Hernia - teaching summary PDF

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Summary

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Description

Hernia Protrusion of an organ through opening in the wall of cavity in which it is normally contained

Risk Factor 

Male



Elderly



Previous hernia



Chronic cough



Chronic constipation



Abdominal wall weakness



Smoking

Sign & Symptom 

Visible lump



Heavy discomfort around gut



Pain on exertion



Constipation



Lump enlarge upon coughing

Causes 

Congenital : o



Patent processus vaginalis

Acquired : o

Trauma

o

Surgical incision

Types 

Inguinal hernia o

Direct

o

Indirect

o

Pantaloon (direct + indirect)



Femoral hernia



Insional hernia



Parastomal hernia



Umbilical hernia



Epigastric hernia

Complications 

Irreducible : content of hernia sac cannot be replaced into abdomen



Incarcerated



Obstructed : loop of bowel trapped in hernia sac



Strangulated : blood supply to trapped bowel is cutted off > dead / gangrene

Inguinal Hernia Indirect Inguinal Hernia 

Congenital ; patent processus vaginalis + weakened fascia at deep ring



Hernia sac enters inguinal canal via deep ring, emerges to superficial ring, descend into scrotum



Lateral to inferior epigastric artery



More common in young adult, infants



May cause strangulation at superficial ring (narrow)



Does not readily reduce on lying down



Reduce upward, laterally, backward



Controlled after reduction by pressure over deep ring

Direct Inguinal Hernia 

Weak abdominal muscle



Comorbid condition causing increase intraabdominal pressure



Bulges directly through weakened fascia within Hesselbach triangle o

Lateral : inferior epigastric artery

o

Medial : rectus abdominis sheath

o

Inferior : inguinal ligament



Medial to inferior epigastric artery



More common in elderly



Rarely cause strangulation due to wide hernia neck



Readily reduce on lying down



Reduce upward and straight backward



Controlled after reduction by pressure over superficial ring

Inguinal Canal : 

4-6cm long, oblique passage



Above inguinal ligament



Form deep to superficial ring



Deep ring : midpoint of inguinal ligament (ASIS to pubic tubercle)



Superficial ring : triangular defect in aponeurosis of external oblique



Structure passing through inguinal canal : o

Spermatic cord 



3 concentric layers of fascia : 

Transversalis fascia -> internal spermatic fascia



Internal oblique -> cremasteric fascia and muscle



External oblique -> external spermatic fascia

3 arteries : 

Testicular artery



Artery to vas deferens



Cremasteric artery





o

3 nerves : 

Nerve to cremaster



Autonomic nerve (T10)



Genital branch of genitofemoral nerve

3 others : 

Vas deferens



Pampinifirm venous plexus



lymphatics

Round ligament of uterus

Management Inguinal Hernia Non Surgical 

Reduce intraabdominal pressure : o

Weight loss

o

Avoid heavy lifting

o

Treat medical condition : chronic cough, chronic constipation



Truss



Obstructed / strangulated : o

Nil by mouth

o

IV drip

o

NG tube on suction

o

IV antibiotic

o

Emergency surgery

Surgical (Open / Laparoscopic surgery) 

Herniotomy : removal of hernia sac without repair of inguinal canal



Herniorraphy : repair of posterior wall on inguinal canal + herniotomy



o

Bassini repair

o

Shouldice repair

o

Desarda

Hernioplasty (Gold Standard) : herniotomy + reinforcement of posterior wall of inguinal canal with synthetic mesh o

Lichtenstein

Principles of Surgery 

Reduce bowel



+/- excise hernia sac



Reinforce posterior wall

Type of Laparoscopic Surgery 

Transabdominal Preperitoneal Repair (TAPP)



Total Extraperitonela Repair (TEP)

Complication of Surgery 

GA complication



Immediate : o

Acute urinary retention

o

Bleeding, bruising

o

Injury to surrounding structure





Early : o

Infected wound, mesh

o

Hematoma

o

Wound dehiscence

o

Pain

Late : o

o

Recurrence hernia 

Poor technique of wound closure



Incomplete dissection



Too early mobilization



Uncontrolled comorbidity

Ischemic orchitis and testicular atrophy

Post-Op Monitoring 

Avoid heavy lifting



Treat medical condition



Early mobilization from Day10



Keep area clean and wash carefully

Umbilical Hernia 

Women >40 years old



Weakness of linea alba, contain greater omentum

Risk Factor : 

Pregnancy



Ascites



Pelvic mass / intraabdominal mass eg, fibroid



Obesity

Surgery : Mayo’s vest over pants operation

Femoral Hernia 

Higher risk of strangulation (narrow opening)

Surgery : lotheissen’s Operation

Differential Diagnosis : 

Inguinal hernia



Saphena varix



Enlarged femoral lymph node



Lipoma



Femoral aneurysm...