7 cm. Polypropylene prosthesis with dimensions 15x9x15 or 10x9x15 cm is inserted and it is draped over the abdominal wall with plenty of overlap for all potential hernia defects. Finally, the surgeon desufflates carefully and removes instruments while holding the peritoneal sac ‘inside’ the mesh3,4.

Choice of the most suitable techniqueLately, the use of prosthetic material for inguinal hernia repair has increased dramatically. Tension-free repairs have gained popularity not only for elective or recurrent hernias but also for complicated inguinal hernia repairs as well. Inguinal hernia mesh repair according to Lichtenstein ‘‘tension-free’’ technique has gained great acceptance from the surgeons all over the world, showing efficacy to consolidate the posterior wall of the inguinal canal and to reducepostoperative pain and recurrence risk due to tension on suture lines. Recent clinical trials on tension- free anterior repair of inguinal hernia using a mesh revealed that the immediate postoperative complications were rare and always minor, and rate of long-term recurrence is very low (0.5%) . The presence of a strangulated inguinal hernia cannot be considered a contraindication for the use of a prosthetic mesh, although the use of traditional repairs, such as the Bassini repair in strangulated inguinal hernia is a common practice. Lichtenstein hernioplasty can be successfully used not only as an elective operation but also as an emergency operation for incarcerated inguinal hernia with a good outcome, with a low risk of the local infectious complications and a decently low rate of postoperative complications. However, the outcomes of emergency leichtenstein hernioplasty were inferior to the outcomes of elective Lichtenstein hernioplasty Wound infection is a potential complication of all hernia repairs and an infection involving an inserted mesh may result in chronic groin sepsis, which

usually necessitates complete removal of mesh. Along with the catastrophic effects of a groin sepsis, removal of mesh wouldpotentially result in a weakness of the repair and as a result, a recurrent hernia. It has beenproved however that hernia recurrence following mesh removal for chronic groin sepsis, wasnot a common phenomenon, and the explanation of that fact is that the strength of a meshrepair lies mostly in the fibrous reaction evoked within the transversalis fascia by the prostheticmaterial rather than in the physical presence of the mesh itself. Of course, when there isestablished deep infection, there should be no unnecessary delay in removing an infected meshin order to allow resolution of chronic groin sepsis. However, that procedure has a relativerisk of bowel injury3,4,6.

Surgical techniques and implanted materials are crucial to the results and costs associated withhernia repair considering that specific mesh materials are related to specific complications.Polypropylene meshes are ideal for use in contaminated or potentially contaminated fields.The macroporous structure of the meshes of polypropylene, with pores of diameter larger thanStrangulated Inguinal Hernia 1170 micronmeters, allows contact among the bacteria, which measures almost one micrometerin diameter, and the cells of the immune system, granulocytes and macrophages, with adiameter of 15–20 micronmeters, which is significant for the recovery from infections. Theuse of antibiotic prophylaxis for tension-free mesh herniorrhaphy may contribute in loweringthe incidence of postoperative mesh infection, although there is little direct clinical evidence3,4,6

L. Surgery Complications

Hernia surgery may cause complications in the form of2:

1. Hematoma (injuries to the scrotum) 2. Acute urinary retention 3. Wound infection 4. Chronic Pain 5. Pain and swelling of the testicles that cause testicular atrophy 6. Hernia recurrence

CHAPTER III

MATERIAL AND METHOD

This was a descriptive retrospective study of all incarcerated inguinal hernia patients admitted to the emergency department (ED) of HasanSadikin Hospital, between January 2013 and February 2015.

Inclusion criteria for the study were:

1. Age of patients more than14 years.2. Patients diagnosed with incarcerated inguinal hernia3. Patients underwent emergency surgery at Hasan Sadikin Hospital, Bandung, West Java

Exclusioncriteria for the study were:

1. Patients diagnosed with femoral hernia2. Reducible inguinal hernia

CHAPTER IVRESULT AND DISCUSSION

4.1. ResultThis study includes 105 patients with incarcerated inguinal hernia were recorded at

Emergency Department, Hasan Sadikin Hospital during the period January 2013- February 2015 and conducted clinical examination at Emergency Ward. Based on the distribution of gender all patients are Male. Average age was 47 years old at range 15-85 years old.

Table 1.Distribution of GenderNo Gender Amount (%)1 Male 100 1002 Female 0 0

Table 2. Distribution of Age

No AgeAmount %

1 15-20 7 6.72 21-25 2 1.93 26-30 3 2.84 31-35 3 2.85 36-40 2 1.96 41-45 8 7.67 46-50 6 5.78 51-55 13 12.39 56-60 11 10.510 61-65 22 20.911 66-70 21 2012 71-75 2 1.913 76-80 1 0.914 81-85 4 0.39

From the study about 89 patients (84,7%) were came into emergency room with complain of lump without pain and about 11 (10,3%) of them complain of painful lump. Right side of incarcerated inguinal hernia (55,2%) became the most side of location of the lump. Table 3 Distribution of Symptom

No SymptomAmount %

1 Lump without pain 89 84,72 Painful Lump 11 10,33 Lump with Abdominal pain 3 3,0

4Lump with difficulty of defecation 2 2,0

Table 4Location Of Incarcerated Inguinal Hernia

No Location Amount %

1 Right side 58 55,22 Left side 35 38,33 Booth side 1 0,9

From the study we also know that weight bearing was the most risk factor of developing incarcerated inguinal hernia (96,1%) and followed by prolonged cough (3%)

Table 5Risk Factor

From 105 patient who came and operated at emergency ward Hasan sadikin Hospital found that 88 hernia sac of contain of ileum, it is explained by the anatomical of ileum.

No Risk factorAmount %

1 Weignt Bearing 101 96,1%

2Prolonged cough 3 3%

3 Urine retension 1 0,9%

Table 6Hernia sac ( Intra operative finding )

NoHernia Sac ( Intra Operative Finding )

Amount %

1 Ileum 88 83,9%2 Omentum 6 5,7%3 Ileum+omentum 5 4,7%4 Jejunum 2 1,9%5 Sigmoid 3 2.90%6 Ileocaecum 1 0,9%

Tension free (Leinchesten ) hernioraphy became the most technique to be used by the operator.Table 7Technique Operation

No Technique OperationAmount %

1 Tension Free 90 85,7%2 Mcvay 15 14,3%

4.2. DiscussionBy definition hernia is a protrusion of the coil or segment cavity or tissue through an abnormal opening. We can divide hernia into four types, reducible hernia, irreducible hernia, incarcerated hernia, and strangulated hernia. Ireponibel incarcerated hernia is a hernia that has been followed with signs of mechanical ileus. In the present study, the average of patient was 47.11 ( range 15-85 years) with maximum years is 81 years old. This result significantly more males than females (100% male) presented with incarcerated inguinal hernia, which is consistent with Shakya et all`s report of male to female ratio is 5.3 : 1 among incarcerated inguinal hernia. The average age was 47 with the most frequent of all was aged 61-65 years. Older age and weight bearing become the most risk factor for incarcerated inguinal herna, this also consistent with previous study from Shakya et all and Mesut Gu et all, from both of them study of said that older age has become the most risk factor of developing hernia. It is related to weakness abdominal wall in older age5,7. From the study the most location of incarcerated hernia is in the right inguinal ( 52% ) compared to left side (38%), it is consistent with the anatomy of right abdomen that contain small intestine2,5,7. Most groin hernias occur on the right

side whethercomplicated or simple, inguinal or femoral. Theanatomical basis of this may lie in the attachment ofthe small bowel mesentery and so bowel loops attached to the right of the midline can more easily remain inthe right groin than those attached to the left.1,2 It is also related that almost all intra operative finding in this study is Ileum (83,9%)5,7.This study report that 90% of operation technique is Tension Free hernioraphy ( Leeinchestein) this is the gold standard of hernioraphy technique and use as a Guidline in many country. From this study about 5,6% from the patient were diagnosed with strangulated hernia in intra operative, this result need more deeper study to analyze the co morbid in the patient and the interval symptom6.

CHAPTER VCONCLUSION

Incarcerated inguinal hernia still become problem in emergency ward. Elderly males have a higher propensity for developing incarcerated inguinal hernia it related with the weakness of abdominal wall in elderly male, The most common risk factor to develope hernia is weight bearing which increase the intra abdominal pressure.

Right side inguinal is the most predisposition location of incarcerated hernia, and ileum entrapment is the most intra operative finding .And most of indication of bowel resection in operative finding is necrosis of ileum. Tension free hernioraphy is the gold standard technique to close the defect from the hernia.

REFERENCES

1. Schwartz S. Principles of surgery. 9th ed.chapter 39 inguinal hernia New York: McGraw-

Hill;2009.

2. Acosta, Jose. dkk. In Chapter Abdominal Wall and Hernia in Sabiston D.C, Text Book of

Surgery, 18 th ed, W.B. Saunders, Philadelphia, 2008.

3. Maingot Abdiminal Operation 11th edition. McGraw-Hill;2009. Chapter Inguinal Hernia.

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