HE R

NI
AS
Presented by
Gunawan Tohir SpB.M

H E R N I A
2010

dr.Gunawan

Tohir SpB.MM
F.K.Muhammadiyah Palembang

Pendahulua
n
Sering pada operasi bedah anak

Tampak

sederhana tapi pada bayi-bayi

kecil teknik operasi bisa menyulitkan
Perlu diagnosa & penanganan yg tepat &
cepat - inkarserata
Abad 2: Galen --> abad 16: Ambroise
Pare; terapi bedah --> th 1882: Mitchell
Banks; ligasi kantong tanpa buka can.ing
--> dipopulerkan: th 1990:Mac Lennan &
Herzfeld

Batasan
Hernia inguinalis indirek adalah kegagalan obliterasi
dari processus vaginalis yang terletak antara kavum
abdomen dan kantong vaginal di skrotum.

Etiologi & Insidensi

Sering pada operasi bedah anak
Insiden 1-5%, prematur < 1000 gr 30%,
kembar, kelainan bawaan, riwayat
keluarga
50-60% kanan, 30% kiri, 10-20% bilateral,
P:W: 8-10:1
Indirek - kantong kongenital
Manifestasi setiap saat, terutama 2 bulan
& 1 tahun
Isi: usus halus, tuba falopi

HERNIA BILATERAL:
Insidensi masih kontroversial, perlu karena:
1. Eksplorasi kontralateral negatif adalah operasi yg
tidak perlu.
2. Kesalahan operasi - trauma vaskuler & vas deferen

Patensi proc.vaginalis kontralateral 50%-90% pneumoperitonography 22%-29% - follow up

20%.
Insidensi dipengaruhi: usia<2 bl 63% - 2-16 th
41%, sex; W 50%, ascites, VP shunt, kistik
fibrosis, letak Eksplorasi bilateral rutin pada:
semua laki-laki < 2 thn
semua wanita
infan & anak2 dg predisposisi penyakit tertentu
semua pasien yang dicurigai

Embriologi
* Fase desensi interna
---> Proc.Vaginalis berupa penonjolan/divertikel dr
peritoneum ke dalam dinding abdomen anterior
dekat cincin interna.
* Fase desensi eksterna
* Kontraksi proc.vaginalis menjadi fibrous cord
* Putus hubungan dengan kavum peritoneum sblm,
saat kelahiran s/d usia 2 th (otopsi 37-94%)
* Kegagalan ---> hernia, hidrokel

Anatomi
Cincin

interna - di fascia tranversalis

cincin eksterna - celah dalam aponeurosis
obliquus eksternus
---> lewat fun.spermatikus & lig.rotundum
Dewasa: dinding inguinal post - bgn fascia
endoabdominal/fascia tranversalis -->
herniorafi
Struktur cord: vas deferen, arteri
(a.spermatika int& ekst, a.deferensia),
pleksus pampiniformis

Biologi & Fisiologi (anak & dewasa)

* Asal; kongenital --> proc.vaginalis --> obliterasi:
fibrous cord
* Dewasa; kombinasi 2 faktor, yaitu:
1. Ruang potensial dalam proc.vaginalis
2. Kelemahan krura fascia tranversalis

* Teori kantong Russell meluas + kelemahan fascia

* Integritas kanalis inguinalis dipertahankan oleh:
1. Shutter mechanism; arkus aponeurosis tranversus
2. Sphincter mechanism; sling fascia tranversalis

Fisik.
Anamnesa dari orang tua penting: adanya benjolan yang
hilang timbul - sering dokter bedah tidak bisa
membuktikan. Pemeriksaan fisik berupa asimetri daerah
inguinal - sampai adanya benjolan(spontan, nangis) palpasi: silk golve sign.

Penatalaksana
an
Hampir semua kasus dapat direduksi
Operasi segera setelah reduksi sulit
1-2 jam tidak berhasil --> operasi
Prinsip:

insisi tranversal
ligasi tinggi kantong hernia
penutupan kulit dengan jahitan
subkutikuler

Teknik Operasi

Beberapa hal yang berkaitan

* Testicular Feminizing Syndrome
- familial, G/ awal hernia inguinal (prolaps ovary)
- vagina pendek, labia besar, 46-XY, wanita
- Buccal smear; Barr bodies - jk (-) --> biopsi gonad
* Sliding Hernia
- Buli, Ovarium &Apendiks(apendektomi)
* Tidak didapatkan Vas Deferen
Bisa mjd td awal fibrosis kistik pankreas
* Hernia Direk
Hernia Pantaloon, Ekstrofi buli, Sindr.Ehlers-Danlos

Diagnosa
Banding

Sering pada operasi bedah anak

Insiden 1-5%, prematur < 1000 gr 30%,
kembar, kelainan bawaan, riwayat
keluarga
50-60% kanan, 30% kiri, 10-20% bilateral,
P:W: 8-10:1
Indirek - kantong kongenital
Manifestasi setiap saat, terutama 2 bulan
& 1 tahun
Isi: usus halus, tuba falopi

Komplikasi
Inkarserata:70% 1 tahun - menurun s/d usia 8 tahun

Strangulata
Infark testis 38%, atrofi testis 15%
Kekambuhan 0,8% - 3,8% (predisposisi: tek.intra
abdomen meningkat, ggn pertumbuhan, prematur,
malnutrisi, pykt jar.ikat, ekstrofi buli, undencensus
testiculorum)

Congenital Diaphragmatic
Hernia
a problem unresolved

Congenital Diaphragmatic Hernia

Herniation of abdominal viscera into the thorax
Result from failure of the pleuroperitoneal canal
to close at ~ 8th wk of gestation or early
return of midgut to the peritoneal cavity
Most challenging and frustrating of all neonatal
surgical emergencies

Congenital Diaphragmatic Hernia

50% mortality regardless of the method of
treatment
Incidence: 1:2,000-5,000 live births
M<F 1:1.8, frequently full term
Etiology: unknown
no genetic factors have been
implicated
Antenatal history: polyhydramnios

Congenital Diaphragmatic Hernia

Classification
Absent diaphragm : rare
Diaphragmatic hernia
80% posterolateral L >R
(Bochdalek)
2% anterior (Morgagni)
15 - 20% paraesophageal
Eventration (15 - 20%)

Congenital Diaphragmatic Hernia

Associated anomalies (20-50%)

cardiovascular

13 - 23%

CNS

28%

gastrointestinal

20%

genitourinary

15%

increase the mortality rate

Congenital Diaphragmatic Hernia

Classic Triad
Dyspnea
Cyanosis
Apparent dextrocardia

Congenital Diaphragmatic Hernia

Physical Exam
scaphoid abdomen and barrel chest
bowel sounds in the chest
displaced heart sounds
Laboratory Studies
CBC

ABG

electrolytes

calcium

glucose

Congenital Diaphragmatic Hernia

Diagnosis: chest x-ray

loops of bowel in the
chest
mediastinal shift
absent lung markings

Congenital Diaphragmatic Hernia

IMMEDIATE
Intubation
+
Stomach Decompression

Congenital Diaphragmatic Hernia

Determinants of Survival
degree of pulmonary hypoplasia
ipsilateral lung > contralateral lung

development pulmonary
vasculature

Congenital Diaphragmatic Hernia

Goals of Management
maximize arterial oxygenation
mechanical ventilation: use low inflating
pressures
increases pulmonary blood flow

prevention of pain
fentanyl infusion 3-10 mcg/kg/hr

correction of acidosis

Congenital Diaphragmatic Hernia

Standard Management Strategy

Reduce pulmonary HTN
Moderate alkalosis
pCO2 < 40 mmHg
PaO2 >100 mmHg

Congenital Diaphragmatic Hernia

Recent Strategy
Permissive hypercapnia and hypoxemia
Pressure-limited ventilation (<25 cmH2O)
Postductal pCO2 40-65 mmHg
Preductal SpO2 85-90%
Postductal SpO2 ignored unless pH is
< 7.20 or pCO2 > 65

Congenital Diaphragmatic Hernia

Bohn (1986)
reevaluation of the traditional mad dash
surgical strategy
recommended 24 48 hrs medical stabilization
assessment of efficacy of delayed approach
infants unresponsive to initial therapy will fail to
survive with surgery or any other treatment
including ECMO

Congenital Diaphragmatic Hernia

The Relationship Between PaCO2 and Ventilation

Parameters in Predicting Survival in CHD
Arterial CO2 accurately reflects the degree of
lung development
Poor survival in the presence of severe
pulmonary hypoplasia
CO2 retention and severe preductal shunting
have 90% mortality
Bohn, DJ, et al
J of Pedia Surg 19: 666-671, 1884

Congenital Diaphragmatic Hernia

nomogram:
to predict the degree of pulmonary hypoplasia in
the infants and chance of survival
used the preop PaCO2 and an index of ventilation (Vi)
If PaCO2 < 40 and Vi < 1000: survival almost universal
If PaCO2 > 40 and Vi > 1000: death virtually inevitable
Vi = mean airway pressure x respiratory rate

Congenital Diaphragmatic Hernia

Relationship of Alveolar-arterial Oxygen

Tension Difference in Diaphragmatic
Hernia in the Newborn
A-aDO2 on 100% O2
< 400 mmHg: usually survive
400 - 500 mmHg: intermediate chance
> 500 mmHg: unlikely to survive
Harrington J, et al
Anesthesiology 56: 473-476, 1982

Congenital Diaphragmatic Hernia

Acid Base Balance and Blood Gases in

Prognosis and Therapy of CHD
High Mortality
pH < 7.0
pCO2 >60 mmHg
pO2 < 50 mmHg
Boix-Ochoa J, et al
J Pediatric Surg 9:49-57, 1974

Congenital Diaphragmatic Hernia

Indications of Surgical Repair

Reversal of ductal shunting
O2 index of < 40
Arterial pCO2 maintainable under
40 mmHg
Hemodynamic stability

Congenital Diaphragmatic Hernia

Preoperative Preparation

Look for associated anomalies

Labs: CBC, electrolytes, ABG, glucose,
blood type and crossmatch
Ancillary procedures: CXR, Echo
Venous access: upper extremities
preferred
Prevention of hypothermia

Congenital Diaphragmatic Hernia

Intraoperative Management
Monitors:
ASA standard
invasive : arterial line CVP
foley catheter
* 2 pulse oximeters: preductal and postductal
* precordial stethoscope on the right axilla

NGT to decompress the stomach

Adequate IV access

Congenital Diaphragmatic Hernia

Intraoperative Management
Induction
awake intubation
rapid sequence IV induction and
intubation with assisted or controlled
ventilation
* avoid mask ventilation or PPV before intubation
Supine position, left subcostal incision

Congenital Diaphragmatic Hernia

Intraoperative

Maintenance of anesthesia
volatile agents + IV narcotics + muscle relaxants
TIVA
avoid nitrous oxide
avoid increase in PVR leading to RL shunting:
hypoxia, acidosis, hypothermia, pain
treat metabolic acidosis
replace significant blood loss

Congenital Diaphragmatic Hernia

Intraoperative
Mechanical Ventilation
adjust FiO2 to achieve
PaO2 80 -100 mmHg
SpO2 95 - 98%
small tidal volume to keep airway pressure
< 20-30 cm H2O
high respiratory rate 60-120 /min to
PaCO2 25-30 mm Hg

Congenital Diaphragmatic Hernia

Intraoperative
Surgical repair
primary closure
staged procedure
Transabdominal subcostal incision
Thoracoscopic repair has been reported

Congenital Diaphragmatic Hernia

Intraoperative

Potential Problems
Hypoxemia
distension of stomach
1 pulmonary hypoplasia / pulmonary HTN

Contralateral pneumothorax
Hypotension or IVC compression
Cardiac arrest

Congenital Diaphragmatic Hernia

Postoperative Care
Ventilatory support
Close fluid management
Hemodynamic monitoring
Honeymoon Period followed by deterioration
increase abdominal pressure
impaired peripheral and visceral perfusion
limited diaphragmatic excursion
worsening of pulmonary compliance

Congenital Diaphragmatic Hernia

Management of PPHN
Minimize ETT suctioning
Vasodilators : rarely effective
tolazoline

isoproterenol

nitroglycerin

SNP

PGE1

Inhaled nitric oxide

endothelium - derived relaxing factor (EDRF)
selective pulmonary vasodilation
rapidly metabolized
has not been shown to improve survival

HERNIA FEMORALIS

Incisional Hernia-Treatment
Treatment

is surgical unless
comorbidities preclude this.

HERNIA UMBILIKALIS