hernias pres 1custom

7/27/2019 Hernias Pres 1custom

1/32

Presented by:

Al-Fadel M. Alshebani

&

AbdulMohsin A.Babsail

Supervised by:

PROF. ABDULLAH ALDHOHAYAN


2/32

Introduction

Anatomy


3/32


4/32


5/32

Embryological development of the testicles

Processus vaginalis

Testis descend


6/32

Internal spermatic fascia transversalis fascia

Cremastic muscle internal oblique muscle

Externa spermatic fascia external oblique muscle


7/32

What is a Hernia composed of?1. Sac:a folding of

peritoneum consisting of amouth, neck, body andfundus.

2. Body: which varies in sizeand is not necessarilyoccupied.

3. Coverings:derived fromlayers of the abdominalwall.

4. Contents:which could beanything from theomentum, intestines, ovary


8/32

Indirect Inguinal hernia Pathophysiology

Processus vaginallis


9/32

Scenario


10/32

Reducible form.

Irreducible form:

- Incarceration

- Obstruction

- strangulation


11/32

Direct Hernia


12/32

Pathophysiology

Acquired or congenital

The presentation


13/32

Direct inguinal

herniaIndirect inguinal

hernia

medialataralelation to ep igastricvessels

Absentresentrocessus vaginalis

Acqiuredongenitalauses


14/32


15/32

Individual hernias1. Direct & indirect Inguinal

hernia.

2. Femoral hernia.

3. Umbilical hernia &

paraumbilical hernia.

4. Incisional hernia.

5. Epigastric hernia.

6. Rare external Hernias.


16/32

Femoral Hernia Femoral Hernias occur just below the

inguinal ligament, when abdominalcontents pass through a naturallyoccurring weakness called the femoralcanal.

The Femoral canal :

The most medial structure in thefemoral sheath,.

extending from the femoral ringto the saphenous opening.

1.25cm x 1.25cm.

Contains fat, lymph vessels andthe lymph node of cloquet.


17/32

Femoral Hernia (cont..) Symptoms:Femoral hernias are more common in women, They

typically present as a groin lump. They may or may not beassociated with pain, a femoral hernia has often been found to be

the cause of unexplained small bowel obstruction.

Signs:an absent Cough impulse, with a more globular lump thanthe pear shaped lump of the inguinal hernia.

Differential Diagnoses: Inguinal Hernia.

Femoral Artery Aneurism.

Femoral Lymphadenopathy.

Psoas Abscess.


18/32

Umbilical & paraumbilical HerniaA. Umbilical Hernia:

Seen in infants & children.

Effecting boys more than girls.

tend to resolve without any

treatment by around the age of5 years.

Obstruction and strangulationof the hernia is rare.

Babies are prone to thismalformation because of the

process during fetaldevelopment by which theabdominal organs form outsidethe abdominal cavity, laterreturning into it through anopening which will become theumbilicus.


19/32

B. Paraumbilical Hernia:

Affects adults.

The defect is either supra orinfraumbilical through the lineaalba.

The female to male ratio is

20:1. May contain omentum, small

intestine or transverse colon.

Etiology:

1. Obesity.

2. Flabbiness of the abdominalmuscles.

3. Multiparity.

Clinical Features:

Clolicky pain and/or irreducibilty

due to omental adhesions.


20/32

Incisional HerniaDefinition:Anincisional herniaoccurs when the area of weakness is the

result of an incompletely healed surgical wound. These can be among themost frustrating and difficult hernias to treat. It can occur at any incision,but tend to occur more commonly along a straight line from the sternum

breastbone straight down to the pubis, and are more complex in theseregions. Hernias in this area have a high rate of recurrence.

Causes:

Any reasons leading to an icrease in intraabdominal pressure

postoperatively such as: chronic cough, vomitting, infection,malnutrition diabetes, steroid treatment or a tension closure doneduring the previous operation.

Clinical Features:

Swelling at the incisional site +/- pain.


21/32


22/32

Epigastric Hernia Due to a defectin the linea alba between the

xiphoid process and the umbilicus

Starts as a protrusion of the extraperitoneal fatat the site where a small vessel pierces the linaalba and as it enlarges it drags a pouch of

peritoneum after it.

Clinical Features:

Swelling +/- pain similar to a peptic ulcer pain.


23/32

Rare external HerniasSince many organs or parts of organs can herniate through many orifices,it is very difficult to give an exhaustive list of hernias, with all synonymsand eponyms. But her are Other hernial types and unusual types ofvisceral hernias:

1. Spiglian Hernia: Occurs at the spaces of the semilunar line and the lateral edge of

the rectus muscle (inferior to the arcuate line).

The posterior rectus sheath jis weak thus leading to theprotrusion.

Preoperative diagnosis is diffucult & only correct in 50% of thepatients.

u/s & c.t are helpful tools in the diagnosis

Depending on the size of the defect, treatment varies from sutureapproximation to using a mesh.


24/32


25/32

Rare hernias (cont..)2. Lumbar Hernias:

In the lumbar region, in the form of a broad bulging hernia, that arenot vulnerable to incarceration.

Devided into:A. Petits hernia:which occurs in the inferior lumbar triangle.

B. Grynfeltts Hernia:which occurs in the superior lumbartriangle and is less common that Petits.


26/32

Rare hernias (cont..)3. Obturator Hernia:

The obturator canal is covered by amembrane pierced by the obturatornerve and vessels. Any enlargementin the canal or weakness in themembrane may lead to herniation ofthe intetines.

Because of differences in anatomy, itis much more common in womenthan in men.

It often presents with bowelobstruction.

The Howship-Romberg sign is

suggestive of an obturator hernia,exacerbated by thigh extension,medial rotation and adduction. It ischaracterized by lancilating pain inthe medial thigh/obturatordistribution, extending to the knee;

caused by hernia compression of theobturator nerve.


27/32


28/32

EXAMINATION:Hernias must be examined with the patient standing and insupineAlways examine both groins.

INSPECTION:

Visible swelling. (site, size and shape)Visible cough impulse.Easily reducibleReappear on straining, standing or coughingElucidate Fothergill and Carnet signs.

PALPATION:Examine as a mass and thenPalpable cough impulseReduceOcclusion testThree Finger test ( Zimmans test)


29/32

Examinationalso asses the following:PositionTemperatureTenderness

ShapeSizeTensionCompositionExpansile cough impulseReducible.

PERCUSSION AND AUSCULTATION:

Bowel sound.


30/32

TreatmentMost abdominal hernias can be surgicallyrepaired.

Uncomplicated hernias are principally repairedby herniorrhaphy.

aHerniorrhaphy (Hernioplasty) is a surgicalprocedure for correcting hernia, which can bedevided into four techniques:

Groups 1 and 2: open "tension" repair:

in which the edges of the defect are sewn backtogether without any reinforcement orprosthesis. In the Bassini technique, theconjoint tendon (formed by the distal ends ofthe transversus abdominis muscle and theinternal oblique muscle) is approximated to theinguinal canal and closed. [4]

Although tension repairs are no longer thestandard of care due to the high rate of

recurrence of the hernia, long recovery period,and post-operative pain, a few tension repairs


31/32

Treatment (cont..)Group 3: open "tension-free" repair:

Almost all repairs done today are open"tension-free" repairs that involve theplacement of a synthetic mesh to strengthenthe inguinal region.

This operation is called a 'hernioplasty'. Themeshes used are typically made frompolypropylene or polyester. The operation istypically performed under local anesthesia, andpatients go home within a few hours ofsurgery, often requiring no medication beyondaspirin or acetaminophen.

Recurrence rates are very low - one percent orless, compared with over 10% for a tension

repair


32/32

Treatment (cont..)Group 4: laparoscopicrepair "Lap" repairs are also tension-free, although

the mesh is placed within the preperitonealspace behind the defect as opposed to in orover it.

It is further sub-devided into: T.A.P.P repair (transabdominal

preperitoneal)

T.E.P repair (totally extraperitoneal)

It has no proven superiority to the openmethod other than a faster recovery timeand a slightly lower post-operative painscore.

laparoscopic surgery, though, requiresgeneral anesthesia, more expensive and

consumes more O R time than open repair

hernias pres 1custom

Documents