hernia yuda

7/22/2019 Hernia Yuda

1/54

Hernia

RSST KlatenKoas stase bedah A13.1


2/54

IDENTITAS : Nama : Tn S

Usia : 53 th

Alamat : Gondangan, Klaten No CM : 82****

Tanggal masuk RS : 15 Juni 2014

melalui poli


3/54

Anamnesis Keluhan utama: benjolan lipat paha kiri

Pasien memiliki benjolan di lipat paha

kiri sudah satu tahun namun dibiarkan,bisa keluar masuk, BAB dan BAK tidak

terganggu


4/54

Pemeriksaan fisik TD 130/100

N 90

RR 22

S Afebris

Keadaan umum: CM, baik I: Tampak benjolan di lipat paha kiri dapat keluar-

masuk

P: NT (-)

P: Suara ketukan di abdomen timpani (+)

A: Peristaltik abdomen(+)


5/54

Pemeriksaan penunjang (12/6): Kimia darah

BUN= 18,6 (>)

AST = 32,6 (>)

Darah Lengkap

Hb = 9 g/dl


6/54

Diagnosis: Hernia inguinalis lateralis sinistra reponibilis

Anemia


7/54

Plan: perbaikan kondisi di bangsal,transfusi PRC 2 kolf, setelah Hb > 10 g/dl

pro herniorepair


8/54

Follow up: tanggal 23/6 dilakukan herniorepair 24/6

S: BAK (+), BAB (-), flatus (+)

O: KU: baik, CMstatus lokalis inginal

I : belas operasi tertutup perban, tidak ada rembesan

P : Nyeri tekan (-)

A: HIL dextra reponibilis post herniorepair hari ke 1

P: Inj Ceftriaxone 1 gr/12 jam

Inj Ketorolac 30 mg/8jam

Inj Ranitidine 1A/12 jam

Mobilisasi duduk Diit bebas

Laxadine syrup 3 X C2


9/54

Definition

A hernia is a protrusion of a viscus or part

of a viscus through an abnormal opening

in the walls of its containing cavity .


10/54

Anatomy The inguinal canal :-

The inguinal canal is approximately 4 cm long and is directed

obliquely

inferomedially through the inferior part of the anterolateral

abdominal wall. The canal lies parallel and 2-4 cm superior to

the medial half of the inguinal ligament.This ligament extendsfrom the anterior superior iliac spine to the pubic tubercle.

The inguinal canal has openings at either end :

The deep (internal) inguinal ring is the entrance to the inguinal

canal. It is thesite of an outpouching of the transversalis

fascia. This is approximately 1.25 cm superior to the middle of

the inguinal ligament

The superficial, or external inguinal ring is the exit from the

inguinal canal. It is a slitlke opening between the diagonal

fibres of the aponeurosis of the external oblique


11/54

Inguinal canal

walls of The inguinal canal :- The anterior wall is formed mainly by the aponeurosis of the

external Oblique

The posterior wall is formed mainly by transversalis fascia

The roof is formed by the arching fibres of the internal oblique

andtransverse abdominal muscles.

The floor is formed by the inguinal ligament, which forms ashallow trough. It is reinforced in its most medial part by the

lacunar ligament.


12/54


13/54

Content :-

1. Spermatic cord ( round ligament of the uterus in female )

The Cord Itself.The contents of the spermatic cord are

(a) the ductus (vas) deferens and its artery .

(b) the testicular artery and venous (pampiniform) plexus.

(c) the genital branch of the genitofemoral nerve.

(d) lymphatic vessels and sympathetic nerve fibers.

(e) fat and connective tissue surrounding the cord and its

coverings in various amounts2. Ilioinguinal nerve .

Ilioinguinal lymph node .


14/54

Femoral Canal

The major feature of the femoral canal is the femoral sheath.This sheath is a condensation of the deep fascia (fascia lata)

of the thigh and contains, from lateral to medial, the femoral

artery, femoral vein, and femoral canal. The femoral canal is a

space medial to the vein that allows for venous expansion

and contains a lymph node (node of Cloquet). Other featuresof the femoral triangle include the femoral nerve, which lies

lateral to the sheath,

Wall of The Femoral canal

anterior is the inguinal ligament

posterior is the iliopsoas, pectineal, and long adductor muscles

(floor).

Medial is lacunar ligament

Lateral is femoral vessle


15/54

Predisposing:

All hernias occur at the site of WEAKNESS OF THE

ABDOMINAL WALL which are acted on by repeated

INCREASE in abdominal pressure


16/54

repeated INCREASE in abdominal pressure is

usually due to

Chronic cough

Straining

Bladder neck or urethral obstruction

Pregnancy

Vomiting

Sever muscular effort Ascetic fluid


17/54

Types

Inguinal Femoral

Epigastric

Para umbilical

Umbilical Obturator

Superior lumbar

Inferioer lumbar

Gluteal Sciatic

Incisional


18/54

Indirect Inguinal HerniaHernia through the inguinal canal

Direct Inguinal HerniaThe sac passes through a weakness or defect of the

transversalis fascia in the posterior wall of the inguinalcanal

Femoral HerniaHernia medial to femoral vessels under inguinal ligament

Umbilical HerniaHernia through the umbilical ring


19/54

Paraumbilical Hernia

A protrusion through the linea alba just

above or sometimes just below theumbilicus

Epigastric Hernia

Protrusion of extraperitoneal fat through thelinea alba anywhere between the xiphoidprocess and the umbilicus

Incisional Hernia

Hernia through an incisional site Lumber Hernia

occur through the inferior lumber triangle ofPetit


20/54

Inguinal hernia

History:

1.Age ( young vs. old)

2.Occupation ( nature ?? )

3.Local symptoms: Swelling, discomfort

and pain

4.Systemic symptoms: if there is

obstruction or strangulation

5.Precipitating factors


21/54

Inguinal hernia

Examination:

1.Inspection for site, size, shape and

color.

2.Palpation for surface, temp,

tenderness, composition and

reducibility.

3.Expansible cough impulse.

4.General exam: for common causes of

increase intra abdominal pressure


22/54

Indirect Versus Direct inguinal hernias

Indirect is the most common form ofhernia and its usually congenital due

to patent processus viginalis

Direct usually acquired occur in old

men with weak abdominal muscles.


23/54

Indirect Versus Direct inguinal hernias

Indirect Inguinal Hernia Direct Inguinal HerniaPass through inguinal canal. Bulge from the posterior wall of the inguinal canal

Can descend into the scrotum. Cannot descent into the scrotum.

Lateral to inferior epigastric vessels. Medial to inferior epigastric vessels.

Reduced: upward, then laterally and backward. Reduced: upward, then straight backward.

Controlled: after reduction by pressure over the internal (deep)

inguinal ring.

Not controlled: after reduction by pressure over the internal (deep)

inguinal ring.

The defect is not palpable (it is behind the fibers of the external

oblique muscle).

The defect may be felt in the abdominal wall above the pubic

tubercle.

After reduction: the bulge appears in the middle of inguinal

region and then flows medially before turning down to the

scrotum.

After reduction: the bulge reappears exactly where it was before.

Common in children and young adults. Common in old age.


24/54

Note that examination using finger and thumb across the

neck of the scrotum will help to distinguish a swelling of

inguinal origin and one that is entirely intrascrotal


25/54

Femoral hernia

Small femoral hernia may be unnoticed

by the patient or disregarded for years

perhaps until the day it strangulates.Adherence of the greater omentum

sometimes causes a dragging pain.

Rarely a large sac is present .


26/54

Femoral hernia

History Age ; uncommon in children , most

common in old age female .

Sex; women > men (but still commonest

hernia in women the inguinal hernia ) The patient came with local symptoms

1- discomfort and pain

2- swelling in the groin General ; femoral hernia is more likely tobe strangulated than the inguinal hernia

Multiplicity ; often bilateral


27/54

Femoral hernia versus inguinal hernia

Inguinal hernia Femoral hernia1- more common in male 1- more common in females

2- pass through the inguinal canal 2- pass through the femoral canal

3- neck of the sac is above and medial the pubic tubercle 3- neck of the sac is below and lateral the pubic tubercle

4- less common to be strangulated 4- more common to be strangulated

5- can be treated without surgery 5- must be treated surgically

6- the two diagnostic signs of hernia + 6- the two diagnostic signs of hernia -

7- the sac mainly contain ; bowel 7- the sac mainly contains ; omentum


28/54


29/54

Umbilical hernia

Signs and symptoms

Age ; doesnt appear until the umbilical

cord has separated and healed .

No specific symptoms

Have wide neck and reduce easily ,

rarely give intestinal obstruction.

Nature history ; 90 % disappear

spontaneously during the first year.


30/54

Examination Inspection

Site ; in the center of the umbilicus

Size and shape ; size can vary from vary smallto very large . Shape is usually hemispherical.

Palpation

Composition ; contain bowel , which makes it

resonant to percussion . They reducespontaneously when the child lies down .

Reducibility ; easy

Cough impulse; invariably present .


31/54

Acquired umbilical hernia

Hernia through the umbilical scar , so it isa true umbilical hernia.

Not common and is usually secondary toincrease intra abdominal pressure.

The most common causes

1- pregnancy

2- ascitis

3- ovarian cyst

4- fibrodis

5- bowel distention


32/54

Incision hernia

Signs and symptoms Previous operation or accidental trauma

Age ; all ages , but more common in old age.

Symptom ; lump ,pain ,intestinal obstruction ( distention ,colic,vomiting ,constipation , sever pain in the lump )

Examination

1- reducible lump 2- expansile cough impulse

3- if the lump dose not reduse and dose not have coughimpulse , than it may be not a hernia

Ddx

Tumor Chronic abscess

Hematoma

Foreign body granuloma


33/54

Preoperative assessment

proper history and examination identify high risk patients

prepare the preoperative notes :

consent.. pre op Dx

procedure planned

surgeons Anasthesia anticipated (general , local,

spinal)


34/54


Investigation data ( pre operative tests ) :1. Lab :

* CBC : to check hemoglobin level anemia and WBCsinfections

* U&E : to check for any electrolyte imbalance

* LFTs : indicated in jaundiced patients and suspectedhepatitis or any clotting problems

* PT & PTT

* ABG

* grouping and cross matching

2. Imaging :* Chest X ray : for all patients

3. ECG : for any patient who is more than 40 years of age


35/54


current medications or allergies

any major (chronic) illness

pre op orders :

1. skin preparation

2. diet (NPO)3. GIT preparation

4. Sedation

5. Preanesthetic medications

6. Other medications

7. Antibiotics8. Blood transfusion ( if needed )

9. Bladder preparation


36/54

Management and repair

l


37/54

Inguinal Hernia Repair

Reduction

Surgical

TTT

Pre op

Evaluation

&

preparation

Surgical TTT

Choice of

AnestheticTTT of hernial sac

Inguinal floor

reconstruction


38/54

Pre op evaluation &preparation

Watchful Waiting Surgical TTT

May be appropriate for pt with asymptomatic hernia or elderlypt with minimal symptoms or easily reduced inguinal hernia.

Routine F/U with health care professionalA Randomized trial concluded that this is an acceptable option for men with minimally symptomatic inguinal hernia and that delaying repair until symptoms increase is safedue to low rate ofincarceration. 23 of pt initially treated with watchful waiting crossed over to surgical ttt due to increase in symptoms (most often hernia-related pain) ,

only 1 pt (0.3 ) experienced acute hernia incarceration without strangulation within 2years, a second had acute incarceration withBowel obstruction at 4 years, corresponding to frequency of acute intervention of 1.8/1000 pt-years (JAMA 2006,295:285)


39/54

Pre op preparation

Most pt are treated surgically Increase IAP abnormalities (Chronic cough,

Constipation, Bladder outlet obstruction)

should be evaluated and remedied to extent

possible before elective herniorrhaphy.

In case of intestinal obstruction and

possible strangulation, Broad spectrum

AB,NG suction may be indicated, correctionof volume status& elctroyles.


40/54

Reduction

Uncomplicated: ManualGentle pressure over hernia

Gentle traction over the mass sedation

and trendelenburg position.

Complicated (strangulated):

no attempt should be made to reduce the

hernia because of potential reduction of

gangrenous segment of bowel with the

hernial sac.


41/54

Surgical TTT

1.choice of anesthetic:

elective open repair : Local is

preferred

Laproscopic hernia repair: morecommonly under GA.


42/54

2.TTT OF HERNIAL SAC

INDIRECT: sac is dissected free from thecord structures and creamsteric fibers. Sacshould be open away from any herniatedcontents. Contents are then reduced, andthe sac is ligated deep to inguinal ring with

an absorbable suture

DIRECT:

Too broadly based for ligation and shouldnot be opened, simple freed fromtransversalis fibers and inverted.


43/54

3.Inguinal Floor

Reconstruction

Some method of

reconstruction of the

inguinal floor isnecessary in all adult

hernia repairs to

prevent recurrence.

3.Inguinal

Floor

Reconstruction

Primary tissue repair Open tension freerepair Laproscopic &preperitoneal repairs


44/54

1.Primary tissue repair

Bassini repair:inferior arch oftransversalis fascia (TF) or conjointtendon is approximated to shelvingportion of inguinal ligament.

McVay:TF is sutured to cooperligament.

Shouldice:TF is incised andreapproximated.


45/54

2.Open tension free

repair

Lichtenstein repair &Patch and Plugtechnique: Mesh is used to reconstruct

inguinal floor

Mesh plug technique : place mesh in

the hernial defect

Laproscopic &


46/54

Laproscopic &

preperitoneal repairs

TAPP (transabdominal prepeitoneal procedure):peritonealspace entered by conventional lap at umbilicus andperitoneum overlaying inguinal floor is dissected away as flap.

TEP (Total extraperitoneal repair):preperitoneal space isdeveloped with a balloon inserted between posterior rectus

sheath and peritoneum

balloon inflated to dissect theperitoneal flaps awau from posterior abdomianl wall and thedirect and indirect spaces, other ports inserted into thispreperitoneal space without entering peritoneal cavity.

After lap. Dissection and reduction of hernia sac , a largepiece of mesh is placed over inguinal floor


47/54

Femoral hernia repairFemoral hernias should be repaired very soon after thediagnosis has been made because of the high risk of

strangulation.

There is no place for a truss for a femoral hernia.Different approaches :

Open VS Laparoscopic


48/54

Open surgery

Three approaches have been described foropen surgery :

1.Infra-inguinal approach (Lookwood)

2.Supra-inguinal approach ( McEvedy)3.Trans-inguinal approach ( Lotheissen)


49/54

Each technique has the principle of

dissection of the sac with reduction of its

contents, followed by ligation of the sac

and closure between the inguinal andpectineal ligaments.

L k d i f i i l


50/54

Lockwoods infra-inguinal

approach

The sac is dissected out below theinguinal ligament via groin creaseincision.

Then the sac is opened and thecontents are inspected and reducedinto the abdomen.

Then the neck of the sac is pulled

down , ligated and allowed to retractthrough femoral canal.

Then close the femoral canal by mesh

plug or non absorbable sutures.


51/54

McEvedys high approach

Vertical incision is made over the femoralcanal and continued upwards above theinguinal ligament.

This incision provides good access to the

preperitoneal space and then to theperitoneum itself.

Use finger dissection to sweepperitoneum from anterior abdominal wall

, so the neck of the sac can beidentified.

Dissect the sac , reduce the contentsand repair the defect by mesh or sutures.

L th i t i i l


52/54

Lotheissens trans-inguinal

approach

The incision is made superior andparallel to inguinal ligament extending

from pubic tubercle to mid inguinal

point.


53/54

Thank

You


54/54

hernia yuda

Documents