HERNIA - Weebly19thbatch.weebly.com/uploads/2/3/9/4/23941270/hernia.pdf · Surgical Anatomy:...
Transcript of HERNIA - Weebly19thbatch.weebly.com/uploads/2/3/9/4/23941270/hernia.pdf · Surgical Anatomy:...
Prof. Deepaka Weerasekera
HERNIA
HERNIA
Objectives
To discuss the surgical anatomy
To discuss the principles of treatment
on the basis of surgical anatomy
Definition:
Protrusion of viscus or part of a viscus,
through a defect or a weakness of the wall
of its containing cavity
Clinically:
A reducible lump with an expansile
cough impulse
Risk Factors
Straining
Chronic cough
Lifting heavy weights
Obesity
Pregnancy
Intra-abdominal malignancy (adults)
Classification
Irrespective of site,
1. Reducible: lump reduces it self or can be reduced
by patient or doctor
2. Irreducible: contents can’t be returned
3. Obstructed: irreducible hernia containing intestine; obstructed from without or within; no impairment of the blood flow
4. Strangulated: if the blood flow to the viscus in the hernial sac becomes compromised
5. Inflamed
INGUINAL HERNIA
Surgical Anatomy:
Superficial inguinal ring
Deep inguinal ring
Inguinal canal
Contents of the spermatic cord
Superficial Inguinal Ring
Deep Inguinal Ring
Indirect
Inguinal
Hernia
Contents of the spermatic cord
Three arteries
– Artery to vas deferens
– Testicular artery
– Cremasteric artery
Three nerves
– Ilioinguinal nerve
– Nerve to cremaster
– Autonomic nerves
Three fascial layers
– External spermatic fascia
– Cremaster
– Internal spermatic fascia
Three others
– Vas deferens
– Pampiniform plexus
– Lymphatics
Inguinal Hernia
Direct Inguinal Hernia: (10-15%)
• Is one that is due to weakened trasversalis fascia
in Hesselbach’s triangle
• Most unusual for the sac to pass into the scrotum
• Always acquired
• >50% bilateral
• Neck is large – i.e.: rarely strangulate
• Neck is medial to epigastric vessels
Indirect Inguinal Hernia: (commonest)
• Pass through the deep inguinal ring and extends
down the canal towards the scrotum
• “Inguinoscrotal”
• Common in males
• 30% bilateral
• 3 types:
1. Bubonocele
2. Funicular
3. Inguino-Scrotal (Complete)
Clinical Features
1. Lump
2. Increasing in size with straining
3. Pain (not always) Clinical Examination Examine in the standing position
can I get above the swelling ?
cough impulse
Examine in the lying down position
Look for the direction of the appearance of
the swelling oblique or direct
Define and obliterate the internal ring
Treatment
Principle
Reinforce the posterior wall of the
inguinal canal and to recreate the internal
ring
Conventional method: “ Bassini’ repair “
Approximation of the conjoint tendon to the medial
part of the inguinal ligament, behind the cord
without tension, using non-absorbable suture
material
New method: Lichtenstein's open Tension Free
Hernioplasty
Reinforce the posterior wall and reconstruct the
internal ring with a prolene mesh
Specific Complications of inguinal hernia
repair
Urinary retention
Bruising
Pain
Haematoma
Infection
Ischaemic orchitis – 0.5%
Recurrence – <0.5%
Femoral Hernia • 3rd common type
• 20% of hernias in females
• 5% of hernias in males
• Most liable to become strangulated due to
1. Narrow neck
2. Rigidity of femoral ring
• Neck is below and lateral to pubic tubercle
Clinical Features • 20-40 years of age
• Small in size
• Sometimes painful
(before strangulation)
Surgical Anatomy
Urgent operation (Give early date)
– Due to constant risk of strangulation
Treatment
Incisional Hernia
Umbilical Hernia
TYPES: 1. Congenital Umbilical Hernia
2. Acquired Umbilical Hernia
3. Para Umbilical Hernia
Congenital Umbilical
Hernia Para Umbilical Hernia
Congenital Umbilical Hernia
Minor defects in neonates are common but
usually repair spontaneously.
In older children
– Tend to have a narrow neck and folds of peritoneum
stuck within this neck
– Can get strangulated
– Most resolve before puberty
– Only repaired in symptomatic children
Acquired Umbilical Hernia
May be caused by,
– Pregnancy
– Ascites
– Ovarian cysts
– Fibroids
– Bowel distension
More commonly require surgical repair.
Scrotal Lumps
Differential diagnosis:
– Inguinoscrotal hernia
– Epididymal cyst
– Spermatocele
– Testicular tumours
– varicocele
Scrotal Lumps
Epiddymal Cyst
Scrotal Lump
Hydrocele
Scrotal Lump
Varicocele
Examination of Scrotal Contents
Inspection
Note ;
• Size
• Shape
• symmetry
Palpation
-Gently support scrotum on fingers
-Feel testis and other lumps between index finger
and thumb (Do not squeeze)
-Does the scrotum have two testis?
-Testis has unique sensation to the patient
-Can you define the testis and epididymis?
If it is a Scrotal Lump –
• Is it confined to the scrotum? – Can you
get above it?
• Does the lump transilluminate?
• Does it have an expansile cough impulse?
• Is it Tender?
THANK YOU