SURGERY
Abdominal hernia
Feb 11, 2008
INGUINAL HERNIAS o Starts in the internal inguinal ring
• Differentials: inguinal canal scrotum (complete
a) Hydrocoele = differentiate thru indirect IH)
TRANSILLUMINATION o Usually associated w/ patent PROCESSUS
b) Hernia = no enlargement; w/ bulging VAGINALIS
**condition w/ hernia & hydrocoele is o Increase intra-abdominal pressure
common in children weaken the internal ring causing
• Protrusion of visceral contents through the herniation
abdominal wall a) Complete – end up in scrotum
• Important Components: b) Incomplete – only in the area of
a) Defect in the aponeurosis (size/neck, inguinal canal
location & fascial opening) c) Completely open processus vaginalis
b) Hernia Sac – peritoneal outpouching that & testis with the sac-communicating
contains the abdominal viscera hydrocoele
• Examples: (patient lies down, hernia disappears,
a) SLIDING HERNIA stands up reappears)
= retroperitoneal organs as the sigmoid, o Lateral to the inferior epigastric vessels
bladder/ ureter forms part of the wall
B. DIRECT INGUINAL HERNIA
b) RICHTERS HERNIA o Sac protrudes directly outwards through
= anti-mesenteric portion of bowel protrudes the floor of the inguinal canal & passes
into the sac the Hesselbach triangle
o Rarely will it descend into the scrotum
c) LITTRES HERNIA o MEDIAL to the inferior epigastric
= sac contains Meckel’s Diverticulum vessels
o REPAIR: strengthening the floor of
SITES OF HERNIATION: Inguinal Canal specially in elderly
• occurs where the aponeurosis fascia are devoid o MANUEVER: to differentiate 3 inguinal
of the protective support of striated muscles hernia to determine what type of surgical
• sites include: intervention
a) groin inguinal hernia ↓
b) umbilicus umbilical hernia Px is standing & Dr. is behind
↓
c) linea alba epigastric hernia
3 Finger-test
d) semilunar line of Espreghel spigelian RT hand: middle(ext oblique)
hernia Index ( femoral)
e) diaphragm hernia of Morgagni, hernia of Thumb ( Hasselbach)
Bochdalek Px: strain / cough
f) surgical incisions incisional hernia a. Herniotomy – if there is no weakening of
the inguinal floor
**Recommended to observe: until 2y/o specially if b. Buttress repair – if there is recurrent
the defect is quite & small (circumference>5) hernia and weakness at the floor
c. Mesh repair
GROIN HERNIAS C. FEMORAL HERNIAS
• Hernias located above the abdomino-crural o Mass located at the medial base of
areas scarpas’s femoral triangle or medial side
• Protrusion of peritoneal sac through the of the femoral sheath
transversalis fascia spanning the myopectineal o Iliopubic tract shifted medially widening
orifice of Fruchaud the ring
A. INDIRECT INGUINAL HERNIA ETOLOGY & PATHOPHYSIOLOGY
o Sac passes obliquely or indirectly toward EVOLUTION:
& ultimately into the scrotum
Marco, Fars, jassie, April, viki 1 of 5
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- Absence of the posterior rectus sheath below FRUCHARD CONCEPT (1956)
the arcuate line • Cause of all groin hernias is the failure of the
- Insubstantial transversalis fascia (strongest transversalis fascia to retain the peritoneum
layer of the abdominal wall)
• He further emphasized that the common origin
- Unsupported by muscles and aponeurosis
of all groin hernias begin with a single weak area
known as the MYOPECTINEAL ORIFICE
PATENT PROCESSUS VAGINALIS
Primary cause of indirect inguinal hernia RUTLEDGE LICHUTENSTEIN UERM
Common in pediatric TYPES
(n-1437) (n-4000) (n-49)
Additional factors in adults Indirect ring
60% 44.4% 97%
hernia
SHUTTER MECHANISM Direct Ring
36% 43.4%
Maintains the integrity of sites with natural hernia
Femoral
weakness by: 4%
hernia
a) Strengthens the arch & lie close to the Pantalon 11.4%
Inguinal ligament
b) Pulls up & tenses the crura causing Sliding hernia 2%
Recurrent 4%
closure of the internal ring
c) Counter-pressure exerted by the external
**PANTALON = combination of direct and indirect
oblique muscle
hernia
d) Inguinal ligament pulled upwards
**INDIRECT INGUINAL HERNIA = most common
• Decrease pressure of
myopectineal orifice
**HERNIA is more common in the RIGHT than the
left because:
**defined in the lower portion of internal
a) Delayed descent of the right testis &
oblique muscle, the shutter mechanism of
obliteration of processus vaginalis
the deep ring and expose the floor of
b) Tamponade effect of the sigmoid over the
inguinal canal
left side
RAISED INTRA-ABDOMINAL PRESSURE
e.g. patients wit prostatic hyperplasia excessive SIGNS & SYMPTOMS
straining 1) Non-specific discomfort – exquisite pain in
a) Patent processus vaginalis causes hernia the scrotal area
b) Attenuated muscle (as patient gets older) 2) Slow enlargement of the patient of
c) Umbilical defect irreducibility & disfigurement
3) Palpable impulse generated by the sac with
INTEGRITY OF TRANSVERSALIS FASCIA its contents
a) Ability to stand increase intra-abdominal 4) Failure to transilluminate
pressure 5) Mass below the inguinal ligament
b) Strength rely on COLLAGEN FIBER Immediate Tx: cold compress to reduce swelling
o Ehlers Danlos Syndrome taxis (return to original position surgery
o Marfan’s syndrome
o Hereditary & connective tissue IMAGING
disease 1) Herniography
- Inject soluble dye in peritoneal cavity, if
CIGARETTE SMOKING the dye descends into scrotal cavity
• Investigation revealed abnormal metabolism of 2) UTZ, Ct scan & MRI
collagen - Exclude other masses
• Presence of elastase and anti-protease 3) IVP (intravenous pilography
• Impaired leukocyte response to oxidants
CLASSIFFICATION OF GROIN HERNIA
GENETIC FACTORS Acceptable class should be:
a) Age a) Blueprint for understanding the inguinal &
b) Lack of exercise femoral canal
c) Multiparity b) Aid in scientific appraisal of various surgical
d) Surgical procedures repairs
c) Evaluation of special outcome
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d) Differentiate anatomic problems a) Anterior – dividing structure in & around the
inguinal canal
I. GILBERT CLASSIFICATION, 1988 1. Open & prosthesis
a) Hernial Sac 2. Open anterior non prosthesis
b) Size & competency of the internal ring
c) Integrity of the posterior wall within the b) Posterior/ Preperitoneal Herniography
Hesselbach triangle - Exposure of the orifice by entering the
peritoneal space
Type 1(N) ,2(<4cm),3 (>4cm) = Indirect
inguinal Hernia TREATMENT BASE ON GILBERT’S CLASSIFICATION
Type 4,5 = Direct TYPES
Inguinal Hernia 1,2 Sutures less hand-rolled mesh plug
Rutkow & Robbins 6 = Pantalon 3 Same plug, single suture lateral to the cord for the
Hernia incompetent sling shutter mechanism
7 = Femoral Hernia 4,5 Circumscribed fusiform sac, invaginated with plug inserted
Tx: 1-3 minimize by sutures through the defect & interrupted suture placed
6 Multiple plugs. All direct & indirect are reinforced with only
4-5 suture and buttress the
patch
inguinal hernia 7 Plug through the growing of the femoral canal
II. NYHUS CLASSIFICATION, 1991
TREATMENT BASED ON NYHUS CLASSIFICATION
- State of the internal Ring posterior wall
• Based on strict functional state of the inguinal
of the Internal Canal
ring & posterior wall of the canal
I Indirect Inguinal Hernia, high ligation & no facial repair
TYPE HERNIAS
II High ligation of sac, ring is closed or strengthened with few
1 Indirect Hernia without dilation of Internal
sutures
ring
III Shouldice, McVay & Stoppa’s GPRVS for femoral hernia –
2 Indirect Hernia with dilation of Internal Ring
posterior iliopubic repair without mesh plug/ simply mesh
3a Direct with backwall defect
plug
3b Indirect Hernia with backwall defect
IV Posterior iliopubic tract repair with on lay buttress of mesh
(combined)
3c Femoral Hernia
4 Recurrent GILBERTS MARCY, 1871
- High ligation of the sac
- Closure of the ring by suturing the
Transversalis Fascia to the inguinal ligament
TREATMENT
- Indicated in: pediatrics, female & puberty
• Pressing cold compress= decreases swelling;
reduce spontaneously MARCUS SIMPLE RING CLOSURE
• Anesthesia for Repair - Few interrupted stitches approximating the
= SPINAL anesthesia – relaxation of abdominal transverse aponeurotic tract which will
wall return the _____ to its normal size
→ decreases mass -
• Check if there is: EDOARDO BASSINI, 1887
a) Reducibility? - Reconstruction of the floor by suturing:
b) Recurrence? a) Internal oblique muscle
c) Strangulation? b) Transverses abdominal muscle
d) Bowel involvement? c) Transversalis fascia with iliopubic tract & the
e) Gangrene? Small or serous sanguineous shelving edge of the inguinal ligament
fluid?
McVAY/ COOPER’S LIGAMENT REPAIR
• HERNIA DEVICES - Approximate of the transverses abdominal
- Temporary muscle(TAM) & transversalis fascia to
Femoral = not used →compression→gangrene Cooper’s ligament
- McVay repair approximate the transverses
OBJECTIVE IN THE REPAIR aponeurotic arch to Cooper’s ligament and to
= prevent peritoneal protrusion the femoral sheath. The suture in the medial
= restoration & closure of the myopectineal orifice side of the femoral sheath is called the
transition stitch. Excess tension is always
TYPES OF REPAIR present & relaxing is mandatory.
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- TAPP ( Transabdominal Preperitoneal)
EARLE SHOULDICE, 1953 - I POM ( intraperitoneal On-Lay Mesh)
- Similar to Bassini but using running sutures - TEP ( Totally Extraperitoneal)
to imbricate the several layers (not
interlocking) COMPLICATIONS
- Repairs the innermost aponeurotic fascial
Recurrence
layers by imbrication
10% reported for groin hernia repair
o Indirect 1-7%
COMPARISON OF RESULTS
- Multicenter prospective Randomized o Direct 4-10%
controlled Trial, Recurrence after 5year o Femoral 1-7%
Bassini 8.6% o Recurrent 5-3%
McVay 11.2% 50% of recurrence occur within 5years
Shouldice 6.5% 75% becomes evident within 10years
ANTERIOR REPAIR WITH PROSTHESIS CAUSES OF RECURRENCE:
- Conceived in the 9th century 1) Failure to diagnose multiple hernia
A. Pierre Nicholas Gerdy 2) Failure to close large internal ring
o Conceptualized plugging the internal 3) Breakdown of repair under tension
canal with folded skin using the scrotum 4) Missed bilateral hernia
skin 5) Infection 50% of recurrence
6) Suture material
B. C.W. Wutzer 1789-1869 7) Suturing technique
o Wood plug pushing the scrotal skin 8) Genetic Factor
C. Theodore Billroth, 1829-1894 NERVE ENTRAPMENT (2%)
o Prophesized effective resolution with - High in McVay & Shouldice repair
- Numbness, pain
artificial replacement of attenuated
- Paresthesia
tissue
- Felt in 2weeks after surgery
D. IRVING LICHTENSTEIN, 1986
- Treatment:
o Criticized suturing tendinous structure
a) rest for 8weeks
not normally in apposition
b) corticosteroid/ nerve block
o Creating tension, a violation of surgical
c) exploration & neurorectomy
principle
o Attenuated structures TESTICULAR COMPLICATION
o Impaired collagen metabolism (Ehler, - orchitis, atrophy and vas deferens injury
Marfans) - secondary to venous thrombosis
- swelling, hard cord & epididymis
MESH PLUG - fever & leucocytosis
- Gilbert 1980 - precautions:
- Cone shaped plug readily made from 6-8 cm a) avoid distal dissection beyond pubis
square of polypropylene mesh that has been b) avoid distal dissection in the sac
partially slit and then rolled around the apex c) delay control repair for 1year
if the slit
VASCULAR INJURY (1-8%)
Comparison of Results - inferior epigastric, femoral and testicular
(Folis & Lindahl prospective studies, recurrence vessels
after 2 year foolow-up, 2000+) - bowel of bladder in sliding hernia
Lichtenstein Moray McVay BOWEL OBSTRUCTION
102(10%) 53(3.8%) 53(26%) - in adhesive complications with the used of
mesh
OTHER TYPES
- Open preperitoneal, Lloyd Nyhus 1960 WOUND INFECTION - case considered a clean
- Giant prosthetic reinforcement of visceral wound
sac (GPRVS) - increase due to use of mesh
- increase with length of operating time
LAPAROSPCOPIC REPAIR (1990) - prophylactic antibiotics
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SEROMA – collection of serous fluid
- tissue reaction to foreign body
- increase incidence with mesh
HEMATOMA – collection of blood
- evacuation
- closed by 2ndary intention
VISCERAL INJURIES
OSTEITIS PUBIS – accidential suture of Coopers
ligament
Conclusion: haaay huwag na 2!
“ Considering all that is written about the medical tx
of inguinal hernias up until now, it has been
somewhat pushy to try to publish more about –
Eduardo Bossini
GUYZ,compl2 na toh…sbrang effort kami mgcopy nila fars at
jassie ng powerpoint n khit n22log n lahat ng mga kaklase nmn,
todo kopya kmeng apat……at thanx sa notes ni April!!!
Sana mak2long tong trans!!!
Thanx din kay Paul kc pinhiram niya ung laptop nya skin….kaya
natpos ko n 2ng trans at di ko n kailngan mgrent. Pasaway kc
ang mga virus nasira ko 2loy computer nmn s bahay. Hehehe.
Lagot tlga ako sa kuya ko!!!
Anyways ang bagong MOTTO ngun sa buhay ay di bale nang
BUMAGSAK pero MASAYA k nmn at my BUHAY!!!!hehehe
Guys gud luck sa exams…kaya natin toh.
Waaaahahaha. Nag adik din kami sa pagsususlat. Hahahahahaha
- MR and brim
