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Overview of Hernias with special emphasis on Inguinal Hernias. Management of obstructed, strangulated hernia, Bassini repair, McVay's repair, Tanner's slide

Overview of Hernias with special emphasis on Inguinal Hernias. Management of obstructed, strangulated hernia, Bassini repair, McVay's repair, Tanner's slide


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  1. 1. HERNIAS Dr. Ernest Salami (MBBS, Ekpoma), Department of Surgery, Sacred Heart Hospital, Lantoro-Abeokuta. 1
  2. 2. OUTLINE  Hernias  Introduction  Definition  Classification  Epidemiology  Aetiopathogenesis  Pathology  Complications  Inguinal Hernia  Surgical Anatomy of the Inguinal canal  Classification of Inguinal Hernias  Clinical Presentation  Treatment  Complications of Hernia Repair  Conclusion  References 2
  3. 3. INTRODUCTION  Hernias are among the oldest recorded “afflictions” of mankind.  They are a significant cause of small bowel intestinal obstruction and other life threatening complications, especially in our environment where patients do not present for treatment early, either due to financial reasons, or because according to them, it is not “paining” them. 3
  4. 4. DEFINITION  A hernia is defined as the protrusion of a viscus or part of a viscus through a point of weakness or defect in the wall of its containing cavity.  For example, the area of weakness in direct inguinal hernias is the Hesselbach’s triangle, whereas for indirect inguinal hernias, the defect is the deep ring, both in the inguinal region. 4
  5. 5. CLASSIFICATION Anatomical classification  Internal hernias: Protrusion of a viscus through an anatomic foramen or a congenital or acquired defect in the peritoneum or mesentery with the organ remaining within the body. They include:  Diaphragmatic hernia  Hiatal hernia  Sigmoid mesocolon hernia  Winslow hernia  Paracaecal hernia  Paraduodenal hernia  Foramen magnum hernia (coning) 5
  6. 6. 6
  7. 7.  External hernias: These communicate with, and can be seen at the exterior as a bulge or swelling. They include:  Groin hernias • Inguinal hernia • Femoral hernia  Ventral hernias • Incisional hernia • Umbilical hernia • Paraumbilical hernia • Epigastric hernia • Spigelian hernia • Lumbar hernias For the purpose of this presentation, we will be more concerned about the external hernias which happen to be commoner. 7
  8. 8. 8
  9. 9. EPIDEMIOLOGY  The prevalence of external hernias is estimated to be about 11-12% of the population.  Hernias as a whole, are commoner in males, manual labourers and with advancing age.  Inguinal hernia is the commonest type of hernia – 80-92%. It is equally common in all communities, and is the commonest type of hernia in both males and females. 9
  10. 10.  Femoral hernia in turn, makes up 2-5% of all hernias. It is much more common in Europe and North America than in Black Africa, and is present in females than in males  Others include umbilical hernias (2%), epigastric hernias (1%) and incisional hernias (1 – 6%)  Internal hernias on the other hand are rare. The overall incidence is <1%, and a substantial percentage remain asymptomatic. 10
  11. 11. AETIOPATHOGENESIS There are two factors implicated in hernia development:  Predisposing factors: These cause a defect or weakness in the abdominal wall  Precipitating factors: These lead to repeated increased intra-abdominal pressure which leads to the protrusion of the viscus. 11
  12. 12.  The Predisposing factors include:  Normal anatomic defects e.g. deep inguinal ring  Embryological defects e.g. patent processus vaginalis  Surgical defects  Nerve injury  Advancing age  Connective tissue disorders  Cigarette smoking  Obesity 12
  13. 13.  The Precipitating factors include:  Chronic cough  Chronic constipation  Bladder outlet obstruction  Heavy manual labour  Multiple pregnancies  Abdominal mass  Ascites  Peritoneal dialysis 13
  14. 14. PATHOLOGY  Most hernias comprise of the sac, its coverings and its contents  The sac is a diverticulum of peritoneum with mouth, neck, body and fundus. Note:  Hernia without neck: Those hernias with larger mouth lack neck, e.g. direct inguinal hernia, incisional hernia.  Hernia without sac: Epigastric hernia—it is protrusion of extra-peritoneal pad of fat.  The coverings are the layers of the abdominal wall the sac carries along with it as it passess through the defect in the abdominal wall. 14
  15. 15. 15
  16. 16. 16
  17. 17. 17
  18. 18. o Contents of the sac  Omentocoele—omentum.  Enterocoele—intestine.  Cystocoele—urinary bladder.  Littre’s hernia—Meckel’s diverticulum.  Amyand hernia – vermiform appendix  Maydl’s hernia (hernia-en-W) – a bowel loop in the shape of the letter “W”  Sliding hernia (hernia-en-glissade) – extraperitoneal bowel or urinary bladder  Richter’s hernia—part of the bowel wall. 18
  19. 19.  A – Richter’s  B – Pantaloon’s  C – Amyand’s  D – Sliding  E – Littre’s  F – Maydl’s 19
  20. 20. COMPLICATIONS  Note that, a hernia is described as reducible if its contents return completely into the abdomen when the patient lies down or when pressure is applied on it. Usually, reducible hernias are uncomplicated.  Irreducible (incarcerated) hernia:  Contents cannot be returned to the abdomen due to a narrowed neck or adhesions.  Irreducibility predisposes to obstruction and strangulation. 20
  21. 21. 21
  22. 22. Obstructed hernia:  It is an irreducible hernia with a stoppage in the onward flow of intestinal contents, but blood supply to the bowel is not interfered.  It eventually may lead to strangulation.  Note that features of intestinal obstruction may be absent in case of omentocele, Richter’s hernia, Littre’s hernia 22
  23. 23.  Strangulated hernia:  It is an irreducible hernia with obstruction to blood flow.  This causes ischaemia, gangrene and consequently peritonitis  The swelling is tense, tender, with absent cough impulse and with features of intestinal obstruction. Overlying skin is dark or purplish  Other complications of hernias include:  Inflamed hernia  Rupture  Peritonitis  Fistula formation 23
  24. 24. INGUINAL HERNIA 24
  25. 25. SURGICAL ANATOMY OF THE INGUINAL CANAL  The superficial inguinal ring is a triangular opening in the external oblique aponeurosis and is 1.25 cm above the pubic tubercle.  The deep inguinal ring is a U-shaped condensation of the transversalis fascia, lies 1.25 cm above the midpoint of the inguinal ligament.  The inguinal (Poupart’s) ligament is formed by the lower border of the external oblique aponeurosis which is thickened and folded backwards on itself, extending from anterior superior iliac spine to pubic tubercle. 25
  26. 26. 26
  27. 27. The inguinal canal is an oblique passage in lower part of abdominal wall, 4 cm long, situated above the medial ½ of inguinal ligament, extending from deep inguinal ring to superficial inguinal ring. The inguinal canal in females is known as the ‘canal of Nuck.’ Contents of the inguinal canal  Spermatic cord in males  Round ligament in females  Ilio-inguinal nerve 27
  28. 28.  The spermatic cord comprises of:  Three fascia coverings  Internal spermatic fascia derived from fascia transversalis  Cremasteric fascia derived from internal oblique aponeurosis  External spermatic fascia derived from external oblique aponeurosis  Three arteries Testicular artery Artery to vas Cremasteric artery 28
  29. 29. 29
  30. 30.  Three veins Pampiniform plexus of veins Vein of vas Cremasteric vein  Three nerves Genital branch of genitofemoral nerve Sympathetic plexus (T10 – T11) around the artery to vas Parasympathetic nerve fibres  Three other structures Vas deferens Lymphatics of the testis Remains of processus vaginalis 30
  31. 31.  Boundaries of the inguinal canal  Anterior wall: Skin, subcutaneous tissue, external oblique aponeurosis (medial two-thirds) and internal oblique muscle (lateral one-third).  Posterior wall: Fascia transversalis (lateral half) and conjoined tendon (medial half).  Roof: Arched fibres of internal oblique, and transversus abdominis.  Inferiorly: Inguinal ligament, and lacunar ligament (medially) 31
  32. 32. IMAGE 32
  33. 33.  The ‘Hesselbach’s triangle’ is a weak point in the anterolateral abdominal wall, susceptible to direct inguinal hernias. It is bounded:  Medially by the lateral border of rectus muscle,  Laterally by the inferior epigastric artery,  Inferiorly by the iliopubic tract 33
  34. 34. 34
  35. 35. CLASSIFICATION  Anatomical classification:  Indirect hernia. It comes out through the internal ring along with the cord. It is lateral to the inferior epigastric artery.  Direct hernia. It occurs through the posterior wall of the inguinal canal through the ‘Hesselbach’s triangle.’ Sac is medial to the inferior epigastric artery.  Saddle-bag or pantaloon hernia has got both medial and lateral (direct and indirect components). 35
  36. 36. 36
  37. 37. IMAGE 37
  38. 38.  Classification according to extent 38
  40. 40.  HISTORY  Biodata: Age: Indirect hernias are congenital in majority of cases and are commoner in children whereas direct hernias are usually acquired and hence, are commoner in adults. Occupation: Manual jobs  Presenting complaint – a groin or scrotal swelling; that was initially or is still reducible (spontaneously or manually), that is precipitated or aggravated by standing, straining or coughing 40
  41. 41.  History of Aetiology:  The risk factors that predispose to or precipitate hernia formation may be elicited in the history  It is important to also rule in/out possible differential diagnoses such as inguinal lymphadenopathy, saphenous varices, etc.  NB: Most differentials are excluded via physical examination.  History of Complications: Hernia may have become irreducible Colicky abdominal pain, bilious vomiting, abdominal distension and constipation – intestinal obstruction Severe, constant pain, fever – strangulation, gangrene, peritonitis 41
  42. 42.  PHYSICAL EXAMINATION  Examination of an inguinal hernia is done in both the standing and the supine positions.  Inspection is done in the standing position, while palpation involves both standing and lying down.  Inspection: First, compare contralateral side. Then examine for site, size, shape, extent, nature of skin over swelling, visible cough impulse, transillumination, inspect the surrounding. 42
  43. 43.  Palpation (standing position): Differential temperature, tenderness, surface, extent (try to get above/below it), consistency, feel for the testis, palpable cough impulse, palpate the contralateral hemiscrotum.  Palpation (supine position):  Hernia may reduce spontaneously, but, if not, attempt is made to reduce manually or ask the patient to help  If reducible, deep ring occlusion test is done with the index finger  Note the relationship in position between the hernia and the pubic tubercle.  Examine the abdominal muscle tone – Magaigne bulges 43
  44. 44. 44
  45. 45.  NB: The deep ring is located 1.25cm (a finger breadth) superior to the midpoint of the inguinal ligament The deep ring occlusion test is positive when no impulse or hernia bulge is seen medial to the deep inguinal ring on coughing suggestive of an indirect inguinal hernia. Otherwise, it is a direct inguinal hernia 45
  46. 46.  Other examinations  General examination – examine patient’s general state, check for fever, dehydration, etc  Respiratory examination – respiratory pathologies  Abdominal examination – examine for scars, abdominal distension, ascites, masses, other hernia orifices, bowel sounds  Urogenital examination – examine for urethral induration  Rectal examination – examine for haemorrhoids, enlarged prostate, rectal masses 46
  47. 47.  Examination findings for normal/complicated hernias  Reducible hernia:  Good general state  Inguinal swelling,  Positive cough impulse.  Normal overlying skin  Soft  Reducible  No differential warmth  Irreducible (incarcerated) hernia:  Inguinal swelling  Absent cough impulse  Skin may be oedematous  Firm  Non-reducible  Tenderness may be elicited 47
  48. 48.  Obstructed hernia General examination Acutely ill looking Fever Dehydration Examination of groin swelling  Overlying skin hyperaemic and oedematous  Absent cough impulse  Tense  Tender  Irreducible Abdominal examination  Abdominal distension  Hyperactive bowel sounds 48
  49. 49.  Strangulated hernia: General examination: Toxically ill looking Fever Dehydration, shock Groin swelling: Overlying skin, purplish or dark; may be hyperaemic in early stages Absent cough impulse Differential coldness Tense Tender Irreducible 49
  50. 50. Abdominal examination Abdominal distension Rebound tenderness Bowel sounds may be hyperactive  NB: Most strangulated hernias are also obstructed, exceptions are Richter’s hernia, hernias in which the content is not a bowel. 50
  51. 51.  Differential diagnoses  Femoral hernia – inferolateral to the pubic tubercle  Encysted hydrococoele of the cord – transilluminates, may get above and below  Vaginal hydrocoele – transilluminates, can get above it  Saphena varix – no cough impulse, may be associated with varicose veins  Varicocoele – feels like a bag of worms 51
  52. 52.  Lipoma of the cord – lobulated surface, slipping sign, no cough impulse  Inguinal undescended testis – only one testis palpated in the scrotum, cough impulse may be present  Enlarged inguinal lymph node – no cough impulse  Inguinal abscess – no cough impulse  Femoral artery aneurysm – pulsatile, compressible 52
  53. 53.  INVESTIGATIONS  Diagnosis of inguinal hernias is clinical  However, specific investigations may be done as indicated  Chest X-ray: Tuberculosis, COPD  Abdominal USS: Masses, prostate  Urethrogram: Urethral stricture  Abdominal X-ray, erect and supine: Intestinal obstruction  Routine investigations  Serum E/U/Cr  FBC  Hepatitis screening  RVS 53
  54. 54. TREATMENT  REDUCIBLE HERNIA  Treatment is operative, and it is elective.  Precipitating factors must be addressed first before surgery to correct the hernia. Surgeries  Children – Herniotomy  Herniotomy – Sac is excised after reduction of contents  Lytle’s repair may be done to narrow the deep ring if wide  Adults – Herniorrhaphy, Hernioplasty  Herniorrhaphy – Sac is excised, and the posterior wall reinforced with non-absorbable sutures  Hernioplasty – Sac is excised, and an artificial material such as prolene mesh is applied 54
  55. 55. 55
  56. 56.  Types of herniorrhaphy:  Bassini – approximation of conjoint tendon to inguinal ligament  McVay’s – approximation of conjoint tendon to iliopectineal ligament  Shouldice – double breasting of transversalis fascia  Types of hernioplasty:  Lichtenstein – prolene mesh fixed in the inguinal canal  Nylon darning – multiple continuous nylon sutures approximating conjoint tendon to inguinal ligament without tension 56
  57. 57. 57
  58. 58.  Indications for mesh repair  Recurrent hernias  Incisional hernias  Massive hernias  Old age  Weak abdominal muscle tone  Sliding hernias  Direct hernias  Connective tissue disorders e.g. Ehlers syndrome, Marfan syndrome 58
  59. 59.  IRREDUCIBLE HERNIA  Reduction of the hernia is attempted under sedation and muscle relaxant  If reduction is successful, do herniorrhaphy or hernioplasty later (24-48hrs later) when oedema subsides  If hernia remains irreducible, emergency surgery is done. 59
  60. 60.  OBSTRUCTED/STRANGULATED HERNIA  Adequate resuscitation and optimization of patient for surgery Fluid resuscitation Nasogastric intubation to rest the bowel Urethral catheterization to monitor urine output Intravenous broad spectrum antibiotics Correction of electrolyte deficits  When patient is fit for surgery, a groin exploration is done 60
  61. 61.  During the surgery, it is important not to reduce the content of the sac until it is examined to be viable.  Viable bowel is/has Pinkish/reddish Glistening Peristalsis Pulsation of the mesenteric arteries  Resect non-viable bowel and do end-to- end anastomosis 61
  62. 62.  Non-viable bowel is/has Gangrenous Lustereless No peristalsis No pulsation in the mesenteric arteries  For omentum, the affected part is excised.  Then, inguinal herniorrhaphy is done 62
  63. 63. 63
  64. 64. COMPLICATIONS HERNIA REPAIR  Intraoperative complications: Injury to contiguous structures;  Testicular artery  Vas deferens  Inferior epigastric vessels  Ilioinguinal nerve  Genital branch of genitofemoral nerve  Sac content e.g. bowel 64
  65. 65.  Post-operative complications:  Early complications  Urinary retention  Scrotal haematoma  Wound haematoma  Wound infection  Late complications  Sinuses e.g. stitch sinus  Neuralgic pain  Painful scar  Testicular atrophy (due to injury to testicular artery)  Recurrence 65
  66. 66. Anastomotic complications  Anastomotic stenosis  Anastomotic gangrene  Anastomotic leakage  Peritonitis  Enterocutaneous fistula  Intraperitoneal abscess  Surgical site infection 66
  67. 67. CONCLUSION  In an environment like ours where majority of patients only show up for care in the midst of the raging storm, it is important as physicians that we are well grounded on how to weather these storms.  And this we can do by possessing a sound knowledge of what hernias are, how they are diagnosed, and the life-saving ways to manage them. 67
  69. 69. REFERENCES  Baja’s Principles and Practice of Surgery (including Pathology in the Tropics) 5th ed; E.Q. Archampong et al  SRB’s Manual of Surgery 5th ed; Sriram Bhat M  Browse’s Introduction to the Signs and Symptoms of Surgical Disease 4th ed; Norman L. Browse et al  Clinical Surgery Tutorial Manual 2nd ed; Omoigiade E. Udefiagbon  MBBS Undergraduate Notes; Osaigbovo Uhunmwagho, Omoigiade E. Udefiagbon  emedicine.medscape.com 69