CSS HERNIA INGUINAL LATERAL (HIL)

Ayu Niendar Puspita Dewi12100114024

Program Pendidikan Profesi Dokter Fakultas Kedokteran Universitas Islam Bandung

PreseptorLiza Nursanty, dr., SpB., M.Kes

Bagian Bedah Umum Rumah Sakit Al-Islam Bandung

ANATOMY

Inguinal Canal

Because the vast majority of inguinal hernias occur in men, general descriptions of groin anatomy contained herein will pertain to males. The inguinal canal is approximately 4 to 6 cm long and is situated in the

anteroinferior portion of the pelvic basin. Shaped like a cone, its base is at the superolateral margin of the basin,

with its apex pointed inferomedially toward the symphysis pubis. The canal begins intra-abdominally on the deep aspect of the abdominal

wall, where the spermatic cord passes through a hiatus in the transversalis fascia (in females, this is the round ligament).

This hiatus is termed the deep or internal inguinal ring. The canal then concludes on the superficial aspect of the abdominal wall musculature at the superficial or external inguinal ring, the point at which the spermatic cord crosses the medial defect of the external oblique aponeurosis.

Indirect inguinal hernia

DEFINITION

An indirect inguinal hernia is an inguinal hernia that results from the failure of embryonic closure of the deep inguinal ring after the testicle has passed through it. Like other inguinal hernias, it protrudes through the superficial inguinal ring.

EPIDEMIOLOGY 75% percent of all abdominal wall hernias occur in

the groin. Indirect outnumber direct by about 2:1, with femoral hernias making up a much smaller proportion. Right sided groin hernias are more common than those on the left. The male : female ratio for inguinal hernias is 7 : 1.

AGE (YEARS) 25-34

35-44

45-54 55-64 65-74 75+

Current prevalence (%)

12 15 20 26 29 34

Lifetime prevalence (%)

15 19 28 34 40 47

RISK FACTORS AND ETIOLOGY

Inguinal hernias may be considered congenital or acquired diseases. In adult patient with a groin hernia

include old age, short duration, femoral hernia, and coexisting medical illness.

In children, the risk factors are very young age, male sex, short duration and right sided hernia.

PRESUMED CAUSES OF GROIN HERNIATION1. Coughing2. COPD3. Obesity4. Straining (Constipation , prostatism)5. Pregnancy

6. Birthweight less than 1500g7. Family history of a hernia8. Valsava maneuvers9. Ascites10. Upright position11. Congenital connective tissue disorders12. Defective collagen synthesis13. Previous right lower quadrant incision14. Arterial aneurysms15. Cigarette smoking16. Heavy lifting17. Physical exertion (?)

PRESUMED CAUSES OF GROIN HERNIATION

1. Coughing2. COPD3. Obesity4. Straining (Constipation ,

prostatism)5. Pregnancy6. Birthweight less than 1500g7. Family history of a hernia8. Valsava maneuvers9. Ascites10. Upright position

11. Congenital connective tissue disorders

12. Defective collagen synthesis

13. Previous right lower quadrant incision

14. Arterial aneurysms15. Cigarette smoking16. Heavy lifting17. Physical exertion

CLINICAL MANIFESTATION

diagnosis HistoryPatients who present with a symptomatic groin hernia will frequently present with groin pain. Less commonly, patients will present with extrainguinal symptoms such as change in bowel habits or urinary symptoms. Regardless of size, an inguinal hernia may impart pressure onto nerves in the proximity, leading to a range of symptoms. These include generalized pressure, local sharp pains, and referred pain. Pressure or heaviness in the groin is a common complaint, especially at the conclusion of the day, following prolonged activity. Sharp pains tend to indicate an impinged nerve and may not be related to the extent of physical activity performed by the patient. Lastly, neurogenic pains may be referred to the scrotum, testicle, or inner thigh. PhysicalThe patient should be examined in a standing position, with the groin and scrotum fully exposed. The standing position has the advantage over the supine position in that intra-abdominal pressure is increased, and thereby, the hernia can be more easily elicited. Inspection is performed first, with the goal of identifying an abnormal bulge along the groin or within the scrotum. If an obvious bulge is not detected, physical examination is performed to confirm the presence of the hernia.

DIAGNOSISPalpation is performed by placing the index finger into the scrotum, aiming it toward the external inguinal ring. The patient is then asked to cough or bear down (i.e., Valsalva's maneuver) to protrude the hernia contents.

ImagingThe most common radiologic modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI).

Clinical grading

GRADE REDUCTION

PAIN OBSTRUCTION

TOXIC

Reponible + - - -Irreponible - - - -Incarceration

- Colic + -

Strangulation

- Steady increase

+ ++ leucocytosis

Differential diagnosis Malignancy (lymphoma, retroperitoneal sarcoma, metastasis, testicular tumor) Primary testicular (varicocele, epididymitis, testicular torsion, hydrocele,

ectopic testicle, undescended testicle) Femoral artery aneurysm or pseudoaneurysm Lymph node Sebaceous cyst Hidradenitis Cyst of the canal of nuck (female) Saphenous varix Psoas abscess Hematoma Ascites

Nyhus Classification System

Type IIndirect hernia; internal abdominal ring normal; typically in infants, children, small adultsType IIIndirect hernia; internal ring enlarged without impingement on the floor of the inguinal canal; does not extend to the scrotumType IIIA Direct hernia; size is not taken into accountType IIIBIndirect hernia that has enlarged enough to encroach upon the posterior inguinal wall; indirect sliding or scrotal hernias are usually placed in this category because they are commonly associated with extension to the direct space; also includes pantaloon herniasType IIICFemoral herniaType IVRecurrent

Gilbert Classification System

Type 1 Small, indirectType 2 Medium, indirectType 3 Large, indirectType 4 Entire floor, directType 5 Diverticular, directType 6 Combined (pantaloon)Type 7 Femoral

TREATMENT

treatment

The definitive treatment of all hernias is surgical repair. A hernia defect will not decrease in size, but likely increase and possibly progress to incarceration or strangulation of the sac's contents. Surgery can be delayed or avoided in situations where the patient's medical status prohibits operative treatment. Conservative management is aimed at alleviating symptoms related to the inguinal hernia, such as pain, pressure, and protrusion of abdominal contents. Simple maneuvers include assuming a recumbent position, which aids in self-reduction of the hernia.CONSERVATIVE Reposition Injection Belt

OPERATIVE Herniotomy Hernioraphy Hernioplasty

Eduardo Bassini Herniorhhapy :

Chester B McVay,MD,PhD 1940 (Cooper’s ligament repair):

S EE Shouldice, 1945

Tension Free =Mesh Graft1987 : Gilbert

Complication Recurrence Chronic groin pain (nociceptive, somatic, visceral) Neuropathic (iliohypogastric, iliolinguinal, genitofemoral, lateral cutaneous, femoral) Cord and testicular (hematoma, ischemic orchitis, testicular atrophy, dysejaculation, division of vas

deferens, hydrocele, testicular descent) Bladder injury Wound infection Seroma Hematoma (wound, scrotal, retroperitoneal) Osteitis pubis Prosthetic complication (contraction, erosion, infection, rejection, fracture) Laparoscopic (vascular injury, intra abdominal, retroperitoneal, abdominal wall, gas embolism Visceral injury (bowel perforation, bladder perforation Trocar site complications (hematoma, hernia, wound infection, keloid) Bowel obstruction (trocar or peritoneal closure site hernia, adhesion) Miscellaneous (diaphragmatic dysfunction, hypercapnia) General (urinary, paralytic ileus, nausea and vomiting, aspiration pneumonia, cardiovascular and

respiratory insufficiency)

PROGNOSIS

Traditionally, the most important measure of success was the recurrence rate of the hernia, although newer measures focus on quality of life and return to normal activities. Surgeons who perform a large volume of the Shouldice repair are able to

demonstrate recurrence rates around 1%. In less experienced hands, such low recurrence rates are not demonstrated, yet

overall, recurrence rates for the Shouldice repair are consistently lower than those of the Bassini or McVay repair. Other comparative studies have demonstrated that the Shouldice repair, even with a recurrence rate near 6%, is superior to the Bassini repair (8.6% recurrence rate) and McVay repair (11.2%).

Common causes of hernia recurrence postrepair include patient, technical, and tissue factors. Patient factors that affect tissue healing include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors include mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors include wound infection, tissue ischemia, and increased tension within the surgical repair. Most recurrences are of the same type as the original hernia.

THANK YOU FOR THE ATTENTION