prof c m k reddy. a tribute to a great teacher and social worker - prof rnr
TRANSCRIPT
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Prof C M K Reddy
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A TRIBUTE TO A GREAT TEACHERAND SOCIAL WORKER - Prof RNR
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Prof R Nanjunda RaoCME Program forUndergraduates
INGUINAL HERNIA
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ACKNOWLEDGEMENTS
Prof R Nanjunda Rao&
A S I – Chennai City Branch
Prof D Nagarajan, PresidentDr G Chandrasekar, Secretary
Dr Ravindran Kumeran, Treasurer
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BY
Prof C M K REDDYDSc (Hon) FRCS (Glas) FRCS (Ire)
Emeritus Professor, TN Dr MGR Med University
General & Vascular Surgeon
Apollo Hospitals & Halsted Surgical Clinic
C H E N N A I
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President
TN Medical Practitioners’ Association
(TAMPA)
Indian Chapter, Royal College of
Surgeons in
Ireland
Core Committee for Hosp. Waste Mgmt.
of
Chennai
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FormerlyMedical Director, Sri Jayendra
Saraswathi Inst of Med Sciences
Honorary Professor of Surgery Stanley Medical College
President, Tamil Nadu Medical Council
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Receiving Dr B C Roy National Award as EminentMedical Teacher from the President of India (2000)
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Honorary Doctorate (DSc) conferred by the TN Dr MGR Medical University (2007)
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INGUINAL HERNIA
HERNIA IS DEFINED AS AN ABNORMAL PROTRUSION OF A VISCUS THROUGH NORMAL OR ABNORMAL OPENING LINED BY A SAC
IF A VISCUS FORMS A PART OF THE SAC, IT IS CALLED A SLIDING HERNIA
IF THERE IS NO SAC, IT IS A PROLAPSE
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SLIDING HERNIA(Hernie-en-glissade)
PROPLASE RECTUM & UTERUS
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INGUINAL HERNIAPROLAPSE OF BOWEL (TRAUMA)
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INGUINAL HERNIA
GROIN
IS A COLLOQUIAL TERM TO INCLUDE THE FOLLOWING REGIONS :
INGUINAL
FEMORAL
ROOT OF SCROTUM or LABIA MAJORA
WHILE DESCRIBING A MASS, THE PARTICULAR AREA TO BE SPECIFIED
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INGUINAL HERNIA
ANATOMY OF INGUINAL CANAL
IT IS AN OBLIQUE CANAL, 6cm LONG, EXTENDS FROM DEEP TO SUPERFICIAL RING
PARALLEL TO THE MEDIAL HALF OF THE INGUINAL (POUPART) LIGAMENT
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INGUINAL ANATOMY
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INGUINAL HERNIA
EXTERNAL (SUPERFICIAL) RING
A TRIANGULAR OPENING IN THE EXTERNAL OBLIQUE APONEUROSIS
2cm ABOVE & MEDIAL TO PUBIC TUBERCLE
IT DOESN’T NORMALLY ADMIT TIP OF A FINGER. FORCIBLE ATTEMPT IS RESISTED DUE TO DISCOMFORT
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INGUINAL HERNIA
INTERNAL (DEEP) INGUINAL RING
IT IS A ‘U’ SHAPED DEFECT IN THE TRANSVERSALIS FASCIA, 2cm ABOVE THE MIDPOINT OF INGUINAL LIGT
(MIDWAY BETWEEN ANT SUP ILIAC SPINE & PUBIC TUBERCLE)
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INGUINAL HERNIA
BOUNDARIES OF ING CANAL
FLOOR : INGUINAL LIGT
POST WALL : TRANSVERSALIS FASCIA & MEDIALLY CONJOINT TENDON
ROOF : ARCHING FIBRES OF CONJOINT TENDON
ANT WALL : EXT OBLIQ APONEUROSIS &
INT OBLIQ MUSCLE LATERALLY
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INGUINAL HERNIAHESSELBACH’S TRIANGLE
WEAK AREA IN POSTERIOR WALL THROUGH WHICH DIR HERNIA PRESENTS
BOUNDARIES
LATERAL : INF EPIGASTRIC VESSELS
RAISING LATERAL UMBILICAL LIGT (FOLD)
MEDIAL : LATERAL BORDER OF RECTUS
INFERIOR : MEDIAL THIRD OF ING LIGT
FLOOR BISECTED BY MEDIAL UMB LIGT, FORMED BY OBLITERATED UMB ARTERY
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INGUINAL HERNIA
HESSELBACH’S TRIANGLE
Laparoscopic viewfrom inside
EXTERNAL DISSECTION
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INGUINAL HERNIA
• AS WE GO FROM OUTSIDE
• SKIN
• TWO LAYERS OF SUPERFICIAL FASCIA SUPERFICIAL (FATTY) : CAMPER’S FASCIA
DEEP (MEMBRANOUS) : SCARPA’S FASCIA
A THIN AREOLAR LAYER IMMEDIATELY OVER THE EXT OBLIQ APONEUROSIS :
FASCIA INNOMINATUM (OF GALLAUDET)
EXT OBLIQ APONEUROSIS & EXT RING
INGUINAL CANAL & SPERMATIC CORD
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INGUINAL HERNIALaparoscopic Anatomy
FEMORAL
DIRECT
INDIRECT INFERIOREPIGASTVESSELS
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INGUINAL HERNIAMyopectineal Orifice of Fruchaud
BoundariesMedial : Rectus muscleLateral : IliopsoasSuperior : Conjoint tendonInferior : Pectin pubis
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INGUINAL HERNIA
INGUINAL HERNIA MAY BE
DIRECT – THRO’ THE H’ TRIANGLE
INDIRECT – THRO’ THE INT RING
SADDLE or PANTALOON (ROMBERG)
WITH BOTH COMPONENTS SADDLED BY INF EPIGAST VESSELS
• ALL OF THEM ULTIMATELY COME OUT THRO’ THE EXTERNAL RING
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INGUINAL HERNIA
DIRECT TYPE
ACQUIRED
SAC LIES SEPARATE FROM AND POSTERIOMEDIAL TO THE CORD
STRANGULATION IS RARE SINCE THE NECK OF THE SAC IS WIDE
IT IS GLOBULAR AND DOESN’T READILY DESCEND INTO SCROTUM
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INGUINAL HERNIAINDIRECT TYPE
CONSIDERED TO BE CONGENITAL
DUE TO IMPERFECT OBLITERATION OF PROCESSUS VAGINALIS
COMES OUT THRO’ BOTH RINGS
RETORT SHAPED
DESCENDS READILY INTO SCROTUM
DUE TO THE ‘READY MADE’ SAC
SAC LIES WITH IN AND ANTEROSUPERIOR TO THE CORD STRUCTURES
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Diff between Ind. & Dir. Ing Hernia
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INGUINAL HERNIA
HOW DO WE SAY IF AN IRREDUCIBLE HERNIA IS DIRECT OR
INDIRECT ?
SHAPE
WHETHER DESCENDED INTO SCROTUM
THE FACT IT IS IRREDUCIBLE, IS IN FAVOR OF INDIRECT HERNIA
BUT IT IS ONLY OF ACADEMIC INTEREST, SINCE EARLY SURGERY IS NECESSARY & IT COULD BE DECIDED AT THAT TIME
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INGUINAL HERNIA
TOPOGRAPHIC TYPES
BUBONOCELE (Boubon : Groin)
FUNICULAR TYPE
(UPTO THE TOP OF TESTIS)
COMPLETE or CONGENITAL
ENTIRE PROCESSUS IS PATENT TESTIS BECOMES A CONTENT
OF THE HERNIAL SAC
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INGUINAL HERNIABubonocele Funicular Complete
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INGUINAL HERNIABILATERAL BUBONOCELES
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INGUINAL HERNIA
GIBBON’S HERNIA
LARGE INGUINAL HERNIA PRODUCING SECONDARY HYDROCELE, DUE TO COMPRESSION OF VENOUS AND
LYMPHATIC CHANNELS
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INGUINAL HERNIA
INTERPARIETAL or INTERSTITIAL TYPE
DOWN’S or PRUNE BELLY SYND
UNDESCENDED TESTIS
SAC DISSECTS INTO THE LAYERS OF ABDOMINAL WALL
PREPERITONEAL
INTERPARIETAL or INTERMUSCULAR
(COMMONEST)
EXTRAPARIETAL or
INGUINO-SUPERFICIAL
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LARGE RIGHTINGUINAL
INTERSTITIALHERNIA
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INGUINAL HERNIA
RIGHT INGUINAL
INTERSTITIALHERNIA
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INGUINAL HERNIA
CLASSIFICATION
REDUCIBLE (UNCOMPLICATED)
IRREDUCIBLE
OBSTRUCTED
STRANGULATED
INFLAMED
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INGUINAL HERNIA
COMPRESSIBLE Vs REDUCIBLE
COMPRESSIBLE SWELLING REFILLS IMMEDIATELY (SPONTANEOUSLY) AS SOON AS THE PRESSURE IS RELEASED
Eg : HEMANGIOMA, LYMPHANGIOMA,
ANEURYSM, MENINGOCELE ETC
REDUCIBLE SWELLING MAY REQUIRE SOME MANEUVERING TO BRING IT OUT AFTER REDUCTION
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INGUINAL HERNIA
PREDISPOSING / PRECIPITATING FACTORS
CHRONIC COUGH / COPD (SMOKING)
CHRONIC CONSTIPTION
OBSTRUCTIVE UROPATHYBPH or STRICTURE URETHRA
STRENUOUS PHYSICAL ACTIVITY
PREVIOUS SURGERY
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INGUINAL HERNIA
HISTORY OF PREVIOUS SURGERY
IN LINE WITH ILIOHYPOGASTRIC & ILIOINGUINAL (L-1) NERVES
APPENDECTOMY THRO’ McBURNEY’S
DRAINAGE OF PSOAS ABSCESS
LUMBAR SYMPATHECTOMY
URETERIC or RENAL SURGERY
EXTENDED PFANNENSTEIL INCN
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INGUINAL HERNIA
SYMPTOMS
ASYMPTOMATIC, MAY BE DISCOVERED DURING ROUTINE EXAM
A MASS APPEARING / DISAPPEARING
VAGUE LOCAL DISCOMFORT
IRREDUCIBLE or PAINFUL LUMP
FEATURES OF INTEST OBSTRUCTION
FEATURES OF SEPTICEMIA (LATE CASES OF STRANGULATION)
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INGUINAL HERNIA
SIGNS
SHOULD BE EXAMINED BOTH IN
STANDING & SUPINE POSITIONS
TWO CLASSICAL SIGNS OF UNCOMPLICATED HERNIA :
EXPANSILE COUGH IMPULSE
& REDUCIBILITY
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INGUINAL HERNIA
WHY SHOULD IT BE EXAMINED
IN ERECT POSITION ?
IN SUPINE POSITION, NORMAL PROTECTIVE MECHANISMS
COME TO PLAY BEFORE THE VISCERA ENTER THE DEEP RING
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INGUINAL HERNIA
SIGNS …..
POSITION
SCROTAL or INGUINOSCROTAL
COUGH IMPULSE (EXPANSILE)
CONSISTENCY (DOUGHY or ELASTIC)
REDUCIBILITY
OMENTOCELE : INITIALLY EASY
ENTEROCELE : INITIALLY DIFFICULT &
REDUCES WITH A GURGLE
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INGUINAL HERNIABUBONOCELE, LEFT
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INGUINAL HERNIALARGE LEFT INGUINAL HERNIA IN A CHILD
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INGUINAL HERNIA
SIGNS ….
INTERNAL RING OCCLUSION TEST
2cm ABOVE THE MIDPOINT OF ING LIGT
DON’T SAY POSITIVE or NEGATIVE
THIS TEST IS NOT POSSIBLE IF THE HERNIA IS IRREDUCIBLE
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INGUINAL HERNIA
SIGNS ….
EXTERNAL RING INVAGINATION TEST
NORMLLY PAINFUL
SIZE OF EXTERNAL RING (IMPORTANT)
STRENGTH OF POSTERIOR WALL
IMPULSE TOUCHING THE TIP or PULP OF THE FINGER (UNRELIABLE)
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INGUINAL HERNIAEXT RING INVAGINATION TEST
NOTE : PATIENT EXPERIENCS DISCOMFORT
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INGUINAL HERNIA
EXT RING INVAGINATION IS
NOT POSSIBLE IN
WOMEN
ASSOCIATED WITH LARGE HYDROCELE or FILARIAL SCROTUM
IRREDUCIBLE HERNIA
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INGUINAL HERNIA
SIGNS ….
THREE FINGER TEST (ZIEMAN’S)
DIFFICULT TO ELICIT
NEVER DONE BY SENIORS
BETTER TO EXAMINE INDIVIDUAL AREAS FOR COUGH IMPULSE
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INGUINAL HERNIA DIFF DIAGNOSIS (COMMON CONDITIONS)
HYDROCELE– VAGINAL– ENCYSTED– INFANTILE– BILOCULAR– OF CANAL OF NUCK (in females) RARE
FEMORAL HERNIA
VARICOCELE
CANALICULAR (UNDESCENDED) TESTIS
DIFFUSE LIPOMA OF THE CORD
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INGUINAL HERNIA DD : Types of Hydrocele
Vaginal Congenital Infantile Encysted (communicating) YOU MAY NOT GET ABOVE THE SWELLING IN B, C & D TYPES and BILOCULAR TYPE
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INGUINAL HERNIA
INGUINALVs
FEMORALHERNIA
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INGUINAL HERNIADD : Testicular descent
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INGUINAL HERNIADD : Varcocele, left
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INGUINAL HERNIA
DIFF DIAGNOSIS (RARE)FUNCULITIS
LYMPH VARIX
PSOAS ABSCESS
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INGUINAL HERNIA
HOW TO DIFFERENTIATE
A LARGE SCROTAL HERNIA FROM
A HYDROCELE
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INGUINAL HERNIA
VAGINALHYDROCELE
LEFT
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INGUINAL HERNIADiff between Hydrocele & Scrotal Hernia
NOTE : BOTH CONDITIONS MAY COEXIST
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INGUINAL HERNIA
IS IT CONGENITAL (COMMUNICATING)
HYDEROCELE OR
CONGENITAL HERNIA ?
DEPENDS UPON THE SIZE OF
THE NECK OF THE SAC
WHETHER IT ALLOWS ONLY FLUID
OR VISCERA
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INGUINAL HERNIA
HERNIA OF A HYDROCELE
LOCALIZED THINNING OF TUNICA LEADING TO PSEUDOPODIUM-LIKE PROJECTION, USUALLY SEEN WHEN THE SAC IS THICK AND FLUID IS UNDER TENSION
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INGUINAL HERNIA
HYDROCELE OF A HERNIA
FLUID SEQUESTRATION IN A LOCULUS OF THE HERNIAL SAC, RESEMBLING HYDROCELE. THIS IS SEEN IN LONG STANDING CASES WITH ADHESIONS WITHIN THE SAC
MORE COMMON IN VENTRAL HERNIA CONTAING OMENTUM
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INGUINAL HERNIA
MALGAIGNE BULGING
IT IS A PHANTOM HERNIA, LOCATED
JUST ABOVE THE INGUINAL LIGT, MEDIAL TO ANT SUP ILIAC SPINE
MAY BE SEEN IN NORMAL THIN ELDERLYINDIVIDUALS
DENOTES LOSS OF TONE OF CONJOINT TENDON (WHICH IS MORE MUSCULAR)
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INGUINAL HERNIA
MALGAIGNE BULGES ….
SEEN IN STANDING POSITION or
HEAD RISING (CARNETT’S) MANEUVER
VALSALVA MANEUVER
THEY ARE NOT DIAGNOSTIC OF HERNIA THEIR PRESENCE DOES NOT IMPLY A GOOD HERNIORRHAPHY CAN’T BE DONE
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INGUINAL HERNIALEG RAISING (CARNETT) TEST
TO LOOK FOR MALGAIGNE BULGES
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INGUINAL HERNIAMAYDL’S HERNIA (HERNIA-en-W)
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MAYDL’S HERNIAHERNIA-en-W
orRETROGRADE STRNGULATION
‘NORMAL’ LOOKINGLOOPS
NECROZED LOOP
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INGUINAL HERNIA
INVESTIGATIONS
NO SPECIFIC INVESTIGATIONS REQUIRED FOR THE DIAGNOSIS
ONLY TO ASSESS THE FITNESS FOR ANESTHESIA / SURGERY
SCREEN PRECIPITATING CONDITIONS
COPD, BPH, COLORECTAL LESIONS
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INGUINAL HERNIA
INVESTIGATIONS - BASIC
ROUTINE BLOOD, URINE, CXR, ECG
IN AN ELDERLY PATIENT
USG ABDOMEN IF BPH IS SUSPECTED
COLONOSCOPY IF COLORECTAL LESION IS SUSPECTED
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HERNIOGRAPHYCONTRAST STUDY
OF THE PERITONEAL SAC(RARELY DONE)
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SLIDING HERNIA WITH BLADDER(SCROTAL CYSTOCELE)
PELVIC PART
URINARYBLADDER
SCROTAL PART
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INGUINAL HERNIA
TREATMENT
NO MEDICAL TREATMENT
ONLY FOR PREOPERATIVE OPTIMIZATION
TRUSS SHOULD NOT BE PRESCRIBED
SURGERY IS THE ONLY TREATMENT
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INGUINAL HERNIATRUSS SHOULD NOT BE ADVISED
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INGUINAL HERNIA
TREATMENT
TREAT THE PREDISPOSING CONDITIONS BEFORE ELECTIVE SURGERY
STOP SMOKING (AT LEAST 10 DAYS)
TREATMENT OF CHRONIC COUGH
IF BPH WITH SIGNIFICANT OUTFLOW OBSTRUCTION PRESENT, IT SHOULD BE APPROPRIATELY TREATED
CONSTIPATION SHOULD BE CORRECTED
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INGUINAL HERNIANot only it can cause hernia, it may increase its postoperative morbidity
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INGUINAL HERNIA
SURGERY
HERNIOTOMY
HERNIORRHAPHY
HERNIOPLASTY
OPEN (CONVENTIONAL)
LAPAROSCOPIC
CARDINAL PRINCIPLES
NO TENSION
NONABSORBABLE SUTURES
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INGUINAL HERNIA
HERNIOTOMY
HIGH LIGATION IS IMPORTANT
IN CHILDREN AS THE ONLY PROCEDURE
DONE BEFORE OTHER PROCEDURES
DIRECT SAC MAY BE INVERTED BY
A PURSE-STRING SUTURE
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INGUINAL HERNIA
HERNIORRHAPHY
BASSINI REPAIR (& MODIFICATION)
HALSTED REPAIR
SHOULDICE REPAIR
WILLI MEYER REPAIR (& MODIFICATION)
LA ROQUE REPAIR (FOR SLIDING TYPE)
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INGUINAL HERNIA
ADJUVANT PROCEDURES
RELAXING INCISION (TANNER)
RESECTION OF SPER CORD (KOONTZ)
ORCHIDECTOMY
OMENTECTOMY
ARTIFICIAL TENSION
PNEUMOPERITONEUM
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INGUINAL HERNIAVery Large, reaching the Knees
NOTE THE SUPRAPUBICPOLYTHENE TUBE TOCREATE ARTIFICIAL
PNEUMOPERITONEUM
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INGUINAL HERNIA
HERNIOPLASTY
AUTOLOGOUS TISSUE
SYNTHETIC MESH (MORE COMMON)
POLYPROPYLENE (PROLENE)
(MOST COMMON)
PTFE (GORE-TEX)
MARLEX
DACRON
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INGUINAL HERNIA
HERNIOPLASTY ……
OPEN :
LICHTENSTEIN REPAIR (TENSION-FREE)
LAPAROSCOPIC : (ALWAYS MESH USED)
TRANS ABDOMINAL PRE PERITONEAL
(TAPP)
TOTALLY EXTRA PERITONEAL (TEP)
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INGUINAL HERNIALICHTENSTEIN’S MESH REPAIR
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INGUINAL HERNIATRILAMINAR HERNIA SYSTEM (PROLENE)
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INGUINAL HERNIA
LAPAROSCOPICSURGERY
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INGUINAL HERNIA
STRANGULATION
IS IT OBSTRUCTED or STRANGULATED SYMPTOMS
IRREDUCIBILITY
LOCAL PAIN
FEATURES OF INT OBSTRUCTION
VOMITING (EVEN IN OMENTOCELE)
ABDOMINAL DISTENTION
COLICKY ABD PAIN
ABSOLUTE CONSTIPATION
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INGUINAL HERNIA
SIGNS OF STRANGLATION
INGUINO-SCROTAL SWELLING
TENSELY CYSTIC IN CONSISTENCY
IRREDUCIBLE
NO COUGH IMPULSE
MAY BE SIGNS OF INT OBSTRUCTION
IN LATE CASES
SIGNS OF PERITONITIS
FEATURES OF SEPTICEMIA
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INGUINAL HERNIA
STRANGULATION ……
URGENT SURGERY
ONLY ESSENTIAL INVESTIGATIONS
IF FEATURES OF INT OBSTRUCTION
IV FLUIDS
ANTIBIOTICS
NASOGASTRIC ASPIRATIONS
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INGUINAL HERNIASURGERY FOR STRANGULATION
INGUINO-SCROTAL INCISION
OPEN THE SAC FIRST (BEFORE CUTTING THE EXT RING)
SUCK OUT THE TOXIC FLUID
HAVE A HOLD ON THE BOWEL LOOP
THEN DIVIDE THE CONSTRICTING BAND DRAW MORE BOWEL LOOPS INTO THE FIELD
ASCERTAIN THE VIABILITY OF THE LOOP BEFORE REDUCTION
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INGUINAL HERNIA
SURGERY FOR STRANGULATION ……
IF THE BOWEL IS VIABLE :
REST OF THE PROCEDURE IS SIMILAR TO AN ELECTIVE CASE
IF THE BOWEL IS NONVIABLE :
BOWEL RESECTION & ANASTOMOSIS
CONTINUE IV FLUIDS, ANTIBIOTICS &
NG ASPIRATIONS, TILL THE RETURN OF BOWEL ACTIVITY (48-72 HRS)
AVOID MESH PLASTY- FEAR OF INFECTION
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INGUINAL HERNIAGangrenous loops of bowel due to
Strangulation (delayed)
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INGUINAL HERNA
CAUSES OF RECURRENCE
PREOPERATIVE
OPERATIVEPOSTOPERATIVE
COMMON CAUSES
INFECTION
TECHNICAL REASONS
UNRESOLVED PREDISPOSING FACTORS
EARLY RETURN TO ACTIVITY
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INGUINAL HERNIA
WHAT TO DO IF
AFTER GOOD COUNSELING
THE PATIENT REFUSES SURGERY ?
LET HIM GO TO
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130 CHAPTERS800 PAGES
1000 PICTURES
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CHARLES DARWIN1809 - 82
“It is not the strongest nor the most intelligent species that survives, but only the one
capable of adopting to the changed environment”
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ACKNOWLEDGEMENTS
Prof R Nanjunda Rao&
A S I – Chennai City Branch
Prof D Nagarajan, PresidentDr G Chandrasekar, Secretary
Dr Ravindran Kumeran, Treasurer
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IF I COVERTOO MUCH YOU MAY
LOSE INTEREST
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C M K Reddy