Case Report

Nama : An. Alfath

Umur : 1 tahun
Jenis Kelamin : Laki laki
Agama : Islam
Suku : Betawi
Alamat : Jakarta timur

Anamnesis
Keluhan Umum : Sesak Nafas
RPS :
Pasien datang dengan keluhan sesak nafas
sejak semalam namun memberat dalam 2 jam
SMRS. Demam tinggi sejak 2 hari lalu,
mendadak, terus-menerus. Batukdan pilek sejak
2 hari lalu. Batuk berdahak dan 2x diakhiri
muntah. Batuk panjang disangkal. Sudah berobat
tapi belum ada perubahan. Selain itu terdapat
benjolan di kantung buah zakar sebelah kanan
Berwarna kemerahan. BAB Mencret , BAK sedikit

 RPD : hydrocelle Operasi jabulay

(1 bulan SMRS)
RKP

Pemeriksaan Fisik

KU : TSS
Kesadaran : Composmentis GCS E4V5M6
TD : RR: 60x
Nadi : 130x S :36,5
BB=8kg
Kepala : Normocephali
Leher : KGB tidak teraba membesar
Thorax :
I : Pergerakan dinding dada simetris
kanan dan kiri, retraksi sela iga +
P: Vocal fremitus simetris kanan & kiri
P : Sonor simetris kanan & kiri
A : BND bronkhovesikuler Rh -/- wh -/-

Abdomen : I : Perut tampak datar

A : BU 4x/menit
P : Supel, NT (-)
P : Timpani, NK (-)
Ekstremitas : Akral hangat, CRT < 2

Status Lokalis
Regio scrotalis
I : Benjolan bentuk lonjong, hiperemis
Pa : Testis teraba, konsistensi kenyal, NT
(+), batas tegas
Transiluminasi : (-)

Foto klinis

TINJAUAN PUSTAKA

Inguinal Hernias

Historical Hernias

Hernias have been

documented
throughout
history with
varying success
at either
reduction or
repair.

Trusses & Techniques

Anatomic Considerations
The inguinal region must be understood
with regard to its three-dimensional
configuration
A knowledge of the convergence of tissue
planes is essential
If repairing the hernia laparoscopically, the
anatomy must be well understood from the
peritoneal surface outward
There is a considerable amount of anatomic
variability with regard to:
Size and location of the hernia
Degree of adipose tissue

Anatomic Considerations
The surgeon must also be aware of
the precise location of the:
Femoral nerve
Genitofemoral nerve
Lateral femoral cutaneous nerves

Pelvic & Inguinal Anatomy

Both the ilioinguinal
nerve and the
genitofemoral
nerve traverse
the usual herniarepair operative
field. The femoral
vein also runs just
deep to the
inguinal floor
laterally.

Myopectineal Orifice of
Fruchaud
The MPO is bordered:
Above by the arching fibers of the
internal oblique and transversus
abdominus Muscles,
Medially (towards the center or to the
right) by the Rectus Abdominus Muscle
and its fascial Rectus Sheath
Inferiorly by Coopers Ligament, and
Laterally by the Ileopsoas Muscle
Running diagonally thru the MPO is the
inguinal ligament

Myopectineal Orifice of
Fruchaud

Hesselbach's triangle
Boundaries:
Medial:
Rectus abdominis
muscle
medially,
Inferiorly:
Inguinal ligament
Laterally:
Inf. Epigastrics

Diagnosis
The patient usually presents (for groin
hernia) with the complaint of a bulge in
the inguinal region
They may describe minor pain or vague
discomfort associated with the bulge
Extreme pain usually represents
incarceration with intestinal vascular
compromise
Paresthesias may be present if inguinal
nerves are compressed

Diagnosis
Physical exam
The patient should be standing and facing
the examiner
Visual inspection may reveal a loss of
symmetry in the inguinal area or bulge
Having the patient perform valsalvas
maneuver or cough may accentuate the
bulge
A fingertip is then placed in the inguinal
canal; Valsalva maneuver is repeated
Differentiation between indirect and direct
hernias at the time of examination is not
essential

Hernia Exam

Diagnosis
Physical exam
Incarcerated hernias sometimes can be
reduced manually
Gentle continuous pressure on the
hernial mass towards the inguinal ring is
generally effective (Trendelenburg)

Nyhus Classification
Type I: Indirect inguinal hernia
Internal inguinal ring normal
(simple pediatric hernia)
Type II: Indirect inguinal hernia
Internal inguinal ring dilated but
posterior inguinal wall intact
(inferior deep epigastric vessels
not displaced)

Nyhus Classification
Type III: Posterior wall defect
A. Direct inguinal hernia
B. Indirect inguinal hernia- internal inguinal
ring dilated (massive scrotal or sliding hernia)
C. Femoral hernia

Type IV: Recurrent hernia

A. Direct
B. Indirect
C. Femoral
D. Combined

Inguinal Hernia
Indirect inguinal hernia
Is a congenital lesion
Occurs when bowel, omentum or other
abdominal organs protrudes through the
abdominal ring within a patent
processus vaginalis
If the processus vaginalis does not
remain patent an indirect hernia cannot
develop
Most common type of hernia

Indirect Hernia Route

Note:
The hernia sac
passes outside
the boundaries
of Hesselbach's
triangle and
follows the
course of the
spermatic cord.

Inguinal Hernia
Direct inguinal hernia
Proceeds directly through the posterior inguinal
wall
Direct hernias protrude medial to the inferior
epigastric vessels and are not associated with
the processus vaginalis
They are generally believed to be acquired
lesions
Usually occur in older males as a result of
pressure and tension on the muscles and fascia

Direct Hernia Route

Note:
The hernia sac
passes directly
through
Hesselbach's
triangle and
may disrupt
the floor of the
inguinal canal.

Incidence
Approximately 700,000 hernia repairs are
performed as an outpatient procedure
each year
Approximately 75% of all hernias occur in
the inguinal region
Approximately 50% of hernias are indirect
inguinal hernias
A vast majority occur in males
Hernias more commonly occur on the right
side

Causes of Groin Hernias

Divided into two categories:
congenital & acquired defects
Congenital factors are responsible for the
majority of groin hernias
Prematurity and low birth weight are significant
risk factors
Direct hernias are attributed to the wear and
tear stresses of life
Groin hernias have been demonstrated to
occur more frequently in smokers than
nonsmokers especially women

Specific Surgical
Procedures
Lichenstein (Tension Free) Repair
McVay (Coopers Ligament)
Repair
Shouldice (Canadian) Repair
Laproscopic Hernia Repair
Bassini Repair

Bassini Repair
Is frequently used for indirect inguinal
hernias and small direct hernias
The conjoined tendon of the
transversus abdominis and the
internal oblique muscles is sutured to
the inguinal ligament

Bassini Repair

McVay Repair
AKA: Coopers ligament Repair
Is for the repair of large inguinal hernias,
direct inguinal hernias, recurrent hernias
and femoral hernias
The conjoined tendon is sutured to
Coopers ligament from the pubic
cubicle laterally

McVay Repair
Note:
This repair
reconstructs
the inguinal
canal without
using a mesh
prosthesis.

Shouldice Repair
AKA: Canadian Repair
A primary repair of the hernia
defect with 4 overlapping layers of
tissue.
Two continuous back-and-forth
sutures of permanent suture
material are employed. The closure
can be under tension, leading to
swelling and patient discomfort.

Shouldice Repair

Lichtenstein Repair
AKA: Tension-Free Repair
One of the most
commonly performed
procedures
A mesh patch is sutured
over the defect with a
slit to allow passage of
the spermatic cord

Lichtenstein Repair
Note:
Open mesh
repair. Mesh is
used to
reconstruct the
inguinal canal.
Minimal
tension is used
to bring tissue
together.

Laparoscopic Hernia
Repair
Early attempts resulted in
exceptionally high reoccurrence rates
Current techniques include
Transabdominal preperitoneal repair
(TAPP)
Totally extraperitoneal approach (TEPA)

Laparoscopic Mesh
Repair
Note:
Viewed from inside
the pelvis toward the
direct and indirect
sites. A broad portion
of mesh is stapled to
span both hernia
defects. Staples are
not used in proximity
to neurovascular
structures.