CASE PRESENTATION

HERNIA INGUINALIS LATERALIS REPONIBLE

SINISTRA

Pembimbing :
Dr. Herry Setya Yudha Utama, SpB, MHKes, FInaCS

Disusun oeh :
Nabilah Fajriah Barsah
1102012187

CLINICAL CLERKSHIP OF SURGERY DEPARTEMENT

FACULTY OF MEDICINE YARSI UNIVERSITY
ARJAWINANGUN DISTRIC GENERAL HOSPITAL 2016
CASE PRESENTATION

I. IDENTITY
Date of hospital entry : May, 17, 2016
Name : Mr. A
Age : 52 years
Gender : Male
Occupation : Labor
Addres : Geyongan
Religion : Islam
Marital status : Married

II. ANAMNESIS

Main complaint

Patient complain of a lump in the groin left since 2 months ago.

History of disease

Mr. A came to RSUD Arjawinangun with complain of a lump in the groin left since 2

months ago. the patient said, when he got up and lift heavy object the lump will arise,

and the lump will disappear when he lie down. The patient also experience pain on a

lump, but no complain about fever, vomiting, nausea, and bloating.

History of past disease

Mr. A said he never had experienced the same symptoms before. The patient had no

history of surgery. Patient said he had a history of hypertension.

History of family disease

Mr. A said, there is no family members with the same disease as patient.

III. PHYSICAL EXAMINATION

a. Present Status
Genereal condition : Mild pain
Awareness : Compos mentis
Blood pressure : 150/90 mmHg
Pulse : 88 x/minute
Breathing : 20 x/minute
Temperature : 36,7 oC
Head
Form : Normocephale, symmetrical
Hair : Black, no hair fall
Eye : Anemic conjungtivas (-/-), icteric schleras (-/-),

light relexes (+/+), isochore pupil right = left

Ear : Normal form, cerumen (-), thympany

membrane intact
Nose : Normal form, septum deviation (-), epitaxis(-/-)
Mouth : Normal
Neck
Enlargement of lymph nodes (-), trachea in the middle, no mass found
Thorax
Lungs pulmonary
Inspection : the chest is symmetrical both left and right
Palpation : fremitus vocale and tactile are symmetrical,

crepitation (-), tenderness (-), rebound

tenderness (-)
Percussion : Resonance sound in both lung fields
Auscultation : Vesicular abd bronchial sound in the entire

lung field, ronchi (-/-), wheezing (-/-)

Abdomen
Inspection : Flat, symmetrical, mass (-)
Palpation : Tenderness (-), rebound tenderness (-)
Percussion : Tympanity sound in four quadrants
Auscultation : Intestine sound (+)
Extremities
Upper
Muscle Tone : normal
Movement : active / active
Mass :-/-
Strenght :5/5
Oedema :-/-
Lower
Muscle tone : normal
Movement : active / active
Mass :-/-
Strenght :5/5
Oedema :-/-

Genitalia
No abnormalities
 b. Localized Status
Regio : Inguinalis Sinistra
Inspection : Mass appears with 7x5 cm size, same color

as the surrounding skin, and there are no signs of

inflammation
Palpation : Palpable masses with flat surfaces
Auscultation : there is no intestinal peristalsis sound
c. Laboratory Examination

Test Result Unit

Full Blood
Hemoglobin 14,8 gr/dl
Hematocrit 43,8 %
Leukocyte 9,30 10e3/L
Trombocyte 434 10e3/L
Erythrocyte 5,18 mm3
Erythrocyte Indexes
MCV 84,5 fl
MCH 28,6 pg
MCHC 33,8 g/dl
RDW 12,9 fl
MPV 7,4 fl
PDW 43,5 Fl
Counts (DIFF)
Eosinophil 14,2 %
Basophil 1,0 %
Segmen 50,1 %
lymphocytes 27,2 %
monocytes 4,9 %
Stab 2,5 %
LED
LED 1 jam 20 mm/jam
Coagulation
Clotting time 4 menit
Bleeding time 2 menit
Clinical chemistry
Ureum 19,1 Mg/dL
Creatinine 0,75 Mg/dL
Immunology
HBsAg 0,01
Anti HIV non reaktif

IV. DIAGNOSIS
Hernia inguinalis lateralis sinistra reponible
V. DIFFERENTIAL DIAGNOSIS
 Hernia inguinalis medialis
Limfadenopati inguinal sinistra
VI. TREATMENT
Operative
Hernioraphy
Medicamentosa
Ketorolac, Ranitidin, Cefuroxim
VII. PROGNOSIS
Ad vitam : ad bonam
Ad sanationam : ad bonam
Ad fungsionam : ad bonam

LITERATURE REVIEW
I. DEFINITION
In general hernia is a bulging (protrusion) fill a cavity through a defect or

weak parts of the cavity wall concerned. In abdominal hernia, abdominal contents

bulging through a defect or weak parts of the musculo-aponeurotik layers of the

abdominal wall. Hernia consists of rings, bags and contents of the hernia.

II. EIDEMIOLOGY
Seventy-five percent of all abdominal hernias occur in the inguinal (groin).

Others may occur in the umbilicus (belly button) or other abdominal regions.

Inguinal hernias are divided into two, namely the inguinal hernia medial and

lateral inguinal hernia. If the lateral inguinal hernia bag reaches the scrotum

(testicles), called a hernia hernia scrotalis. The lateral inguinal hernia occurs more

frequently than the medial inguinal hernia with a ratio of 2: 1, and it turned out to

be a man among 7-fold more frequently affected than women. The more we age,

the greater the possibility of a hernia. This is influenced by the strength of the

abdominal muscles that had begun to decline. In addition to those mentioned in

 front of people who have a great opportunity experience hernia that people - those

who experienced the dairy operation.

III. ETIOLOGY
Hernia occurs because of the weakened muscle wall or membrane that

normally keep the organs in place weakened or loosened. Hernia were mostly

suffered by the elderly, because of the elderly muscles begin to weaken and

loosening so that chances are very big to occur hernia. In women the most of a

hernia caused by obesity (excess weight). Another thing that can lead to hernias

include:
1. Lift items too heavy
2. Cough
3. Chronic lung disease pulmonary
4. A result of frequent straining during intestine movements
5. Metabolic disorders in the connective tissue
6. Ascites (abnormal accumulation of fluid in the abdominal cavity)
7. Diarrhea or abdominal cramps
8. Gestation
9. Excessive physical activity
10. Congenital birth (congenital)

IV. CLASSIFICATION
In general, hernias are divided into two types, namely:
1. Internal hernia
A hernia that occurs in the patient's body so that can not be seen with the eye.

Examples diaphragmatica hernia.

2. External hernia
A hernia can be seen by the eye because the lump of hernia penetrate out, so it

can be seen by the eye.

Based on the occurrence, hernia divided into:

1. Congenital hernia
2. Perfect congenital hernia

Based on its location, hernia are divided into :

1. Diaphragmatic hernia, is the prominence of the abdominal organs into the

chest cavity through a hole in the diaphragm (septum which limits the chest

cavity and the abdominal cavity).

2. Inguinal hernia
3. Umbilical hernia, is a lump that go through the ring umbilicus (belly button).
4. Femoral hernia, is a lump in the groin through the femoral ring.

By their character, a hernia can be called :

1. Hernia reponibel, when contents of a hernia can exit and enter again. The

intestines out when standing or straining, and enter again if lying down or

pushed in the stomach, no pain or symptoms of intestinal obstruction.

2. Hernia ireponibel, when the contents of hernia cant be repositioned back

into the abdominal cavity. This is usually caused by the adhesions contents of

the bag in peritoneal. This is called a accreta hernia. No complaints of pain or

intestinal obstruction signs.

3. Incarcerated hernia or hernia Strangulated, when it squeezed by hernia

ring so that the bag is trapped and cant get back into the abdominal cavity.

The result is a passage disorder or vascularization.

In outline, the division of hernia are divided into three, namely:

1. Femoral hernia, is generally found in older women, the incidence in women

about 4 times the male. Complaints are usually be a lump in the groin that

appears especially when doing activities that increase intra-abdominal

pressures like when lifting or coughing. These lumps disappear when lying

down. Often patients come to the doctor or hospital with a hernia Strangulated.

On physical examination found a lump in the groin software under the

inguinal ligamnetum in v.femoralis medial and lateral to the pubic tubercle.

The entrance of the femoral hernia is the femoral ring. Furthermore, contents

of the hernia enter into femoral canal and out of the fossa ovalis in the groin.
2. Inguinal hernia, can occur due to congenital anomalies or because acquired.

Inguinal hernias arise most frequently in men and is more common on the

right than on the left side. In a healthy person, there are three mechanisms that

can prevent an inguinal hernia, the inguinal canal which runs obliquely, their

structure m. obliqus internus abdominis which closes the internal inguinal

annulus when contracted, and their strong transverse fascia which covering

Hasselbach triangle which generally almost not muscular. The most causal

factor that is the process vaginalis (a bag hernia) are open, elevation of

pressure within the abdominal cavity and the abdominal wall muscle weakness

due to age. Inguinal hernia subdivided, namely:

a. Medial inguinal hernia, direct inguinal hernia is almost always caused by

factors of chronic elevation of intra-abdominal pressure and muscular wall

weakness in the hesselbach triangle. Therefore, the hernia are common

bilateral, especially in older men. This hernia rarely experienced

incarceration and strangulation. Sliding hernia may occur, which contains

most of the bladder wall. Sometimes found small defects in m.obliqus

 internus abdominis, at all ages, with stiff and sharp ring that often cause

strangulation. This hernia suffered by the population in Africa.

b. Lateral inguinal hernia, hernia is called latelaris because bulging from

the abdomen in the lateral inferior epigastric vascular. Called indirect

because came out through two doors and channels, namely the annulus and

the inguinal canal. Different from the medial hernia which direct

protruding through the hesselbach triangle and is called a hernia direct. On

examination leteralis hernia, a bulge will appear oval, while the medial

hernia will appear round. In infants and children, latelaris hernia caused by

congenital abnormalities such as not to cover the processus vaginalis of the

peritoneum as a result the process of testicular descent into the scrotum.

Sliding hernia may occur on the right or left. Hernia on the right usually

contain most of the cecum and ascending colon, while the one on the left

contains most of the descending colon.

V. Pathophysiology

Hernia caused by the first two factors are factors congenital failure of closure

of the processus vaginalis during pregnancy can lead to the inclusion of the

contents of the abdominal cavity through the inguinal canal, second factor is a

factor obtained such as pregnancy, chronic cough, work lifting heavy objects and

the age factor , the inclusion of abdominal contents through the canal ingunalis, if

long enough it will protrude from the external ingunalis annulus. If this hernia

bump will continue until the inguinal canal into the scrotum because sperm

contains cord in males, so it caused a hernia.

There is hernias which may return spontaneously or manual, there is also not

able to return spontaneously or manually due to adhesions occur between the

contents of the hernia and pouch wall hernia, so that the contents cant be put

back. This situation will lead to difficulties to walk or move so that the activity

will be disrupted. If there is pressure on ring hernia, the contents of the hernia will

strangle and causing hernia strangulate which would cause symptoms of ileus is

the symptoms of intestinal obstruction leading to impaired blood circulation which

will cause a lack of oxygen supply can cause ischemia. The contents of this hernia

will become necrotic.

If the hernia pouch consists of a intestinal can occur perforation which can

eventually lead to localized abscess or priority if the relationship with the

abdominal cavity. Intestinal obstruction also causes a decrease in intestinal

peristalsis which can cause constipation. In the state strangulate will be symptoms

of ileus are abdominal bloating, vomiting and obstpation.

VI. Clinical Manifestations
In general complaint in adults such as lump in the groin that arise at the time

straining, coughing, or heavy lifting, and disappear when lying. In infants and

children, intermittent lump in the groin usually known by parents. If the hernia is

intrusive and often restless child or baby, cry a lot, and occasionally flatulence,

they must consider the possibility of hernia strangulate. On inspection note the

state of asymmetry in both groin, scrotum, or labia standing and lying down.

Patients are asked, straining or coughing so any lumps or asymmetry situation can

be seen. Palpation performed in a state of a lump hernia, palpable consistency, and

tried pushing if the lump can be repositioned.

VII. Diagnosis
1. Anamnesis
Complaints usually a lump in the groin intermittent, appearing especially

when doing activities that can increase intra-abdominal pressure such as lifting

or coughing, these bumps disappear when lying down or entered by hand

(manual). There are factors that contribute to the occurrence of hernia.

Intestinal passage disorder can occur, especially on incarcerated hernia. Pain

in the state of strangulation, often suffer come to the doctor or to the hospital

with this condition.

2. Physical examination
Found soft lump in the groin under the inguinal ligament in the medial femoral

vein and lateral pubic tubercle. Lump is bounded above is unclear, bowel

sounds (+), transluminasi (-).

Examination Finger Test:

1. Using a finger number 2 or 5.
2. Entered through the scrotum through the external annulus to inguinal

canal.
3. Patients were told to cough:
 If the impulse at the fingertips means

Inguinal Hernia lateral.

If the impulse beside the finger, it

means Inguinal Hernia Medial.

Examination Ziemen Test:

1. Lying position, if there is a bump first insert (usually by the patient).

2. Right Hernia checked with the right hand.
3. Patients were told to cough when stimulation at:
Finger number 2: Inguinal Hernia lateral.
Finger number 3: Medial Inguinal

hernia.
Finger number 4: Femoral Hernia.

Examination Thumb Test:

1. Pressure the annulus internus with the thumb

and the patient was told to push.

2. If the bumps out, it means inguinal hernia medial.
3. When the bumps not out, it means lateral inguinal

hernia.

VIII. Supporting Investigation

Hernia diagnosis based on clinical symptoms. Investigations are rarely done and

rarely have value.

a. Herniography
This technique involves the injection of contrast medium into the peritoneal

cavity and do X-ray, this technique is now rarely performed in infants to

identify contralateral hernia in the groin. May sometimes be useful to ensure

the hernia in patients with chronic pain in the groin.

b. USG
 Often used to judge the hernia which difficult to see clinically, for example in

Spigelian hernia.
c. CT and MRI
Useful for determining hernia rare (eg, obturator hernia).

IX. Management
Operative treatment is the only rational treatment of inguinal hernia rational.

Indication of operation already exists so the diagnosis is made. The basic principle

of a hernia operation consist hernioplasty and herniotomy.

In herniotomy be released hernia pouch up to his neck, pouch was opened and

the contents of the hernia delivered if there is attachment, then repositioned.

Hernia pouch sewn and tied up as high as possible and in pieces.

In hernioplasty action is taken to minimize annulus ingunalis internus and

strengthen the back wall of the inguinal canal. Hernioplasty more important in

preventing recurrent compared with herniotomy. Known various methods

hernioplasty, as minimize ingunalis annulus internus with interrupted sutures,

closing and strengthen the fascia transverse, sewed the meeting of m.transversus

internus abdominis and m.obliqus internus abdominis known as the conjoint

tendon to the inguinal ligament according to Bassini method, or sewed transverse

fascia, m. transversus abdominis, m.obliqus internus abdominus to Cooper

ligament on the method Mc vay.

In congenital hernias in infants and children which factor cause is processus

vaginalis does not close only done by herniotomy because of the internal inguinal

annulus is sufficiently elastic and the rear wall of the canal is strong enough.
X. Diagnosis Differential

Tissue Lump
Skin Sebaceous cysts or epidermoid
Fat Lipoma
Fascia Fibroma
Muscle Tumors hernia through the wrapping
 Artery Aneurysm
Vein Varicose
Lymph Lymphadenopathy
Gonad Ectopic testis / ovary

XI. Prognosis
The prognosis usually good enough if the hernia is treated properly. The

recurrence rate after surgery is less than 3%.

DAFTAR PUSTAKA

Ratnasari, I., G., A., D., 2012. Hernia Inguinalis Lateralis.

Utama, H., S., Y., 2010. Hernia Hydrocele At A Glance. [cites 19 May 2016]

[Available from : https://herrysetyayudha.wordpress.com/tag/hernia-inguinalis/ ].

 Unknown, 2013. Penyebab Hernia. [cites 19 may 2016] [Available from :

http://www.e-jurnal.com/2013/04/penyebab-hernia.html ].