PRESENTATION CASES HERNIA INGUINALIS LATERAL REPONIBLE

MENTOR: DR. W SETIAWAN SP B By: Adil Sultani (030.08.005)

SURGICAL DEPARTMENT DR. MINTOHARDJO HOSPITAL JAKARTA MEDICAL FACULTY OF TRISAKTI UNIVERSITY JAKARTA

VALIDATION SHEET
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Name Student ID Number Departemen

: Adil Sultani : 030.08.005 : Surgical departement Medical Faculty of Trisakti University

Case Mentor

: Hernia inguinalis lateral reponible : Dr W Setiawan Sp B

Jakarta,25 July 2013 Mentor

Dr W Setiawan Sp B

CHAPTER I PRESENTATION CASES

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I. II.

PATIENT IDENTITY Name Age Sex Address Status Religion Race ANAMNESIS : Mr. S : 49 YO : Male : Jl. Kebayoran RT 1 / RW 02, Cilincing : Married : Muslim : Javanese

Autoanamnesis on Sunday, July 8th, 2013 at 20:00 pm a. Main complaints: Lump in the groin since 1 year Before enter the hospital b. Additional complaints: - Pain in the bump (+) - Bowel disorders (-) c. Disease History: Patients come to the surgical departement Dr Mintohardjo Hospital with complaints of a lump in the left groin and out with an emphasis since 1 year before admission. Patients admitted growing lump is felt when the patient is standing or doing activities that suppress stomach, the patient also complained of pain in the lump, especially when the bump out. Patients daily using

special pants that makes lump did not come out. The patient denied any interference flatulence or bowel disorders. d. Past history of disease: The patient has not experienced the same thing before the first complaint at 1 year before admission felt. History of hypertension, diabetes mellitus, asthma, trauma, and malignancy patients denied. e. Family history of disease: No relatives of patients who experienced the same thing. There are patients who have a family history of hypertension and diabetes mellitus. History of asthma, tumors, and malignancies have never experienced the patient's family. f. Medication History Patients not taking any medication. g. History of Allergy The patient denied any history of allergy to food, drug, or other substance. h. History Habits Patients admitted often straining and lifting heavy objects.

III.

PHYSICAL EXAMINATION
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General Awareness Nutrients Weight Height BMI : Compos mentis : Good : 70 kg : 165 cm : 25,7 kg/m2

Vital Sign Blood Preassure Pulse Temperature Respiration Rate : 120/80 mmHg : 95 x/m : 36,8oc : 20 x/m

Generalis Status 1. Skin Colour Lesion : Light brown, no pale, no icteric, no syanosis, and no rash : There are no primer lesion like makula, papul, vesikel,

pustul or sekunder lesion like scar. Hair : dense, black, apportionment.

Turgor : good : normocephali.

2. Head Eyes

Forms Palpebra Motion

: normal, symmetrical position eyeballs : normal, there was no ptosis, lagoftalmus, edema, hemorrhage : normal, there is no strabismus, nystagmus

Conjunctiva: not anemis Sclera Pupil : not icteric : round, isokor.

Ears Form Ear canal Wax : normotia : field : wax is not found on the right or left ear

Pull auricular pain: no pain pull on the right and the left auricular Tragus tenderness: no tenderness in the right and left tragus Nose Exterior :normal, there is no deformity, no hyperemia, no discharge, no tenderness Septum Nasal mucosa : symmetrical, there is no deviation : no hyperemia

Mouth and throat Lips : normal, no pallor, no cyanosis

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Teeth Oral mucosa Tongue Tonsils Pharynx 3. Neck :

: good hygiene, no missing teeth : normal, no hyperemia, not halitosis : normoglosia, no tremors, no dirty : T1/T1 size, no hyperemia : no hyperemia, symmetrical pharyngeal arch, uvula in the middle

Thyroid gland Trachea 4. Lymph nodes Neck Aksila Inguinal

: not enlarged, following the movement of swallowing : in the middle

: No Enlargement : No Enlargement : No Enlargement

5. Thorax

Pulmonal o Inspection : symmetrical, no hemithoraks left during inspiration, breathing

type abdomino-thorakal o Palpation : vocal fremitus equally strong on both hemithoraks

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o Percussion

: resonant to both hemithoraks

o Auscultation :Vesicular breath sounds, no sound ronkhi and wheezing in both lung fields Cor o Inspection o Palpation : no visible pulsation ICTUS cordis : There pulsation ICTUS cordis on ICS V + 1 cm lateral to the

linea midklavikularis the left o Percussion :-

o Auscultation : heart sounds regular I & II, does not sound gallop or murmur 6. Abdomen o Inspection of the veins o Auskultasi o Palpation : positive intestinal noise 3 x / minute : no palpable liver and a lien, there is no pain at the point Mc : flat, there are no striae and leather varieties, there is no widening

Burney press, as well as past pain. o Percussion 7. Ekstremity Inspection Palpation : no deformity : no oedema in the extremity : pain (-)

Lokalis status Inguinalis Regio Inspection : there is a lump in the left groin, size 3 x 2 cm. normal color.

Auscultation : bowel sounds positive 2 x / min on the bump Palpation :soft, lump can be entered with emphasis. Normal temperature. Pain (+)

Ziemen test (+) second finger

IV.

SUPPORTIVE EXAMINATION

Laboratorium result pre-operation on 25th June 2013

Result Leukosit Eritrosit Hemoglobin Hematokrit Thrombosit Bleeding time Clotting time 7.000/Ul 4,35 juta/mm3 12,7 g/dl 38 % 431.000/mm3 2 menit 00 detik 10 menit 00 detik

Normal Score 5.000 10.000/Ul 3,6 5,2 juta/mm3 12 16 g/dl 38 46 % 150 400 ribu/mm3 1 6 menit 10 16 menit
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V.

RESUME Male 49 years came with complaints of a lump in the left groin since 1 year Before enter

the hospital, the lump is felt disturbing because it can enter and painfull.

Inguinal region Inspection : there is a lump in the left groin, size 3 x 2 cm. normal color.

Auscultation : bowel sounds positive 2 x / min on the bump Palpation : soft, lump can be entered with emphasis. Normal temperature. Pain (+)

Ziemen test (+) second finger VI. DIAGNOSE PRE OP POST OP : HERNIA INGUINALIS LATERAL REPONIBLE : HERNIA INGUINALIS LATERAL REPONIBLE POST HERNIORAFI

VII.

MANAGEMENT Non-medikamentosa

-Pro hospitalization for the general state of repair and preparation operations
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-Patient education regarding the disease course and treatment, surgery preparation and goals, as well as the subsequent management of after the results are known -Post - operation: Monitor blood pressure, pulse, temperature and respiration. Fasting to flatus

Medikamentosa IVFD RL and Glukosa 1 : 3 28 drops/minute Ceftriaxone 2x1gr Tramadol 3x1 amp Second day : o Cefadroxil 2x1 mg o Asam mefenamat 2x1 mg o Diazepam 1x1 mg on the night

Herniorafi

VIII. PROGNOSE Ad Vitam Ad Fungsionam Ad Sanationam : ad Bonam : ad Bonam : ad Bonam

FOLLOW UP POST OP H+1

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Subjective (+) Objective

: Still pain in the wound, can not pass gas or bowel movements. Sleep disturbance

: General state Awareness Pulse Temperature RR Bowel Sound Regio Inguinal Inspection

: good : Compos mentis : 96 x/m : 36,3 0C : 18 x/m : (+)

: there is a lump in the left groin, size 3 x 2 cm. normal color.

Auscultation : bowel sounds positive 2 x / min on the bump Palpation :soft, lump can be entered with emphasis. Normal temperature. Pain (+)

. Assesment Planning : Continue therapy Control 1 week post op : Hernia Inguinalis lateral reponible H+1

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CHAPTER II LITERATURE REVIEW EPIDEMIOLOGY

Inguinal hernia has been known since 1500 AD, in Greek hernia lump has meaning. In Latin means crushed or torn. At that time a hernia is commonly used to control buffer or plaster. In 1363, Guy de Chauliac distinguish between inguinal and femoral hernia and also explains the reduction in cases of strangulation techniques. Stromeyer in 1559 presented in full in distinguishing medial and lateral inguinal hernia, and advocated cutting the testicles do not need to be done in hernia surgery. The early 18th century until the 19th century can be explained and defined regions inguinal anatomy appropriately and clearly. The incidence of inguinal hernia is not known with certainty. According to Abrahamson (1997), the age of the children, was found between 10-20 per 1,000 live births. In the western hemisphere the incidence of inguinal hernia in adult age varies between 10% and 15%. While Anson cit Zimmerson and Schwartz (1994), reported the incidence of hernia is 5% of the adult male population. Inguinal hernias occur more in men than women with a ratio of 12: 1. In men aged 25-40 years the incidence varies between 5-8%, whereas in the age of more than 75 years to reach 45%. In 1993, Lichtenstein has reported more than 700,000 cases of inguinal hernia surgery in the United States.1

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DEFINITION
Medial inguinal hernia is a protrusion through a weakening in the transverse fascia Hasselbach triangle. Lateral inguinal hernia is a protrusion of the stomach in epigastrica inferior lateral vessels, which exit through the two doors and the annular channel and the inguinal canal.

ANATOMY
Inguinal region is home to some of the structure of the transition from the abdominal area to organs - to the external genital organs and upper limbs. Anatomical dividing line between the two areas on the form by the inguinal ligament (Poupart) which is located between the pubic tuberculum ossis, on the medial side and the anterior superior spina illiaka, on the lateral side. Actually inguinal ligament is the meeting place of fascia that covers the surface of the stomach and the fascia covering the surface of the leg (fascia lata). Above the inguinal ligament, funikulus spermatikus leaving the abdominal cavity through the inguinal annulus profundus which is located on the lateral. This spermatikus funikulus penetrate the abdominal wall through the inguinal canal which lies parallel to the inguinal ligament and is under the skin in the superficial inguinal annulus which lies medial. Hole in the state these days can easily be palpated under the skin on the abdominal wall, then pushed into the scrotum, and feeling on top of the inguinal crease. Inguinal canal in kraniolateral limited by the internal inguinal annulus which is the open part of the facia and the transversalis aponeurosis. transversus abdominis. Under medially, above the pubic tubercle, the channel is limited by the external inguinal ring, an opening in the aponeurosis. obliqus eksternus. The roof is m. obliqus internus and m. transversus abdominis, and there didasarnya inguinal ligament, the front is limited by

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aponeorosis m. obliqus externus abdominis, rear m. obliqus internus abdominis. Channel containing a rope of sperm in men, and the round ligament in females .

Lateral inguinal hernia (indirect), because peritonem out of the cavity through the internal inguinal annulus which lies lateral to the inferior epigastric vessels, then hernia into the inguinal canal and if sufficiently long, protruding from the external inguinal ring. If this continues hernia, the bulge will be up to the scrotum, is called hernia skrotalis. Whereas the medial inguinal hernia (direct), stand straight ahead through the triangular Hesselbach limited by: . inferior : ligamentum inguinale lateral : vasa epigastrica inferior medial : lateral musculus rectus abdominis

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Hesselbach's Triangle Aponeurosis Obliqus External Obliquus externus muscle aponeurosis formed by two layers: superficial and deep. Together with aponeorosis obliqus internus muscle and transversus abdominis, rectus sheath they form and finally the linea alba. external oblique aponeurosis be superficial boundaries of inguinal canal. Inguinal ligament is located on the spina iliaca anterior superior to the tuberculum pubicum.3,4

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Musculus Oblique Musculus Oblique internus Obliq internus abdominis muscle into the upper edge of the inguinal canal. medial part of the internal oblique aponeurosis blends with the fibers of the transversus abdominis aponeurosis near the tuberculum pubicum to form a conjoined tendon. the conjoined tendon is actually te; ah much debated, but it is thought by many surgeons appear in 10% of patients.2,3,4 Fascia Transversalis Transversalis fascia is considered a continuation of the transversalis muscle and aponeurosisnya. Transversalis fascia described by Cooper has 2 layers: "The transversalis fascia can be divided into two parts, one is located slightly before the other, the thinner parts of the exterior, and he came out of the transversalis muscle tendons on the inside of the spermatic cord and binds to the linea semulunaris. 3,4

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Fascia Transversalis Ligamentum Cooper Cooper ligament is located on the back of the pubic ramus and formed by the pubic rami and fascia. Cooper ligament fixation is an important point in the laparoscopic repair method as the technique McVay. 3 Preperitoneal Space Preperitoneal space composed of fatty tissue, lymphatics, blood vessels and nerves. Preperitoneal nerve that must be considered by the surgeon is the lateral femoral cutaneous nerve and genitofemoral nerves. lateral femoral cutaneous nerve fibers derived from L2 and L3 and sometimes branch of the femoral nerve. This nerve runs along the anterior surface of the muscle and under the fascia iliaca iliaca and melelui attachment below or lateral to the inguinal ligament at the anterior superior spina iliaca. 4 Genitofemoral nerve usually originates from the L2 or L1 and L2 and L3 sometimes from. He fell in front of the psoas muscle and divides into genital and femoral branches. Genital branch into the inguinal canal through the ring while the femoral branch into the hiatus of the lateral femoral arteries. ductus deferens runs through the preperitoneal space to cepal of caudal and medial to lateral to the internal inguinal ring.
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Fat tissue, lymphatics, was found in the preperitoneal space, and the amount of fatty tissue varies. 1,2,3,4

PHYSIOLOGY
In males, the closure is related to the occurrence of hernia require embryological knowledge related to testicular descent. At first the testes grow as a structure in the kidney area in the abdomen (retroperitoneal). During the growth of the fetus the testes will descend (descensus testis) from the back wall into the abdomen to the scrotum. During this decline peritoneum contained and carried in front of him as a tube, which through the canal into the scrotum innguinalis. Protrusion of the peritoneum is known as the processus vaginalis. Before birth processus vaginalis will undergo obliteration, except for the part that surrounds the testis called the tunica vaginalis. If the processus vaginalis persists, will get a direct relationship between the cavum peritonei with the scrotum, it can potentially lead to inguinal hernia later.

ETIOLOGY
Inguinal hernias can occur due to congenital anomalies or because obtained. More in men than in women. Various factors play a role in the formation of a hernia at the entrance of the internal annulus is wide enough so that it can be passed by the bag and contents of the hernia. Besides, it is also necessary to factor the hernia contents push through the door that is already open wide enough. In a healthy person there are three mechanisms that can prevent the occurrence of inguinal hernia, the inguinal canal that goes awry, the muscular structure that covers oblliqus internus abdominis internus inguinal annulus when contracted, and the presence of a strong transverse fascia covering the generally triangular Hasselbach hardly muscular. Disturbances in this mechanism may lead to a hernia. Factors considered causal role is the open processus vaginalis, elevation of pressure in the abdominal cavity, and the abdominal wall muscle weakness due to age.

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The factors - predisposing factors that influence the incidence of inguinal hernia is as follows : 1. Heredity According Macready (Cit. Watson, 1948) hernias are more common in people who have a parent, brother or grandmother with a history of inguinal hernia. 2. Sex Inguinal hernia is far more common in men - men than in women (9:1) (Watson, 1948). Hernias in men - men 95% are inguinal type, whereas in women 45-50%. Difference is caused because of the prevalence of round ligament size, and percentage of obliteration of processus vaginalis testis is smaller than the obliteration of the canal Nuck. 3. Age Lots going on under the age of 1 year, by Macready (Cit. Watson, 1948) mentioned 17.5% boys - boys and 9.16% of girls had a hernia. Tendency hernia increases with increasing activity, around the age of 26-50 years and the incidence decreases after the age of 50 years the incidence increased again because of declining physical condition. 4. Constitution or state agency The number of preperitoneal fat will urge the abdominal wall and causing loci minoris or weakness - weakness and muscle relaxation occurs from the annulus. When fat infiltrating into omentum and mesentery will reduce the volume of the abdominal cavity resulting in increased intra-abdominal pressure. 5. Preterm birth and small birth weight is considered as factors that have a greater risk for causing a hernia. Congenital defects, such as pelvic or ekstrosi abnormalities of the bladder, can cause damage to the indirect inguinal. It is rare congenital kelainanan or collagen defect can lead to the growth of direct inguinal hernia.

PART AND TYPES HERNIA

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Hernia parts : 1. Hernia Sack Abdominal hernias form at the parietal peritoneum. Not all hernias have pockets, such as incisional hernia, adipose hernia, hernia intertitialis. 2. Hernia Contents Form of organ or tissue out through the hernia bag, for example colon, ovarian, and colon tissue buffer (omentum). 3. Hernia Entry Is part minoris resistance locus through which the hernia pouch. 4. Hernia Neck Narrowest part of the bag that suits hernia hernia pouch. 5. Locus minoris resistence (LMR)

Hernia Part

HERNIA CLASIFICATION
a. Hernia generally 1. Internal hernia that bulges intestine without hernia pouch through an opening in the abdominal cavity such as the foramen of Winslow, resesus retrosekalis or acquired defects in mesentrium eg after intestinal anastomosis.
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2. The external hernia hernia protruding through the abdominal wall, waist or peritoneum. b. Hernia by time 1. Congenital hernia congenital or acquired at birth or that have existed since first birth. 2. Hernia acquired or akuisita which is not innate, but acquired hernia after growing and developing after birth. c. Hernia by place 1. Obturatorius Ie hernia through the obturator foramen. This hernia last 4 stages. The first stage first - first retroperitoneal fat bulges into the obturator canal. The second phase followed by a bulge parietal peritoneum. The third stage, hernianya bag may be filled by the curve of the intestine. And stage four experienced partial incarceration, often in Ritcher or total. 2. Epigastrika Hernia is also called the linea alba hernia which is a hernia coming out through a defect dilinea alba between the umbilicus and xiphoid processus. Patients often complain of not feeling in the stomach and nausea, gallbladder abnormalities similar complaints, peptic ulcer or esophageal hiatal hernia. 3. Ventral, is the common name for all hernia in antero lateral abdominal wall hernia sikatriks like. A hernia is a protrusion of peritoneum through sikatriks surgical scar new and old. Factor predisposisinya wound infection is surgery, wound dehiscence, wound closure techniques that are less good, kind of incision, obesity and elevated intra-abdominal pressure. 4. Lumbalis Lumbar area between the ribs and Krista illiaca XII, there are two triangular pieces are triangular kostolumbalis superior (Grijnfelt) inverted triangle and triangle or triangular inferior kostolumbalis illiolumbalis (petit) that form a
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triangle. On physical examination looks and palpable lump waist bottom edge of the rib XII (Grijnfelt) or draped cranial edge of the dorsal. 5. Littre, which is very rare hernia, hernia containing a Meckel's diverticulum. 6. Spiegel, interstitial hernia with or without its contents through the fascia Spieghel. 7. Perienalis, a hernia protrusion through a defect in the peritoneum of the pelvic floor which can be primary or secondary in multiparous women after surgery through a perineal prostatectomy or recession such as the rectum abdominoperienal. 8. Pantalon, is a combination of lateral and medial inguinal hernia on one side. Both bag separated by vasa hernia so inferior epigastric shaped like pants. 9. Diafragma 10. Inguinalis Types of hernia inguinalis: Hernia inguinalis medialis. Hernia inguinalis lateralis 11. Umbilical, is a protrusion of abdominal cavity that contains the content that goes through the umbilical ring due to elevation of intra-abdominal pressure. Umbilical hernia is a congenital hernia at the umbilicus which only covered the peritoneum and skin. 12. Paraumbilical a hernia through a slit in the midline cranial umbilical edge, the edge kaudalnya rare. Spontaneous closure is rare so it is generally necessary correction surgery. 13. Femoral which is the bulge in the groin that appeared especially when conducting activities that increase intra-abdominal pressure such as coughing or lifting. Entrance and exit is through the annulus femoral fossa ovalis thigh crease. Limit - the limit annulus femoral include inguinal ligament in the anterior, medial ligament lacunare, ossis pubi posterior superior ramus and
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muscular fascia and laterally along peknitus m.illiopsoas locus minoris resistennya fascia along the transverse fascia covering called the annulus femoral septum cloquetti. d. Hernia by clinically 1. Hernia reponibel Hernia called so if it contents can be in and out. Gut out when standing or straining and enter again if lying down or pushed in, no complaints of pain. 2. Hernia ireponibel When the contents of the bag can not be returned into the cavity. This is also called hernia hernia accreta and had no complaints of pain or signs of intestinal obstruction. Inkarserata strangulate hernia or hernia. Inkarserata hernia contents of the bag means trapped, unable to get back into the abdominal cavity with the result that the passage of harassment or vascularization. Strangulated hernia disruption vascularization, with various levels of disturbance ranging from dams to necrosis. 3. Richter hernia, when the clamp is only partially strangulated bowel wall. e. Hernia by amount 1. Hernia unilateral 2. Hernia duplek c. Hernia by prostusion 1. Hernia inguinalis lateralis/indirek Indirect inguinal hernia is also called lateral hernia because out of the peritoneal cavity through the internal inguinal ring is located lateral to the inferior epigastric vessels, then hernia into the inguinal canal and if sufficiently long, protruding from the external annulus inguinlais. If this continues hernia, the bulge will get to skortum, this is called hernia skortalis.
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Hernia pockets are located within the muscular cremaster anteromedial to the vas deferent and other structures in the sperm rope. 2. Hernia inguinalis medialis/direk Direct inguinal hernia is also called the medial inguinal hernia, protruding straight ahead through Hesselbach triangle, the area bounded by the inguinal ligament.

PATOPHYSIOLOGI
1. Hernia Inguinalis Inguinal canal in the normal channel of the fetus. In the months - 8 of pregnancy, the desensus vestikulorum through the canal. Testicular descent that will draw the peritoneum to the scrotum area resulting in a bulge peritoneum called the processus vaginalis peritonea. When a baby is born it has undergone a process of the general obliteration, so the contents of the abdominal cavity can not be through the canal. But in some ways are not closed, because the left testicle down first from the right, then the right inguinal canal open more often. Under normal circumstances, this open canal will close at 2 months of age. 1.2 When the process of the open part, then there will be a hydrocele. When the channel is open constantly, because the processus not berobliterasi will arise lateral congenital inguinal hernia.
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Typically these hernias in adults occurs kerana elderly, due to old age weakened muscle wall of the abdominal cavity. In line with increasing age, the body's organs and tissues undergo a process of degeneration. In older people the canal has been closed. However, because this area is the locus minoris resistance, then the circumstances that led to increased intra-abdominal pressure such as coughing - chronic cough, sneezing strong and lifting - heavy objects, straining. Channels that have been closed can be opened again and the lateral inguinal hernia arises because something terdorongnya body tissues and out through the defect. Eventually hit a wall cavity that has been limp due to trauma, protat hypertrophy, ascites, pregnancy, obesity, and congenital abnormalities and can occur at all. 2,3,4 More men than women, because of differences in the reproductive development during fetal male and female. Potential complications occurred adhesions between the contents of the hernia pouch wall hernia hernia so that the contents can not be put back. Suppression of the hernia ring, due to the increasing number of incoming intestines, hernia ring into a narrow channel content and cause intestinal disorders. Obtruksi edema occurs when the intestine is then pressing the blood vessels and then necrosis. If there is a blockage and bleeding will occur flatulence, vomiting, constipation. When inkarserata left, then over time there will be edema resulting in suppression of blood vessels and necrosis. 3,4,5 Also can occur not because of pinched but turned his intestines. If the contents of the stomach may occur sandwiched shock, fever, metabolic acidosis, abscess. Hernia complications depending on the circumstances experienced by the contents of the hernia. Among other simple intestinal obstruction until perforation (hole) which ultimately can lead to intestinal local abscess, fistula or peritonitis. 1,2,3 A. Hernia Inguinalis Direkta (Medialis) This is a type of hernia Henia acquired (akuisita) caused by factors of chronic elevation of intra-abdominal pressure and muscular weakness in the wall of trigone Hesselbach. Course (direct) to ventral through the subcutaneous inguinal annulus. Hernia is not at all related to the seminal cord wrapping, generally occurs bilaterally, especially in older men. This type of hernia is rarely, almost never, experienced incarceration and strangulation. 4,5,6
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Hernia Inguinalis Direct

B. Hernia Inguinalis Indirekta (lateralis) This is called lateral hernia because of the protruding abdomen in lateral inferior epigastric vessels. Known as indirect as it comes out through the door and the two channels, namely the annulus and the inguinal canal. On examination lateral hernia bulge will appear oval. Can occur congenitally or akuisita: 5,6 Hernia inguinalis indirekta congenital.

Processus vaginalis peritonei occurs when babies are born at the same time not shut down. Cavity so that the cavity peritonei keep in touch with the tunica vaginalis propria testis. Thus bowels easily fit into the peritoneal pouch. 1,2,3,4,5 Hernia inguinalis indirekta akuisita.

Occurs when the processus vaginalis peritonei closing only on a part of it. So there are still pockets of peritoneum derived from the processus vaginalis does not close by the time the baby is born. At times it can be filled Kentung peritonei stomach innards, but the contents of the hernia is not associated with the tunica vaginalis propria testis. 1,2,3
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Hernia inguinalis indirect C. Hernia Pantalon A combination of lateral and medial inguinal hernia on one side. Both vasa hernia sac are separated by so inferior epigastric shaped like pants. This situation is found to be approximately 15% of cases of inguinal hernia. Diagnosis is generally difficult to enforce with clinical examination, and usually only discovered during surgery. 5,6

DIAGNOSE
1. Anamnesis The directional history is helpful in establishing the diagnosis. Further descriptions of the main complaints, such as how the nature of the complaint, in which the location and where penjalarannya, how the initial attack and the sequence of events, the factors that aggravate and
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mitigate complaints, other related complaints need to be asked in the diagnosis. Hernia symptoms and clinical signs are determined by the contents of the hernia condition. At hernia reponibel only complaint was a lump in the groin that appears on standing, coughing, sneezing, or straining, and disappeared after lying down. Complaints of pain are rarely found, if there is usually felt epigastric region or the umbilical form of visceral pain due to strain in the mesentery of the small intestine during one segment of the bag into the hernia. Pain accompanied by nausea or vomiting that occurs incarceration emerging as ileus or srangulasi as necrosis or gangren. Patients often complain of discomfort and soreness in the inguinal region, and can be removed by manual repositioning peritonealis into the cavity. But by standing or especially with exercise, then the hernia usually appear again.

2. Physical Examination All hernia has three parts, namely the bag, and the contents of the wrapper. This all depends on the location of the hernia, the contents of the bag were mostly omental hernia. Then ileum, jejunum, and sigmoid. Appendix parts - other parts of the colon, stomach, and liver have been reported even in the bag contained a large hernia. Omentum palpable relatively little is plastic and nodular. Can be suspected if the bowel pockets palpable smooth and taut as hydrocele, but not opaque. Sometimes - sometimes the examiner can feel the gas moving within the bowel loop or by auscultation may show peristalsis. Bowel loop containing gas will tympanic to percussion. Under no circumstances will the patient standing gravity rnenyebabkan hernias are more easily seen and examinations on patients in the state stand to be made more comprehensive. With the patient lying down position will be easier to do a conjecture. Suppose there is a hernia, it can easily be repositioned and the rest of the examination (abdomen and legs) is more easily done. Inspection Swelling arising from the inguinal region and reaches to the base of the labium majus or scrotum, always a lateral inguinal hernia. If there is no swelling kila can see, people were told to
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cough. If the swelling is then seen later were above the inguinal crease and walked over towards the lateral oblique and medial to the bottom, then the swelling is lateral inguinal hernia. But it seems that the swelling immediately appear in the future, then we are dealing with the medial inguinal hernia. Palpation Able to determine the kind of hernianya. To check the left groin to use the left hand, right thigh folding worn right hand. The trick: Ziemen Test : 1. Lying down, if there are bumps enter first (usually by the patient). 2. Right hernia checked with the right hand. 3. Patients were told to cough when stimulation:

Second Finger : Hernia Inguinalis Lateralis. Third Finger : hernia Ingunalis Medialis. Fourth Finger : Hernia Femoralis.

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Ziement Test Thumb Test : annulus internus pressed with the thumb and the patient was told to push When you exit the medial Inguinal Hernia bump means. When not out bumps mean Inguinal Hernia lateral

. Thumb Test Finger Test : 1. Using a finger or fingers 2 to 5. 2. Skrortum inserted through the annulus through the external inguinal canal. 3. Patients were told to cough:

Bila impuls diujung jari berarti Hernia Inguinalis Lateralis.

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Bila impuls disamping jari Hernia Inguinnalis Medialis.

Finger Test

Percution When the gas in the intestinal contents will hear a timpani. When obtained percussion flatulence then should think about the possibility of hernia Strangulated. Hipertimpani, sounding deaf.

Auscultation Bowel sound, if negative then chances auscultation be the omentum hernia contents. Auscultation is also able to determine the degree of intestinal obstruction.

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SUPPORTIVE EXAMINATION
Laboratorium Leukosit > 10.000 18.000 / mm3 Serum elektrolit

Radiologis 1. Herniografi In this technique, 50-80 ml of iodine contrast medium positive peritoneal enter the container using a soft needles. Patients lie down with the head elevated and forming an angle of approximately 25 degrees. Place contrast in the inguinal region stationary or moving from one side to the other will lead to a small pool in the inguinal region. Three inguinal fossa is suprapubic, medial and lateral. Inguinal fossa generally not mcncapai across the edge of the pubic bone to the middle and slightly posterior inguinal wall. Indirect hernias arise from the fossa lateral fossa protruding from the medial or medial direct hernia protruding from suprapubic fossa. 2. ultrasonography This technique is used to clot the difference in the femoral triangle. 3. computer tomography With this technique may be a few cases of hernia can be detected.

MANAGEMENT
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Conservative Conservative treatment is not a definitive act that can recur again. 1. repositioning An attempt or action to enter or return the hernia contents into the peritoneum or abdominal cavity carefully and with gentle pressure and definite. This repositioning is done on the reponibel inguinal hernia by using both hands. One hand holds the curves corresponding to the door (herniated neck palpated carefully, doors widened), while the other hand insert the contents of the hernia through the door. Repositioning is sometimes done on irreponibel inguinal hernia in patients who fear surgery. The trick, part cold compressed hernia, the patient was given a sedative valium 10 ml for the patient to sleep, sleep position trendelenberg. This rnemudahkan hernianya submitted content. If this fails should not be imposed, better surgery the next day.

2. injection Performed after successful repositioning. With a sclerotic rnenyuntikkan liquid alcohol or quinine in the area around the hernia, hernia suffered rnenyebabkan door sclerosis or narrowing, so the contents of the hernia will not go out again from cavum peritonei.

3. hernia belt This belt is given to patients with small rnasih hernia door and refused surgery. Buffer pads use only withstand a hernia that has been aimed at repositioning and never heal so it must be taken for life.

Operative

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Operative treatment is the only rational treatment of inguinal hernia. Indication of existing operations so the diagnosis is made. Indication: 1. Inguinal hernia which had inkarserata, despite the general bad state. 2. Reponibel hernias in infants with more than 6 months old or weighing more than 6 pounds. Course of its operation using a local anesthetic drug doses rnaksimum procain with 200 cc. If local anesthesia is used, digarnbarkan rhombus-shaped incision and given approximately 60 ml xylocain 0.5 percent with epinephrine. There are 3 phase hernia surgery 1. Herniotomy the bag cut open and the contents of the hernia and returns to the abdominal cavity. 2. Herniorafi ranging from hernia neck tie and hung it on the conjoint tendon. 3. Hernioplasty which gives strength to the abdominal wall and removes locus minnoris resistentiae. Hernia inguinalis lateralis surgery Skin incision in inguinal hernia is called an inguinal incision, two fingers cranial and parallel to the inguinal ligament from the mid. And is in accordance with the internal inguinal ring. Long slices depending on the size of the hernia (depending on needs), usually 5-8 cm. At the local anesthetic infiltration procain do not exceed approximately 20 cc. Once the skin is opened, and the subcutaneous fat tissue weeded until obliqus eksternus looks muscular aponeurosis which is the front wall of the inguinal canal. Approximately 2 cm cranial inguinal ligamentun. To the medial opening wedge to the external inguinal ring. In the inguinal canal are wrapped in the muscular cremaster spermaticus funiculus. This muscle weeded until funikulus spermaticus look. Funiculus cleaned or dicanthol up to lateral with gauze, and peritoneum bag will arise next caudomedialnya. This bag is clamped with two
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sirurgik tweezers and removed, then opened by observing that the hernia contents (bowel) is not truncated. Bag open and then clamped with clamps so gut Mickuliks apparent. Then the gut returned to the abdominal cavity with slices rnelebarkan proximal to the pouch until the neck hernia. The rest of the left distal pouch in the scrotum on a large hernia (because it can cause a lot of bleeding), while a small hernia removed the rest of the bag. Then stitched neck tie. Butts is then implanted under the conjoint tendon and hung. Furthermore, because there resistantiae minoris locus, needs to be done hernioplasty. Hernioplasty: 1. Ferguson Ie funiculus spermaticus placed dorsal side of obliqus musculus externus and internus abdominis and the internal and transverse muscular obliqus sewn on ligamenturn spermaticus inguinale and putting in the dorsal funiculus, then obliqus externus aponeurosis muscular sewn back so that there is no longer the inguinal canal. 2. Bassini Muscular obliqus internus and transversus abdominis muscular sewn on to the inguinal ligament. Funikulus spermaticus placed ventral than dorsal muscular earlier but muscular aponeurosis of the external obliqus that both inguinal canal earlier muskuli strengthen the back wall of the inguinal canal, so the locus minoris resistantiae lost.

3. Halstedt Done to strengthen or eliminate minonis resistentiae locus. Third muscular, muscular obliqus externus abdominis, muscular obliqus internus abdominis,
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transversus abdominis muscular obliqus, funikulus spermatikus placed in the sub cutis. 4. Shouldice Open inguinal floor and mengimbrikasi transversalis fascia with continuous suture technique. Hernia inguinalis medialis surgery Herniotomy the medial inguinal hernia at the lateral inguinal hernia surgery techniques. Hernioplasty here reinforce the medial area and the external inguinal ring. Hernioplasty done by Mc. Vay. that is attractive muscular obliqus abdominis internus and transversus abdominis muscular, and then sewn on the conjoint tendon or ligament cowperi pectineum through the dorsal side of the inguinal ligament.

COMPLICATION
Hernia complications depending on the circumstances experienced by the contents of the hernia. Hernia contents can be stuck in the hernia hernia pouch irreponibel, this can occur if the contents of the hernia is too large or composed and omenturn, extra-peritoneal organ (or sliding hernia hernia accreta). Here no clinical symptoms except in the form of lumps. Can also occur by strangulation hernia contents rings Strangulated hernia hernia causing intestinal obstruction that causes symptoms that simple. Blockages can occur as the total or partial Richter hernia. Hernia ring clamps will cause the contents of the hernia tissue perfusion. In the vein of the dam with the previous occur resulting in edema organs or structures within the hernia and hernia transudation into the bag. Onset of edema caused hernia ring clasp on growing and eventually compromised circulatory network. Fill hernia hernia became necrotic and bags will contain a serosanguinous transudate. If Hernis contents consist of the intestine, perforation can occur which can cause local abscess, fistula or peritonitis in case of contact with the abdominal cavity.

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In adult patients. complication rate of open inguinal herniorafi different from 1% to 26% with a lot of reports that are composed of 7% to I 2%. Approximately 700 thousand herniorafi inguinal happens every year, complications arise approximately 10% of these guys have a pretty big problem. Wound infection is a frequent problem encountered. A deeper infections can affect dalarn kernunculan back hernia. Bladder can be injured by time basis inguinal canal reshaped and made for a groin hernia. If rnungkin testicles hurt, vasdeferens, blood vessels or nerves' illiohypogastrik, illioinguinal.

PROGNOSE
Depending on patient age, size and condition of hernia hernia contents of the bag. Prognosis is good if the wound infection, bowel obstruction be addressed. Postoperative complications such as postoperative pain herniorafi, testicular atrophy, and recurrent hernias generally can be overcome.

CHAPTER III CONCLUSION

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An inguinal hernia is a lump of intra-abdominal contents in the inguinal canal. Bulge covered by a layer of peritoneum, causing a breakdown on the basis of the inguinal canal. When this damage appeared laterally to the epigastric artery dalarn, is classified as an indirect inguinal hernia, when a lump is in the middle of the blood vessels, it is called a direct inguinal hernia. Here are some points of difference in diagnosis: 1. Direct inguinal hernia, usually appears after age 40 years and shaped stand or tensed. Can usually be easily and quickly reduced itself. 2. A hernia that is longer than its width often in the form of indirect hernia. 3. Someone who has integrity elderly with weak layers often suffer direct hernia. On a normal lateral inguinal hernia peritoneum bag obliterated so that only the inguinal canal will be filled funikulus spermatikus in males and round ligament in females. If there is a failure of obliteration contents can enter the peritoneal cavity through the inguinal canal inguinal ring (Mc. Dermott, 1990). Whereas the medial inguinal hernia is generally bilateral, rarely mengalarni incarceration and strangulation. Inguinal hernias arise most frequently in men and more often on the right side than the left side. Increased intra-abdominal pressure due to various reasons, which include sudden pengejanan, overactive exercise, obesity, chronic cough, ascites. Straining during bowel movements, abdominal keharnilan and a great time is a predisposition to development of inguinal hernia (Sabiston). Most of inguinal hernia is asymptomatic, and is mostly found on routine physical examination by palpation of a lump in the superficial inguinal ring, or a bag of inguinal annulus profundus tall. The latter is made even more prominent when the patient coughs. One of the first signs of a hernia is a period in the inguinal region or any part of the scrotum. In infants and children intermittent lump in the groin usually known by the parents. If the hernia is disturbing and often restless child or infant, cried a lot and sometimes abdominal bloating, they must consider the possibility of hernia Strangulated. Patients also reported missing lumps in the morning but became bigger during the day. More rarely patients present with acute onset of severe symptoms, especially after the sudden activity or straining.
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An inguinal hernia is never cured by itself, and if symptomatic then tend to become heavy. Although patients may feel increasingly small interference with the passage of time, especially with the change in activity, the symptoms tend to increase.

REFERENCES 1. Brunicardi, F Charles. 2005. Inguinal Hernias. Schwartzs Principles of Surgery. Eighth edition. New York. Mc Graw-Hill. 1353-1394. 2. Townsend, Courtney M. 2004. Hernias. Sabiston Textbook of Surgery.

17thEdition. Philadelphia. Elsevier Saunders. 1199-1217

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3. Syamsuhidayat, R, and Wim de Jong, (2012), Buku Ajar Ilmu Bedah, edisi revisi, 706710, EGC, Jakarta. 4. Inguinal Hernia: Anatomy and Managementhttp://www.medscape.com/viewarticle/420354_4

5. Dunphy, J.E, M.D, F.A.C.S. dan Botsford, M.D, F.A.C.S, Pemeriksaan Fisik Bedah, edisi ke-4, 145-146, Yayasan Essentia Medika, Yogyakarta. 6. Dudley and Waxmann, Scott; An Aid to Clinical Surgery, 4nd ed, 247, Longman Singapore Publisher Ltd, Singapore. 7. Darmokusumo, K, Buku Pegangan Kuliah Ilmu Bedah, Fakultas Kedokteran, Universitas Muhamadiyah Yogyakarta. 8. Norton,Jeffrey A. 2001. Hernias And Abdominal Wall Defects. Surgery Basic Science and Clinical Evidence. New York. Springer. 787-803. 9. http://www.hernia.tripod.com/inguinal.html 10. Schwartz, and Shires, and Spencer, Principles of Surgery, 4nd ed, 1543, Mc. Graw Hill Book Company, Singapore. 11. Sabiston and Lyerly, Text Book of Surgery The Biological Basis of Modern Surgical Practice, 15nd ed, 1.219- 1.232, W. B, Saunders Company.

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