Appendicitis and Hernia.pptx
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Appendicitis and Hernia
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Appendicitis and Hernia.pptx
- 2. Appendicitis
- 3. Gross Anatomy ● Gross Anatomy ○ Vermiform (“worm-like) structure extension from the inferior end of the cecum ○ In an adult the average dimensions of the appendix are as follows: ■ Length: 6-9 cm ■ Outer diameter: 3-8 mm ■ Luminal diameter: 1-3 mm ○ The mesentery of the appendix ( or mesoappendix) contains its vessels and nerves.
- 4. Locations ● Found at the posteromedial wall of the cecum, below the ileocecal valve (of bauhin) 1.5 to 2.5 cm below the terminal part of the ileum ( type 3, appendiceal origin) ● Retrocecal ( most common), pelvic, paracecal and post ileal, paracecal and pre ileal, subcecal, or even in the left lower quadrant ( situs inversus or very long appendix) ● Location of the tip ○ To locate the base of the appendix, follow the three taenia coli of the ascending colon, until their point of convergence at the base of the appendix ● Variations in Appendiceal origin Type 1 Fetal type, funnel-shaped origin Type 2 Appendix originates from the cecal fundus Type 3 Appendix originates posteromedially out of the cecum Type 4 Appendix originates directly beside the ileal orifice
- 5. ● Blood Supply ○ Appendicular artery ● Venous drainage ○ appendicular vein ● Lymph drainage ○ Nodes along the ileocolic artery, into the superior mesenteric nodes ● Innervation ○ Sympathetic innervation - celiac and superior mesenteric ganglia ○ Parasympathetic - vagus nerve ○ Sensory innervation for pain - T8 spinal nerve down to T10-L1 spinal nerves
- 6. Appendicitis
- 7. Pathophysiology ● Inflammation of the appendix caused by obstruction of the appendiceal lumen ( this produces a closed loop, resulting in necrosis and/or perforation) ● Most common acute surgical abdomen ( risk is higher in males) ● Most frequent in the 2nd and 3rd decade of life ( rare in the very young) ● Etiology and pathogenesis: ○ Fecalith: most common cause ○ Obstruction of the lumen: increase intraluminal pressure ( Laplace Law) ○ Hypertrophy of the lymphoid tissue ○ Inspissated barium ○ Vegetable and fruit seeds ○ Intestinal worms ( ascariasis)
- 9. Clinical Manifestations ● History ○ Prime symptom: Periumbilical or diffuse pain ○ Anorexia ○ RLQ Pain ○ Regional inflammation ■ constipation , diarrhea, hematuria ○ Others: nausea, vomiting and fever (in sequence) ○ Murphy’s triad ■ Abdominal pain ■ Vomiting ■ Fever ● Physical Examination ○ Vital signs: no change in uncomplicated cases ○ Direct and rebound tenderness at: ■ McBurney Point: lateral third from the anterior iliac spine (ASIS) to the umbilicus ■ Lanz Point: right third point of the interspinal line ■ Kummel Point: right side below the umbilicus ○ In retrocecal appendix: abdominal findings are less striking ( flank maybe the most tender part
- 10. Clinical Manifestations Special signs on Physical Examination: ● Aaron sign: Referred pain or feeling of distress in epigastrium or precordial region on continued firm pressure over the McBurney point ● Bassler sign: Sharp pain elicited by pinching appendix between thub of examiner and iliacus muscle ● Blumberg sign: Transient abdominal wall rebound tenderness ● Bryan sign: Exacerbation of pain when the uterus is shifted to the right side ● Cutaneous hyperesthesia: In area supplied by spinal nerves on the right ● Dunphy sign: Increased abdominal pain on coughing ● Kocher sign: Migration of pain from umbilical region to the right iliac region ● Markle sign: RLQ pain on dropping from standing on toes to heels ● Massouh sign: Grimace when examiner performs a firm swish with index & middle finger across abdomen from epigastrium to right iliac fossa
- 11. Clinical Manifestations Special signs on Physical Examination: ● Rosenstein sign: Tenderness in RLQ increases when patient moves from supine position to a recumbent posture on the left side ● Rovsing sign: Pain at the RLQ when palpatory pressure exerted at the LLQ ● Iliopsoas sign: Patient lies on the left side, examiner then slowly extends right thigh, stretching the iliopsoas muscle (positive if extension produces pain) ● Obturator sign: Performed by passive internal rotation of the flexed right thigh with the patient in a supine position ● Summer sign: Increased abdominal muscle tone on exceedingly deep palpation of right iliac fossa ● Ten Horn sign: Pain caused by gentle traction and right spermatic cord
- 12. Course ● Progression to perforation is not predictable ● Spontaneous resolution is common ● Perforation more common in the very young (<5 y/o) and very old (>65y/o) ● Rupture incidence is higher in the pediatric and the geriatric age groups
- 13. Diagnostics ● Mostly clinical ● Laboratory results will help rule in or out differentials ● If history is not clear and PE is equivocal: may do imaging studies ● Accuracy of preoperative diagnosis should be >85% (misdiagnosis among women) ● Alvarado scoring
- 14. Diagnostic Tool Description CBC ● Moderate leukocytosis: uncomplicated appendicitis ● With WBC count of >18,000/mm: complicated appendicitis Urinalysis ● Done to rule out UTI ● Bacteriuria generally not seen inappendicitis Radiography ● Abdominal radiograph: fecalith in RLQ is associated with gangrenous acute appendicitis ● Chest x-ray : to rule out right lower lobar pneumonia Ultrasound ● Inexpensive, does not require contrast, applicability among pregnants ● Target lesion: a thick-walled, non compressible, luminal structure in the RLQ ● Signs of appendicitis: wall thickening, periappendiceal fluid Abdominal CT scan with triple contrast ● More sensitive and specific than ultrasound ● More expensive, limited use during pregnancy, can induce iodine /contrast allergies ● Arrowhead sign: thickened cecum that funnels contrast into the appendiceal orifice Diagnostic laparoscopy ● Most useful for evaluating ovulating women with an equivocal examination for appendicitis
- 15. Alvarado Score INTERPRETATION 1-4 Low Likelihood 5-6 Imaging 7-8 High likelihood >9 Almost certain
- 16. Management ● Non-Surgical ○ Antibiotics ○ Fluids ○ Bowel rest ○ Percutaneous drainage ● Surgical ○ Urgent(12-24 hrs)vs emergent ○ (<12 hrs) appendectomy for uncomplicated appendicitis: no significant difference in terms of complicated appendicitis, surgical site infection,abscess formation
- 17. Management Surgical Management 1. Open Appendectomy a. For early nonperforated appendicitis: RLQ incision is made b. McBurney (oblique) or Rocky Davis ( transverse incision)is made 2. Lower midline Laparotomy a. Considered for perforated appendicitis or diagnosis is in doubt b. Abdominal pus should be aspirated 3. Laparoscopic Appendectomy a. Fewer surgical site infections, less pain, shorter hospital stay, same cost, greater patient satisfaction b. Has increased risk of intraabdominal abscess
- 18. Management ● If appendicitis is not found ○ May see a slightly congested or normal looking appendix ○ Cecum and mesentery should be inspected ○ Retrograde evaluation of the small bowels ○ Look for Crohn or Meckel diverticulitis ○ Inspect reproductive organs (female) ○ Extend the incision if pus or bilious fluid is encountered (Valentino appendicitis) ○ Perform medical extension of the incision (Fowler-Weir) or superior extension of the lateral incision to evaluate lower abdomen or right colon ● Complicated Appendicitis ○ Perforated appendicitis commonly associated with abscess or phlegmon ○ Perforation is more common among thievery young and elderly ○ Standard treatment:immediate appendectomy ○ Non operative management: considered for confined abscess or phlegmon, limited peritonitis
- 19. Appendectomy ● Incision is made over McBurneys point ● Cecum is mobilized into the surgical incision ● Mesoappendix is divided and vessels are ligated ● Purse-string suture is placed in the cecum near the base of the appendix and base of the appendix is tied ● Mucosa of appendiceal stump is cauterized to prevent bacterial spillage and stump is inverted. The purse-string suture is tied ● Cecum is returned and wound is closed
- 20. Anatomic Complications Vascular Injury Hematoma of mesentery, hemoperitoneum, intraluminal bleeding, right iliac artery or vein Organ Injury Perforation of cecum or intestinal loop, of right uterine tube or ovary Nerve Injury Temporary numbness or late muscle atrophy due to transection of the lower spinal nerves (T10-L1) resulting to inguinal hernia Inadequate procedure Unnecessary delay in locating appendix, failure to remove tip of appendix, remaining stump too long (appendicitis may recur)
- 21. Hernia
- 23. Hernia ● Represent defects in the abdominal wall fascia and muscle through which intra-abdominal or pre-peritoneal contents can protrude ● Most common finding: mass or bulge, which may increase with Valsalva ● Hernias that cannot be reduced are termed incarcerated and generally requires surgical correction
- 25. Abdominal Hernia
- 26. Primary Ventral Hernias Epigastric Hernia ● Midline between the xiphoid process and the umbilicus ● May be congenital and due to defective midline fusion of developing abdominal wall elements ● Occur at the umbilical ring and may be present at birth or develop later in life ● No need to be repaired unless it causes some symptoms of pain Umbilical Hernia
- 27. Primary Ventral Hernias Spigelian Hernia ● Rare; occur along the spigelian line or linea semilunaris ● Can occur anywhere along the length of the Spigelian line or zone ● Are not always clinically evident as bulge and may come to medical attention due to pain or incarceration
- 28. Incisional Hernia ● Resulting from failed healing of an anterior abdominal wall incision ● Incidence:10-20% of all the surgeries performed ● Risk factors: Obesity, primary wound healing defects, multiple prior procedures, prior incisional hernias and technical errors during repair
- 29. Types of Hernia Repair Surgery
- 30. TYPE OF VENTRAL HERNIA SITE OF HERNIATION CLINICAL ASPECTS MANAGEMENT Umbilical Hernia Umbilical ring ○ 10% of newborns, more common in preterms, most close spontaneously by age 5 ○ Seen in advance liver disease with ascites Elective repair (open surgery or laparoscopic) + mesh if with failure to close Spigelian Hernia Spigelian line (lateral border of rectus abdominis) ○ Presents with pain ○ High risk of incarceration Open or laparoscopic repair Incisional Hernia Site of previous open abdominal surgery ○ Develops in 10-20% ○ At risk: obesity, wound healing problems, multiple previous surgeries, poor surgical technique during closure Mesh repair recommended
- 31. Inguinal Hernia
- 32. ■ 4-6 cm in length ■ Spermatic cord in males and the round ligament in females pass through the internal inguinal ring ■ Boundaries: ○ Anterior: External oblique aponeurosis ○ Lateral: Internal oblique muscle ○ Posterior: Transversalis fascia and Transversus abdominis muscle ○ Superior: Internal oblique and Transversus abdominis muscle ○ Inferior: Inguinal ligament
- 34. Inguinal Hernia ● A sac-like projection of the abdominal cavity extends down the groin on one or both sides toward the scrotum (in boys) or labia (in girls) ● 75% of all abdominal wall hernias are found in the groin ● 95% of groin hernias are hernias of the inguinal canal (with the remainder of femoral area) ● Main concern: strangulation - blood supply to that part of the intestine is interrupted, causing necrosis Risk factors: ❏ Family History ❏ Inherent weakness in the abdominal musculature ❏ Upright posture ❏ Chronic increases in the intraabdominal pressure ❏ Connective tissue disorders ❏ Smoking ❏ Previous RLQ injuries ❏ Strenuous physical exertion
- 35. Inguinal Hernia ● Congenital (patent processus vaginalis) ● Acquired (weakness in abdominal muscles) Etiology:
- 36. HISTORY AND PHYSICAL EXAM
- 37. 1. History ○ Symptoms: pain or discomfort, especially with coughing or straining, improves when lying down ○ Usually presents as a bulge in the groin 1. Physical Examination - Inspection - Percussion and auscultation - Transillumination - General palpation - Swelling test (Compressibility test) - Cough impulse - Invagination test - Relation to pubic tubercle - Three finger test or Zieman technique - Ring occlusion test - Reducibility test
- 38. Diagnostics TOOL Ultrasound Identifying movements of hernia contents through the canal CT Scan Has limited place in the diagnosis of an inguinal hernia MRI Has a sensitivity and specificity of more than 94% and is also useful to reveal other musculo-tendineal pathology Herniography Has high sensitivity and specificity but invasive Indicated in suspected sports hernia, recurrent hernia, possible hydrocele and surgical complications especially chronic groin pain
- 39. Inguinal Hernia CLASSIFICATION OF INGUINAL HERNIAS: ➢ Direct Inguinal Hernia ➢ Indirect Inguinal Hernia ➢ Femoral Inguinal Hernia Epidemiology: ● More common in men ● Lifetime risk of inguinal hernia: ○ 27% in men ○ 3% in women ● Right sided inguinal hernia are more ● common than left MALES FEMALES ● Indirect inguinal hernia outnumber direct by about 2:1 ● Indirect inguinal hernia are more common followed by femoral hernia ● Direct hernia: rare ● Femoral hernia are found more often
- 40. Classification of Inguinal Hernia - Most common occurring - Congenital but may not manifest until later in life - Occurs at the deep inguinal ring - Passess lateral to the to the Hesselback (Inguinal) triangle Indirect Inguinal Hernia
- 41. Classification of Inguinal Hernia INCOMPLETE: ● Bubonocele: hernial sac stops within inguinal canal after entering inguinal ring ● Funicular: hernial sac after emerging out of external ring stops just above the testis COMPLETE: ● Processus vaginalis is patent throughout being continuous with tunica vaginalis of the testis ● A congenital hernia commonly seen in children but it may appear in adult or adolescent life Indirect Inguinal Hernia Types
- 42. Classification of Inguinal Hernia - Occurs in the floor of the inguinal canal through Hesselbach’s triangle - Hernia does not traverse the internal inguinal ring - Usually acquired (Related to straining causing increased intraabdominal pressure) Direct Inguinal Hernia
- 43. Classification of Inguinal Hernia - Occurs when intraabdominal contents protrude along the femoral sheath into the femoral canal - Protrude through the small and inflexible femoral ring - Hernia travels beneath the inguinal ligament down the femoral canal medial to the femoral vessels - Repair: McVay Repair or Mesh plug repair Femoral Hernia
- 45. Management
- 46. Treatment of Uncomplicated Inguinal Hernia ● Conservative (watchful waiting) - Asymptomatic or minimal symptoms ● Surgical Repair - Symptomatic ■ Open approach ○ Tissue repairs - Bassini repair - Shouldice repair - McVay repair ○ Prosthetic repairs - Lichtenstein tension-free repair - Plug and patch - Prolene Hernia System ■ Laparoscopic approach ○ Transabdominal Preperitoneal Procedure (TAPP) ○ Total Extraperitoneal Procedure (TEP)
- 47. Tissue Repairs Bassini Repair Shouldice Repair McVay Repair
- 48. Mini Quiz
- 49. 1. What is the type of Appendiceal origin wherein appendix originates from the cecal fundus? A. Type 1 B. Type 2 C. Type 3 D. Type 4
- 50. 2. Parasympathetic innervation of appendix originates from ________ A. Inferior mesenteric ganglia B. Superior mesenteric ganglia C. Celiac ganglia D. Vagus nerve
- 51. 3. The most common cause of appendicitis A. Fecalith B. Obstruction of the lumen C. Hypertrophy of the lymphoid tissue D. Intestinal worms
- 52. 4. Refers to the point on the lower right quadrant of the abdomen, lateral third from the ASIS to the umbilicus at which tenderness is maximal in cases of acute appendicitis A. Munro's point B. Lanz point C. McBurney’s point D. Kummel point
- 53. 5. Special sign wherein tenderness in RLQ increases when patient moves from supine position to a recumbent posture on the left side A. Rosenstein sign B. Obturator sign C. Rovsing sign D. Summer sign
- 54. 6. What is the most common type of hernia found in women? A. Femoral hernia B. Inguinal hernia C. Obturator hernia D. Umbilical hernia
- 55. 7. An indirect hernia is due to: A. Chronic cough B. Previous surgical incision C. Weakness of transversalis fascia D. Persistent processus vaginalis
- 56. 8. What type of hernia involves passage of intestine through the external inguinal ring at Hesselbach triangle and rarely enters the scrotum A. Indirect inguinal hernia B. Direct Inguinal hernia C. Ventral hernia D. Femoral hernia
- 57. 9. The following are the types of tissue repairs except: A. Bassini repair B. Lichtenstein repair C. McVay repair D. Shouldice repair
- 58. 10. What type in the Nyhus Classification System is Femoral hernia? A. Type I B. Type III A C. Type III B D. Type III C
- 59. CREDITS: This presentation template was created by Slidesgo, including icons by Flaticon, infographics & images by Freepik Thank You
Notes de l'éditeur
- The adult appendix is usually found at the posteromedial wall of the cecum, just below the ileocecal valve (of bauhin) 1.5 to 2.5 cm below the terminal part of the ileum ( type 3, appendiceal origin) The tip of the appendix may be retrocecal ( most common), pelvic, paracecal and post ileal, paracecal and pre ileal, subcecal, or even in the left lower quadrant ( situs inversus or very long appendix) To locate the base of the appendix, follow the three taenia coli of the ascending colon, until their point of convergence at the base of the appendix
- Blood Supply Appendicular artery, which arises from the posterior cecal branch of the ileocolic artery Lymph drainage Nodes along the ileocolic artery, into the superior mesenteric nodes Innervation Sympathetic innervation of the appendix originates from the celiac and superior mesenteric ganglia and parasympathetic innervation originates from the vagus nerve Sensory innervation for pain is carried by T8 spinal nerve down to T10-L1 spinal nerves Histology and Pathology The appendix contains lymphoid follicles in its mucosa and submucosa Previously considered vestigial , it is now known that the appendix, as an immunologic organ, secretes immunoglobulin A Surgical Pearls To locate the base of the appendix, follow the free taenia ( taenia libera, appendix pointer) of the ascending colon or cecum, until the point of origin at the base of the appendix Locating and ligating the appendicular artery is crucial during appendectomy
- Closed loop obstruction → Continuing normal secretion of appendiceal mucus → RApid distention of the appendix with stimulation of visceral nerve pain fibers→ Rapid bacterial multiplication→ Lymphatics, Venules, and capillaries are occluded→ Vascular engorgement & congestion results→ Inflamatory process involves the serosa of the appendix→ Absorption of necrotic tissue and bacterial toxins→ Progressive distention may cause infarction and perforation Since the appendix is a hollow tube, the most common cause of inflammation is something getting stuck in or obstructing that tube, like a fecalith, a hardened lump of fecal matter that finds its way into the the lumen of the appendix and wedges itself there. It could also be other things though, like seeds that weren’t digested, or even pinworm infections, which are intestinal parasites. Another cause of obstruction, especially in children and adolescents, is lymphoid follicle growth, also known as lymphoid hyperplasia. Lymphoid follicles are dense collections of lymphocytes that get to their maximum size in the appendix during adolescence. Sometimes this growth can literally obstruct the tube. Also, when exposed to viral infections like adenovirus, measles, or even after immunizations, the immune system ramps up and these follicles can grow as well. the intestinal lumen, including the appendix, is always secreting mucus and fluids from its mucosa to keep pathogens from entering the bloodstream and also to keep the tissue moist. Even when it’s plugged, the appendix keeps secreting as usual. When this happens, fluid and mucus builds up, which increases the pressure in the appendix, and just like when you fill up a water balloon, it gets bigger and physically pushes ons the afferent visceral nerve fibers nearby, causing abdominal pain. Along with that, the flora and bacteria in the gut are now trapped, and intestinal bacteria that are usually kept in check in the gut, like E. coli and Bacteroides fragilis are now free to multiply. This causes the immune system to recruit white blood cells and pus starts to accumulate in the appendix. This activation of the immune system can be seen in the lab as an increase in the serum white blood cell count. Patients might also develop a fever in response to the infection, which in combination with right lower quadrant abdominal pain at the point roughly where the appendix is, known as mcburney’s point, is a super important sign for identifying appendicitis. Also, along with fever, other classic symptoms include nausea and vomiting. Now if obstruction persists, the pressure in the appendix increases even more. At a certain point, as the pressure keeps growing and it continues to swell up, it pushes on and compresses the small blood vessels that supply the appendix with blood and oxygen. Without oxygen, the cells in the walls of the appendix become ischemic and eventually die. Since these cells were responsible for secreting mucus and keeping bacteria out, now the growing colony of bacteria can invade the wall of the appendix. As more cells die, the appendiceal walls become weaker and weaker and for a small proportion of patients, to the point where the appendix ruptures
- Prime symptom: Periumbilical or diffuse pain Anorexia : constant in most patients Pain becomes localized to the right lower quadrant (RLQ) usually <24 hours (usually the second symptom) Regional inflammation Others: nausea, vomiting and fever (in sequence)
- Ultimate diagnostics is still clinical Laboratory results will help rule in or out differentials If history is not clear and PE is equivocal: may do imaging studies Accuracy of preoperative diagnosis should be >85% (misdiagnosis among women)
- Based on variables that are individually weak discriminators; but when taken together, possesses a high predictive value Alvarado Score:most common scoring system Appendicitis Inflammatory Response score:performs better than Alvarado score in accurately predicting appendicitis
- https://www.verywellhealth.com/hernia-surgery-in-detail-3157226 https://www.kugelherniameshclassaction.com/incarcerated-stangulated-hernia/ The Difference Between Hernioplasty and Herniorrhaphy Herniorrhaphy refers to a surgical technique that relies primarily on sutures to secure herniated tissue in its proper location and strengthen the weakened muscle at the site. Hernioplasty is a different technique that relies primarily on placing synthetic mesh to reinforce the weakened muscle site
- Anterior abdominal wall: 1. Skin: loosely attached to the underlying structures except at the umbilicus “situated in the linea alba”. 2. Subcutaneous tissue: a. Camper’s fascia: Superficial and fatty, b. Scarpa’s fascia: Deep and fibrous. 3. Rectus abdominis. 4. External oblique muscle: in the groin, its aponeurosis forms: a. The inguinal ligament b. The External spermatic fascia of the spermatic cord. 5. Internal oblique muscle: forms the lateral part of the inguinal ligament. 6. Transversus muscle: forms the rectus sheath and the linea alba. 7. Transversus fascia: with the descent of the testicle, the transversalis fascia establishes continuity with the internal spermatic fascia of the spermatic cord. 8. Peritoneum. Layers: Skin > Subcutaneous fat > Scarpa’s fascia > External oblique > Internal oblique > Transversus abdominis > Transversalis fascia > Preperitoneal fat > Peritoneum Now, the abdominal wall is made up of a few layers. The deepest layer is the visceral peritoneum, which covers many of the abdominal organs and lines the peritoneal space. That layer wraps around to form the parietal peritoneum. Then, moving externally, there is the extraperitoneal fat, the transversalis fascia, the muscle layer with the internal and external oblique and transversus abdominis aponeurosis and a layer of fascia which has different names in different regions.
- Abdominal hernias, also called external hernias, are when an abdominal organ, or part of an abdominal organ protrudes through the abdominal wall, usually at a site of weakness. They can be classified into midline hernias and groin hernias. Most frequent types of midline hernias are the epigastric and umbilical hernias, while groin hernias can further be classified into inguinal and femoral hernias. There’s also incisional hernias, which is when contents herniate through an incisional scar from a previous abdominal surgery
- The groin (inguinal region) is the area of junction between The inguinal canal is an approximately 4- to 6-cm long cone- shaped region situated in the anterior portion of the pelvic basin The canal begins on the posterior abdominal wall, at the deep (internal) inguinal ring. (Over the hole in the transversalis fascia) Terminates medially at the superficial (external) inguinal ring (the point at which the spermatic cord crosses a defect in the external oblique aponeurosis) The boundaries of the inguinal canal are the external oblique aponeurosis anteriorly, the internal oblique muscle laterally, the transversalis fascia and transversus abdominis muscle posteriorly, the internal oblique and transversus abdominis muscle superiorly, and the inguinal (Poupart’s) ligament inferiorly. The conjoined tendon is commonly described as the fusion of the inferior fibers of the internal oblique and transversus abdominis aponeurosis at the point where they insert on the pubic tubercle. Deep (Internal) inguinal ring is the entrance to the inguinal canal. It is located above and halfway between the pubic tubercle and the anterior superior iliac spine Superficial (external) inguinal ring is a triangular opening that forms the exit of the inguinal canal. It lies immediately above and medial to the pubic tubercle
- Inguinal hernia is the protrusion or passage of peritoneal sac, with/without abdominal contents through a weakened part of the abdominal wall in the groin. Cause: Peritoneal sac enters the inguinal canal either through deep inguinal ring or through posterior wall of inguinal canal
- The presence of an inguinal hernia can almost always be confirmed on physical examination. Both groins and testicles should be assessed for masses. A reducible mass is best felt with the patient standing and providing intermittent Valsalva such as a cough. A femoral hernia will be felt below the inguinal ligament, adjacent to the femoral vessels.
- Rarely needed in the diagnosis. Used as an adjunct to history and PE for ambiguous diagnosis Groin diagnostic investigations should be performed only in patients with obscure pain and/or swelling If the diagnosis cannot be definitely made with physical examination, ultrasound or computed tomography (CT) scan can be used to assess the integrity of the abdominal wall.
- Incidence of inguinal hernias in males has a bimodal distribution, with peaks before the first year of age and after age 40 (may be due to acquired abnormalities from increased intraabdominal pressure)
- Most common of the two types and this is most common in males during infancy or old age. It is believed to be congenital in origin because some part or all of the embryonic processus vaginalis remains open or patent thats why it is referred to as congenital indirect inguinal hernia This happens when the protruding peritoneal sac enters the inguinal canal by passing through deep or internal inguinal ring that can protrude into the scrotum It passes lateral to the hesselbach or inguinal triangle including inferior epigastric vessels. It may extend part of the way along the canal or as far as the superficial inguinal ring The extent of protrusion down the inguinal canal depends on the amount of processus vaginalis that remains patent Indirect Inguinal Hernia (Most Common): Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one.
- According to extent of Indirect inguinal hernia there are two main types: Bubonocele: here, sac is confined to inguinal canal Funicular: here, sac crosses the superficial ring but doesnt reach the bottom of the scrotum Complete: the sac descends to the bottom of the scrotum
- Direct Inguinal Hernias involve passage of intestine through the external inguinal ring at Hesselbach triangle and rarely enters the scrotum. Peritoneal sac enters the medial end of inguinal canal directly through weakened posterior inguinal wall Protrusion occurs medial to inferior epigastric vessels It is usually acquired may be related to straining that causes increase intraabdominal pressure
- They traverse the empty space between the femoral vein and the lymphatic channels. The borders of the femoral ring include the iliopubic tract and inguinal ligament anteriorly, Cooper’s ligament posteriorly, the lacunar ligament medially, and the femoral vein laterally. Femoral hernias are also common in older patients and in those who have previously undergone inguinal hernia repair 40% of femoral hernias present as emergencies (with incarceration or strangulation) Risk factors: female sex, pregnancy, exertion Femoral hernias can be repaired using surgery to push the bulge back into place and strengthen the weakness in the wall of the tummy. Unlike some other types of hernia, treatment of femoral hernias is almost always recommended straight away because there's a higher risk of complications developing in these cases. The McVay operation uses Cooper’s Ligament instead of the inguinal ligament and is the best operation for femoral hernias or when the inguinal ligament has been damaged. Closure of the defect with mesh plug is operated without tissue tension and so gives a benefit over the conventional techniques (the defect is closed by approximation of the inguinal ligament to pectineal ligament). The plug can be done quickly and easily with satisfactory closure of the femoral canal.
- The Nyhus Classification System categorizes hernia defects by location, size and type
- In some asymptomatic or minimally bothersome hernias, watchful waiting can be an option. Surgical repair is the definitive treatment for an inguinal hernia. As a general rule, all symptomatic inguinal hernias should be repaired when possible Tissue Repairs Tissue repairs are repairs where the native tissue is used to close the hernia defect with suture, and no mesh is used. These repairs are used when the operative field is contaminated or in emergency surgery where the viability of the hernia contents is in question. The 3 main primary tissue repairs are the Bassini, Shouldice, and McVay. The Shouldice has the lowest recurrence rate when experienced surgeons perform tissue repairs. McVay is the only technique that can be used in femoral hernia repair. All surgeons should have a good grasp of the technical aspects of these repairs, as a primary repair will likely be the only option in a contaminated case. Prosthetic repairs are preferred over native tissue repair due to lower incidence of recurrence. Prosthetic Repairs The prosthetic repairs are tension-free repairs, and thus, these have a lower hernia recurrence rate as compared to tissue repairs. The prosthetic repairs are the Lichtenstein tension-free repair, plug and patch, and Prolene Hernia System (PHS). Lichtenstein repair is the most popular and used most around the world. The Prolene Hernia System repair is the only one of the 3 that places a mesh in the preperitoneal space with an open repair. Mesh repairs are contraindicated in a contaminated field due to the high rate of infection. Lichtenstein Tension-Free Repair The Lichtenstein technique allows for a tension-free repair of the inguinal floor by buttressing the floor with a prosthetic mesh (Fig. 37-18). Initial exposure and mobilization of cord structures is identical to other open approaches. The inguinal canal is dissected to expose the shelving edge of the inguinal ligament, the pubic tubercle, and sufficient area for mesh. The most commonly used mesh is “flat iron” shaped with a keyhole for cord egress, it is available in several sizes. It should be noted that when selecting the size, it must be large enough to extend 2 to 3 cm superior to Hesselbachs triangle The medial edge of the mesh is affixed to the anterior rectus sheath such that it overlaps the pubic tubercle by 1.5 to 2 cm. This refinement to the original Lichtenstein technique minimizes medial recurrence PlugandPatchTechnique. AmodificationoftheLichtenstein repair, the Plug and Patch technique was developed by Gilbert and later popularized by Rutkow and Robbins.43 Prior to placing the prosthetic mesh patch over the inguinal floor, a three-dimensional prosthetic plug is placed in the space previously occupied by the hernia sac (Fig. 37-19). In the case of an indirect hernia, the plug is placed alongside the spermatic cord through the internal ring. Prosthetic plugs of various sizes are available, and one of appropriate size is fixed to the margins of the internal ring with interrupted sutures.44 For direct hernias, the sac is reduced, and the plug is sutured to Cooper’s ligament, the inguinal ligament, and the internal oblique aponeurosis. While the technique has good overall outcomes, there have been some isolated case report series of complications involving the presence of the plug, including bowel obstruction and chronic pain. . Laparoscopic Repairs Transabdominal Preperitoneal Procedure (TAPP) The transabdominal preperitoneal procedure TAPP is a technique where a hernia is repaired through an intraperitoneal approach. TAPP can be useful for bilateral hernia repair, large hernia defects, and recurrence after open repair. A large mesh can be placed with this approach covering the direct, indirect and femoral spaces. The disadvantage to this approach is a complication to other intraperitoneal viscera and structures. A patient must be able to tolerate pneumoperitoneum for laparoscopic approaches. Total Extraperitoneal Procedure (TEP) The laparoscopic extraperitoneal procedure is a technique where the hernia repair is completed without intraperitoneal infiltration. This minimizes risks of injury to intraperitoneal viscera and structures when compared to a TAPP repair. The TEP procedure also avoids intraperitoneal adhesions from prior surgery making the dissection quicker and easier. The disadvantage to the TEP procedure is that the surgeon is constrained to limited space while dissecting. Visualization of the surrounding anatomy is limited as compared to TAPP repair. If the peritoneum is violated during the procedure, then conversion to TAPP may be warranted. Laparoscopic repairs compared to open repairs have equivalent recurrence rates. The laparoscopic approach has been shown to improve postoperative pain and patients may resume normal activities sooner as compared to open repair. However, laparoscopic repair is associated with higher operative costs, and technical proficiency can be difficult to achieve. Some studies suggest it takes as many as 250 laparoscopic hernia repairs for a surgeon to reach optimal proficiency.
- Bassini Repair The Bassini repair was a historic advancement in operative technique. Its current use is limited as modern tech- niques reduce recurrence. The original repair includes dissection of the spermatic cord, dissection of the hernia sac with high liga- tion, and extensive reconstruction of the floor of the inguinal canal (Fig. 37-15). After exposing the inguinal floor, the transversalis fascia is incised from the pubic tubercle to the internal inguinal ring. Preperitoneal fat is bluntly dissected from the upper margin of the posterior side of the transversalis fascia to permit adequate tissue mobilization. A triple-layer repair is then performed. The internal oblique, transversus abdominis, and transversalis fascia are fixed to the shelving edge of the inguinal ligament and pubic periosteum with interrupted sutures. The lateral aspect of the repair reinforces the medial border of the internal inguinal ring Shouldice Repair The Shouldice repair recapitulates principles of the Bassini repair, and its distribution of tension over several tissue layers results in lower recurrence rates (Fig. 37-16). Dur- ing dissection of the cord, the genital branch of the genitofemoral nerve is routinely divided, resulting in ipsilateral loss of sensation to the scrotum in men or the mons pubis and labium majus in women. With the posterior inguinal floor exposed, an incision in the transversalis fascia is made between the pubic tubercle and internal ring. Care is taken to avoid injury to preperitoneal struc- tures, which are bluntly dissected to mobilize the upper and lower fascial flaps. At the pubic tubercle, the iliopubic tract is sutured to the lateral edge of the rectus sheath using a synthetic, nonab- sorbable, monofilament suture. This continuous suture progresses laterally, approximating the edge of the inferior transversalis flap to the posterior aspect of the superior flap. At the internal inguinal ring, the suture continues back in the medial direction, approxi- mating the edge of the superior transversalis fascia flap to the shelving edge of the inguinal ligament. At the pubic tubercle, this suture is tied to the tail of the original stitch. The next suture begins at the internal inguinal ring, and it continues medially, apposing the aponeuroses of the internal oblique and transversus abdominis to the external oblique aponeurotic fibers. At the pubic tubercle, the suture doubles back through the same structures lat- erally towards the tightened internal ring. McVay Repair The McVay repair addresses both inguinal and femoral ring defects. This technique is indicated for femoral hernias and in cases where the use of prosthetic material is contraindicated (Fig. 37-17). Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space. The upper flap is mobilized by gentle blunt dissection of underlying tissue. Cooper’s ligament is bluntly dissected to expose its surface. A 2 to 4 cm relaxing incision is made in the anterior rectus sheath vertically from the pubic tubercle. This incision is essential to reduce tension on the repair; however, it may result in increased postoperative pain and higher risk of ventral abdominal herniation. Using either interrupted or continuous suture, the superior transversalis flap is then fastened to Cooper’s ligament, and the repair is contin- ued laterally along Cooper’s ligament to occlude the femoral ring. Lateral to the femoral ring, a transition stitch is placed, affixing the transversalis fascia to the inguinal ligament. The transversalis is then sutured to the inguinal ligament laterally to the internal ring.
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