hernia - weebly19thbatch.weebly.com/uploads/2/3/9/4/23941270/hernia.pdf · surgical anatomy:...
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Prof. Deepaka Weerasekera
HERNIA
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HERNIA
Objectives
To discuss the surgical anatomy
To discuss the principles of treatment
on the basis of surgical anatomy
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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
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Risk Factors
Straining
Chronic cough
Lifting heavy weights
Obesity
Pregnancy
Intra-abdominal malignancy (adults)
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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
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INGUINAL HERNIA
Surgical Anatomy:
Superficial inguinal ring
Deep inguinal ring
Inguinal canal
Contents of the spermatic cord
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Superficial Inguinal Ring
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Deep Inguinal Ring
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Indirect
Inguinal
Hernia
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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
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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
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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)
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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
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Treatment
Principle
Reinforce the posterior wall of the
inguinal canal and to recreate the internal
ring
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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
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Specific Complications of inguinal hernia
repair
Urinary retention
Bruising
Pain
Haematoma
Infection
Ischaemic orchitis – 0.5%
Recurrence – <0.5%
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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)
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Surgical Anatomy
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Urgent operation (Give early date)
– Due to constant risk of strangulation
Treatment
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Incisional Hernia
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Umbilical Hernia
TYPES: 1. Congenital Umbilical Hernia
2. Acquired Umbilical Hernia
3. Para Umbilical Hernia
Congenital Umbilical
Hernia Para Umbilical Hernia
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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
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Acquired Umbilical Hernia
May be caused by,
– Pregnancy
– Ascites
– Ovarian cysts
– Fibroids
– Bowel distension
More commonly require surgical repair.
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Scrotal Lumps
Differential diagnosis:
– Inguinoscrotal hernia
– Epididymal cyst
– Spermatocele
– Testicular tumours
– varicocele
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Scrotal Lumps
Epiddymal Cyst
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Scrotal Lump
Hydrocele
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Scrotal Lump
Varicocele
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Examination of Scrotal Contents
Inspection
Note ;
• Size
• Shape
• symmetry
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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?
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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?
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THANK YOU