Inguinal Hernia - PowerPoint Presentation

Slide1

Inguinal Hernia

Shohreh

Toutounchi

Reference: Schwartz Principles of Surgery

2010

Internship: 1391Slide2

Anatomy

The

inguinal canal

is 4-6 cm long.

The inguinal canal starts in the abdomen from the point that the spermatic cord crosses the

internal/deep inguinal ring

in the

transversalis

fascia (in women the Round ligament).

This canal finally ends in the

external/surface inguinal ring

at the level of the abdominal muscles where the spermatic cord passes from the

aponeurosis

of the external oblique muscle.Slide3

Epidemiology

About

75%

of all hernias happen in the

inguinal region

.

90%

of them are in

men

and

10%

in

women

.

70%

of

femoral hernia repairs

occur in

women

(although the prevalence of inguinal hernia in women is 5 times that of femoral hernia.

The

most common inguinal hernia

in women and in men is the

indirect

inguinal hernia.

The prevalence of hernia in

men

has two

peak ages

:

Under

one

and above

40

.Slide4

Epidemiology

About

1/3

of the patients who present with hernia, also develop a

contralateral

hernia

.

Hernia in the

right side

is more

common

.

In the

laparascopic

repair

of the hernia, the diagnosis of

contralateral

hernia

can be made.

Femoral hernia

in the

elderly

and in those who had a

previous hernia repair

is more common.

The

prevalence

of inguinal hernia

increases with ag

e (especially in

men

).

Inguinal hernia in

adult

s is mainly from an

acquired

weakness

in the abdominal wall (the most important one is a defect in the abdominal muscle).Slide5

Etiology

Inguinal hernia has

two etiologies

:

A) Congenital

B) Acquired

A) Congenital Hernia:

Congenital hernia consists most of the cases of

pediatric hernias

In the

descent of the testes

from the abdomen to the

scrotom

in the third trimester, a part of the

perituneum

descends with it which is called the

process

vaginalis

.

In the weeks

36-40

of gestation this process

vaginalis

closes.

Lack of closure of process

vaginalis

results in a

patent process

vaginalis

which is a reason for the

high prevalence

of inguinal hernia in the

preterm neonates

.

A lot of the process

vaginalises

close

in a few months

after birth

and its patency does not necessarily mean that a hernia will be formed.

Slide6

Etiology

B) Acquired Hernia

:

It seems that most cases of hernia come from an acquired defect in the abdominal wall and the reason for its formation is

multifactorial

:

1-

Strenuous physical activity

can be a factor but it is not known whether the hernia is just from physical activity or in the setting of a patent process

vaginalis

.

2- A

positive family history

which can increase its incidence 8 times.

3-

COPD

increases the direct hernia risk.

4-

Collagen deficiency

associated diseases like collagen type I deficiency relative to type III.

5- An association exists between

aneurisms

and hernias.

Being overweight is to some extent protective (maybe it is from the more difficult diagnosis of hernia)Slide7

Symptoms

The symptoms are variable from a hernia with

no symptoms

to one with

stangulation

.

Asymptomatic hernia

is either found in

physical exam

, or the patient himself realizes the

bulging

, or it is found during

laparascopy

.

Symptomatic patients

mostly present with

inquinal

pain

.

Sometimes patients present with

symptoms outside the inguinal region

such as a

change in bowel habits

, and/or

urinary symptoms

(in the form of sliding hernia).Slide8

Symptoms

With pressure on the

nearby nerves

, hernia can cause different symptoms such as a general feeling of pressure, localized pain, and referred pain.

The feeling of pressure and weight on the inguinal region especially after a

daily activity

is common.

Important Point

: A

sharp pain

indicates

nerve entrapment

and does not have anything to do with physical activity.

Important Point

:

Neurogenic

pains

may refer to the

scrotom

or inside the

thigh

.

Important Point

:

A change in

bowel habits

or in the

urinary symptoms

can indicate involvement of the

bladder

inside the

hernial

sac.Slide9

Symptoms

Important Point:

Pain

in the inguinal region

without bulging

is

usually

not due to a hernia.

Important Point:

The

duration

and the

way

the symptoms progress is important

Usually the patient can

reduce

the hernia but the

bigger

the hernia, the less likely it is to reduce.

The possibility of the

incarceration

of the hernia at the

beginning

of the progress of hernia, for example during the first year , is more likely.

The possibility of

incarceration

is

neonates

is more likely than in adults.Slide10

Physical Exam

The

history

is usually indicative of hernia but the

physical exam

is also an important part of the evaluation.

The examination in

obese

patients is difficult.

It is best that the patient is examined in an

upright position

so that the inguinal region and the scrotum is completely exposed. Slide11

Physical Exam

A) First we

look

to see the

bulging

. If we do not have a bulging, we place a

finger inside the scrotum

and raise it toward the external ring, and ask the patient to

cough

or do the

Valsalva

maneuver

until the

hernial

contents fall.

The

valsalva

maneuver causes an

unusual bulging

and it is possible to realize if this bulging can be reduced or not.

B) We examine the

contralateral

side

and compare the two sides to each other.

The

extent of bulging

on the two sides can be a criteria for the diagnosis of hernia on one or both sides. Slide12

Physical Exam

The

differentiation

between a

direct

and an

indirect

inguinal hernia in the physical exam:

There are

different techniques

for differentiating a direct from an indirect hernia in physical exam.

- If the finger is inside the inguinal canal and the patient exerts pressure or

coughs

and the hernia comes in contact with the

tip of the finger

it is a

direct

hernia.

- If with

closure

of the

internal ring

with the finger while the patient strains (coughs) the

hernial

sac does

not bulge out

the hernia is an

indirect

one, and if the

hernial

sac

bulges

the hernia is a

direct

one. Slide13

Physical Exam

Important Point

: the examination of the

femoral hernia

is difficult. This hernia presents

under the inguinal ligament

and the presence of too much or too little

fat

in the inguinal region can cause an error in the diagnosis. (Femoral

Psuedohernia

)

Therefore even the presence of a smallest

bulging

under the

inguinal ligament

has to raise the suspicion for a femoral hernia.Slide14

Differential Diagnosis

1-Malignancy

:

Lypoma

, metastasis, testicular

tumory

2-Testeicular primary conditions

:

Varicocele

,

Epididimitis

, Testicular torsion,

Hydrocele

, Ectopic testes,

undescended

testes

3- Aneurism or

pseudoaneurism

of the femoral artery

4-

Lymphadenopathy

5-

Sebacious

cyst

6-

Hydroadenitis

7-

Nuck

canal cyst (in women)

8-

Varices

9-Psoas

Abcess

10- Hematoma

11-

AscitesSlide15

Diagnosis

The diagnosis is based on

history

,

physical exam

and sometimes

imaging

.

Imaging in hernia

:

In some conditions

physical exam cannot diagnose

the hernia:

1-

Overwieght

individuals

2- Recurrent hernia

3- Hernias that are not found in the physical exam

In these conditions imaging is importantSlide16

Diagnosis

The most common radiologic conditions include

sonography

, CT, MRI

, and each has its own pros. and cons.

1-

Sonography

: It is

inexpensive

and does

not have radiation

.

Important Point:

In

underweight

individuals the movement of the posterior wall and spermatic cord toward the anterior wall of the abdomen can have

false positive

results (the false positive results of the

sonography

is more than in the

phyisical

exam and MRI)Slide17

Diagnosis

2- CT scan

: Although it gives more information but the

routine use

of it is

not recommended.

Important Point:

In one determined evaluation among the imaging techniques,

MRI

was more truthful, and an

accurate physical exam

was

more

truthful than

sonography

.Slide18

Treatment

The

final treatment

of inguinal hernia is

surgery

.

Now using a

mesh

herniorhaphy

, hernia repair takes place.

Mesh

herniorhaphy

is the

golden standard

because

less tension

is produced and there is

less

recurrency

.

Because of the very good results of mesh the initial tissue repair is not used any more.

Important Point:

Laparascopic

surgery

is used in

bilateral

and

recurrent

conditions or when

another surgery

like prostate surgery has to take place at the same time.

Important Point:

The

laparascopic

procedure

is not different from the open surgery method in the

recurrency

rate. It has

less post-op complications

and a

sooner return to work.

Intestinal obstruction

and

ileus

is seen more often after a

laparascopic

procedure.Slide19

Treatment

Contraindications

of

laparascopy

:

1- A

previous surgery

in the area (a surgery that the surgeon entered the abdomen such as prostatectomy)

2-Primary

medical condition

Important Point

:

In

recurrent

cases,

dissection

in the scar tissue should not be made (due to inability in exactly differentiating the anatomic parts.

Important point

:

In the treatment of hernia

surgery

is necessary, since with a conservative method, the wall defect is not removed but has the tendency to enlarge and cause incarceration.Slide20

Treatment

Indications of

conservative surgery

:

1-Bad coexisting

medical condition

2-A

small asymptomatic

hernia

3-An

elderly

person who is

asymptomatic

Important Point:

Conservative treatment is not used in femoral hernia.Slide21

Anesthesia Method

Anterior surgery can be done with, local, regional, or general anesthesia.

Laparascopic

surgery

has to be done with

general anesthesia

.

Local anesthesia

:

Lidocaine

,

Marcaine

with or without epinephrine.

Important Point:

The use of

epinephrine

in people with

coronary problems

is contraindicated.

Important Point:

Before incision or prep

inguinal nerve

has to be blocked.

Epidural anesthesia

is also a proper method.Slide22

Emergency Surgery

Incarceration, Sliding, Strangulation Emergencies.

Incarcerated Hernia:

Hernia that cannot be reduced for a long time.

Three reasons for incarceration

1- Enlargement of the contents of the hernia

2- Adhesion of sac contents to the canal wall

3- Narrow neck of the sac

Important Point:

Indication for

urgent surgery

is when the intestines are under pressure and the patient has symptoms of

bowel obstruction

either in incarceration or in a sliding hernia.Slide23

Emergency Surgery

Treatment:

1-Simple Reduction

2-Taxis

3-Surgery

Sliding Hernia:

In this condition one side of the intestinal wall is trapped but the lumen is not closed. However with the progress of edema, the lumen closes and sometimes in this kind of hernia, the bladder is entrapped.Slide24

Emergency Surgery

Strangulated Hernia:

NO TAXIS

1-Fever

2-Leukocytosis

3- Hemodynamic instability

4- Tender and warm hernia contents

5-

Erythema

in

hernial

sac

Important Point:

Before surgery Serum and electrolytes, IV Antibiotics, and NG TubeSlide25

Recurrence

Depends on:

1-

Patient condition:

Nutrient deficiency, Immune deficiency, Diabetes, Steroid use, Smoking

2-

Surgical Technique:

Inexperienced surgeon, Not fixing the mesh, a Small mesh

3-

Tissue:

Infection, Tension, Ischemia

To reduce recurrence use a

mesh

Slide26

Diagnosis of Recurrence

Bulging

Important Point:

Can have no

bulging or mass

and still suspect recurrence

Sonography

, CT, or MRI

DDX

of hernia recurrence:

1-Cord

lipoma

2-Seroma

3-Weakness of external oblique muscle

4-CoughSlide27

Complications of Hernia Surgery

1-Pain

2-Spermatic Cord Damage and Ischemic

Orchitis

3-Vas

deferans

cut

4-Wound infection

5-Seroma

6-Urinary RetentionSlide28

Sportsman’s Hernia

Occult hernia, pubic pain in sportsmen, sportsmen’s hernia

Due to

repetitive movement

in lower extremity such as skiing, hockey, or American football, usually hernia is not found in physical exam other than the time of surgery.

Symptoms

:

Acute or chronic

pain

that gets worse with movement, coughing or sneezing and can reduce the sportsman’s function. In the

physical exam

no bulging or evidence of hernia is seen and pain and tenderness in the inguinal canal and the external ring is present.

Diagnosis:

Best choice is

MRI

.

Treatment:

Conservative

, if after 6-8 weeks fails

surgery

inguinal canal repair.Slide29

Pediatric Hernia

Prevalence in children

0.8-44 %

and in

10%

bilateral

.

Prevalence of hernia is higher in,

premature

and

LBW

and on the

right side.

Hernia is more likely

indirect

in children.

Diagnosis:

Made by observation and during crying.

DDx

:

UDT, Testicular Tumor,

Hydrocele

,

Varicocele

Treatment:

to some extent

emergency

even if with

no symptoms

.

In

premature neonates

inguinal hernia repair before hospital discharge.

Surgery

Herniotomy

(Cut in the inguinal area)

Important Point:

Method of exploring the opposite side is somewhat controversial. Now

laparascopy

is mostly used. But

sonography

has also been used.