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HERNIA
RAQUIZA/RAYEL/RICALDE/VENGCO
JI
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HERNIA Latin for r upture
an abnormal protrusion of an organ or tissuethrough a defect in its s urrounding wall
occur only at sites where the aponeurosis andfascia are n ot covered by striated muscle
TERMINOLOGY REDUCIBLE HERNIA - can be replaced
within the surrounding m usculature- can be r eturned t o the ab domen
IRREDUCIBLE OR INCARCERATED
HERNIA cannot be reduced into the abdomen
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STRANGULATED HERNIA - hascompromised b lood supply t o its contents, whichis a serious a nd potentially fatal complication
EXTERNAL HERNIA - protrudes through alllayers of the a bdominal wall
INTERNAL HERNIA - a protrusion ofintestine through a defect within the peritonealcavity
INTERPARIETAL HERNIA - occurs when thehernia sac is contained within amusculoaponeurotic layer of the a bdominal wall
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ETIOLOGY risk factors a re likely multifactorial, the
common denominator being a w eakness in theabdominal wall musculature
ACQUIRED
inguinal hernias i n the a dultsacquired defects i n the a bdominal wall
CONGENITALmake u p the m ajority of pediatric herniasconsidered an impendance of normaldevelopment
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NORMAL COURSE OF DEVELOPMENT the testes descend from the intra-abdominal
space i nto t he sc rotum in the t hird trimester
their descent is preceded by the gu bernaculumand a diverticulum of peritoneum whichprotrudes through the inguinal canal andultimately becomes t he p rocessus va ginalis
between 36 and 40 weeks - the processusvaginalis closes a nd eliminates t he peritonealopening at the i nternal inguinal ring
failure o f the peritoneum to close resu lts inPATENT PROCESSUS VAGINALIS (PPV)
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ANATOMY OFINGUINAL REGION
GROIN REGION a complex network of muscles,
ligaments and fascia that areinterwoven in a multiplanar fashion
INGUINAL CANAL 4 to 6 cm long, shaped like a coneand situated in the anteroinferiorportion of the pelvic b asin
Canal begins intra-abdominally onthe deep aspect of the abdominalwall, where the spermatic cordpasses through a hiatus in thetransversa lis fascia (in females, is
the r ound ligament)
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POUPARTS LIGAMENT comprised of the inferior bers of theexternal oblique a poneurosis
st retches from the anterior su perior i liacspine t o t he p ubic t ubercle
LACUNAR LIGAMENT OF GIMBERNAT is the triangular fanning out of theinguinal ligament as it joins the pubictuberclefusion of the inferior bers o f the internaloblique and transversus abdominusaponeurosis, at the p oint where t hey i nserton the p ubic tuberclemedial border of the femoral canal
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COOPERS OR PECTINEAL LIGAMENTlateral portion of the l acunar l igament that is f usedto t he p eriosteum of the p ubic t ubercle
include bers from the transversus abdominus,iliopubic tract, internal oblique and rectusabdominus
CONJOINED TENDON
a combination of the transversus abdominusaponeurosis, transversalis f ascia, lateral edge of therectus sheath and internal oblique muscles or itsbers
ILIOPUBIC TRACTan aponeurotic band that begins at the ASIS andinserts i nto C oopers l igamentforms on the DEEP side of the inferior margin ofthe t ransversus ab dominus an d transversalis f ascia
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INNERVATION ILIOINGUINAL NERVE (L1)
supplies t he sk in of the u pper and medial thighmales: penis and upper scrotum; females: monspubis and labium majus
ILIOHYPOGASTRIC NERVE (T12-L1)supplies the internal oblique and transversus
abdominus GENITOFEMORAL NERVE (L1-L2)
a. Genital branchMales - scrotum and cremaster muscle
Females - mons pubis and labia m ajorab.Femoral branch supplying the sk in anterior t o
the u pper p art of the femoral triangle LATERAL FEMORAL CUTANEOUS NERVE (L2-L3)
supply the l ateral aspect of the t high
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TRIANGLE OF DOOMBOUNDARIES:
Medial: vas d eferens Lateral: spermatic vessels (testicular arteryand vein)
I nferior: external iliac v essels
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CONTENTS ex ternal iliac a rtery and vein
deep circumex iliac vei n genital branch of genitofemoral nerve femoral nerve
MOST IMPORTANT STRUCTURES Arteria corona mortis Obturator vessels E xternal iliac v essels
Staple should not be applied in this triangleotherwise; chances of mortality are there ifthese great vessels a re i njured
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TRIANGLE OF PAINBOUNDARIES:
Medial: Testicular artery a nd vein Base: iliopubic t ract
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CONTENTS genitofemoral nerve lateral femoral cutaneous nerve femoral nerve
Staple should be less because n erve en trapmentcan cause n euralgia
CIRCLE OF DEATH is a vascular continuation formed by the
common iliac, internal iliac, obturator, aberra nt
obturator, inferior e pigastric a nd external iliacvessels
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DIAGNOSIS OF INGUINALHERNIA
H istory a nd Physical exam P rocedure
examiner place the t ip of the index nger a tthe most dependent part of the scrotum anddirect it into the external inguinal ring
d irect hernia will push against the p ulp of the nger if a bulge progresses f rom deep to su percial
through the inguinal oor indirect hernia
will push against the ngertip a bulge moving lateral to medial in the
inguinal canal
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CLINICAL PRESENTATION groin bulge often asymptomatic dull feeling of discomfort or h eaviness FOCAL PAIN
raise suspicion for incarceration orstrangulation
symptoms of bowel obstruction
IMAGING p lain x-ray: Herniography u ltrasonography MRI CT
Laparoscopy
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HESSELBACHS TRIANGLE h elps i dentify type of inguinal hernia
BOUNDARIES: Medial: rectus abdominis L ateral: inferior e pigastric a rtery
I nferior: inguinal ligament of Poupart
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CLASSIFICATION
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CLASSIFICATION
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TYPES OF INGUINALHERNIA
DIRECT INGUINAL HERNIAMedial to t he i nferior ep igastric a rtery andwithin hesselbachs t riangle
Acquired weakness in the inguinal oor 2 major f actors: increased intra-abdominal pressureassociated with a variety of conditions
relative weakness of the posterioringuinal wall
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INDIRECT INGUINAL HERNIA inguinal hernias that protrude lateral tothe inferior e pigastric vessels t hrough thedeep inguinal ring incomplete or defective obliteration ofprocessu s v aginalis d uring the fetal period remnant layer of peritoneum forms a sac inthe i nternal ringdenervation of the internal oblique muscleby adjacent incisions ( e.g., appendectomy)
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VARIANTS OF INGUINAL HERNIARICHTERS HERNIA
more common in premature infants
partial circumference on small bowel in hernial saconly the antimesenteric border of small intestine isincarcerated in the deep inguinal ring thereforeintestinal obstruction may be absent but gangrenemay occur
LITTRES HERNIAhernia contains M eckels d iverticulum
PETTIT HERNIAhernia at inferior l umbar t riangle
GRYNFELT HERNIAhernia at superior l umbar t riangle
AMYANDS HERNIAcontent of the hernial sac is the vermiform
appendix
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FEMORAL HERNIA more common in females passes m edial to the femoral vessels an d nerve
in the femoral canal through the em pty spa ce
FEMORAL TRIANGLESuperior: inguinal ligament
Lateral: sartorius m uscleMedial: adductor longus muscle
CONTENT: NAVEL
N: femoral nerve A: femoral artery V: femoral vein
E: empty sp ace, site of herniaL: lymphatics of Cloquet
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