direct and indirect inguinal hernia final for website
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Direct and Indirect inguinal Hernia
Dr. Ahmad Uzair QureshiFCPS ( SURGERY) / MCPS ( SURGERY)
MRCS ( ENGLAND) / Dip Med Edu (Cardiff) Colorectal Fellow Yonsei University, South Korea
Assistant Professor of Surgery, King Edward Medical University, Lahore
Objectives• The students will be able to
• Define hernia• Different sites and types of hernia• Enlist clinical features of groin hernia• Enumerate differences in direct and indirect hernia• Describe contents of hernia sac and their origin• Enlist complications which may arise from hernia• Describe the steps of open Hernia repair
ABDOMINAL REGIONS WHERE
HERNIAS OCCUR
What is a Hernia?It is an abnormal protrusion of a viscus or part of a viscus through
a potential weak space of its containing cavity.
CLINICAL FEATURES
Lump at an appropriate anatomical site
Increases in size on coughing or straining.
It reduces in size or disappears when relaxed or supine
position.
Examination may show it to have a cough impulse and to be
reducible
Rt. INDIRECT ING. HERNIA
FACTORS PREVENTING HERNIATION
1- Oblique coarse of the inguinal canal .2- Contraction of conjoint tendon during coughing or straining (shutter mechanism) .3- Contraction of cremasteric muscle : Plugging of inguinal canal
Groin hernia• Inguinal• Femoral• Obturator
•Two (2) types •Acquired •Congenital
Groin hernia•Inguinal
•Direct •Indirect
Depending on the site of origin of sac. And per operatively by relation to the deep
epigastric vessels
Layers of anterior abdominal wall
What is an Direct/ Indirect Hernia?
What is an Indirect Hernia?
• Congenital or acquired weaknesses in TF
• Location: lateral to deep epigastric vessels
• Protrude through deep inguinal ring; may descend into the scrotum
• Men
Deep ring
DIRECT INGUINAL HERNIA
• Acquired weaknesses in TF• Location: Hesselbach’s • Emerge between the deep
epig. artery and rectus abd. muscle and protrude into the ingu. canal but not into the SC.
• More difficult to repair?!• Men
HERNIAS…COMPLICATIONS
• Reducible • Irreducible • Obstructed or incarcerated • Strangulated
COMPLICATIONS
Obstruction • Irreducible• abdominal pain, • distension and vomiting may occur • The hernia will be tense tender and irreducible
Strangulation • become red and tender, • Irreducible• No impulse on cough.• If contains bowel signs of obstruction.
INGUINAL HERNIA REPAIR RATIONALE
TENTION FREE REPAIR
MESH REPAIR
HERNIA…PRINCIPLES OF REPAIR
Irrespective of approach used the following will be achieved
• Dissection of the sac • Reduction / inspection of the contents • Ligation of the sac • Approximation of the inguinal and pectineal ligaments
INGUINAL HERNIA.TYPES OF REPAIR
• Bassini repair : Suturing conjoined tendon to inguinal ligament behind
the cord .
• Lytle repair: Plication of the fascia transversals .
• Shouldice repair : incision of the fascia & double breasting of it .
• Halsted ‘s repair Bassini repair plus reinforced by suturing the 2 leaflets
of external oblique together behind the cord
INGUINAL HERNIA.TYPES OF REPAIR
• Shouldice or Liechtenstein
• Laparoscopic hernia repair:
Surgical Anatomy – land marks
Ant Sup Iliac Spine
Pubic tubercle
Incision
Ext Oblique Muscle
Ext Oblique Muscle - Incised
Ext Oblique reflected
Conjoined Muscle
Inguinal ligam
ent
Spermatic Cord + Indirect Hernia Sac
Pearly white Hernia Sac
Herniotomy (opening of sac)
Spermatic CordVas/ pampiniform plexus
Extraperitoneal fat( extend of dissection)
Transfixation of the hernia sac near the base after twisting the sac , using catgut
Division of sac
Lax porterior wall of inguinal canal
Plication of posterior inguinal canal wall
Darn / Mesh placement using prolene suture
Closure of External oblique
Closure of Skin
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