HERNIA

shu ting
CASE STUDY
MR X, 35 yo gentleman
a manual labour by occupation
presented with a swelling in his right groin and scrotum for last 2
years and pain over the swelling for past 6 months
the swelling appear insidiously,initially in the right groin and
descended to the bottom of right scrotum
the swelling disappeared completely when patient lies downbut
reappear on standing and increases insize as the patient walks,
cough and strains at defaecation
bladder and bowel habit are normal
on examination
a swelling in right inguinoscrotal region extending from right inguinal canal to
bottom of the scrotum,epididiymis cannot be palpated separately
pyriform in shape,skin over the swelling is normal
visible peristalsis and epansile impulse on cough over the swelling
swelling is soft and elastic in feel
swelling lies above and medial to the pubic tubercle
invagination test-coughing in the impulse touches the tip of th index finger
deep ring occlusiion test is positive

Diagnosis
HERNIA
abnormal protrusion of a viscus or part of a viscus through an opening
in the cavity in which it is normally contained.
Location of hernia
INGUINAL HERNIA
ANATOMY
1. INGUINAL LIGAMENT
2. LACUNAR LIGAMENT
3. INGUINAL CANAL
4. DEEP RING
5. EXTERNAL RING

BOUNDARIES of inguinal canal

1. anterior
2. superior
3. inferior
4. posterior
HESSELBACH'S TRIANGLE
CAUSE OF HERNIA
1. CONGENITAL
2. COLLAGEN FIBRE DISORDER
3. OBESITY
4. CHRONIC CAUSE OF INCREASE INTRA-ABDOMINAL PRESSURE
5. WEAKNESS OF CONJOINED TENDON/RUPTURE OF A FEW FIBRES
 DIRECT VS INDIRECT HERNIA
DIRECT HERNIA INDIRECT HERNIA

age common in elderly can occurin any age group

aetiology weakness of posterior wall of inguinal canal preformed sac

precipitating factors chronic bronchitis,enlarged prostate -

on standing pops out does not pop out

side usually bilateral unilateral(30% bilateral)

complication not common because neck is wide common,neck is narrow-obstruction

and strangulation

relationship of sac to cord sac is posterior to cord saic is anterolateral to cord

direction of the sac it comes out of hesselbach's triangle sac comes through the deep ring
NATURE OF HERNIA
1. REDUCIBLE
2. IRREDUCIBLE
incarcerated, strangulated and obstructed

INCARCERATED OBSTRUCTED STRANGULATED

a hernia as being four cardinal signs of occluded blood supply

irreducible but not obstruction(pain,vomit pressure at the neck of
obstructed o ing,distention and hernia
strangulated constipation)
PHYSICAL EXAMINATION
INSPECTION
side where the swelling is present-right /left
position and extend of the swelling:
a swelling is seen in right/left inguinoscrotal region
extend above upto the inguinal cnal and below upto the bottom of scrotum
size
shape
surface- regular/irregular
margin- rounded/ ildefined
expansile impulse on cough over the swelling
skin over the swelling- any scar/engorved vein/pigmentation
any visible peristasis over the sweling
 testis - whether testis could be seen separately from the swelling or
swelling is seen all around the testis

PALPATION
temperature,tenderness
size- a complete hernia is usually pyriform in shape
consistency -
soft anf elastic
doughy
tense and tender
reducibility
 invagination
normally the superficial ring does ot admit the tip of index finger
in complete hernia,superficial inguinal ring become patulous

deep ring occlusion test

(+) if no impulse is sen on coughing after the deep ring is occluded by the
thumb suggesting this to be an indirect inguinal hernia
(-) if expansile impulse is seen in inguinal canal medial to the occluded deep
ring suggesting this to be a direct inguinal hernia

PERCUSSION
resonant ----suggest enterocoele
dull----suggest omentocoele
AUSCULTATION
bowel sound over the swelling suggest enterocoele
TREATMENT
1. herniotomy
2. herniorrhaphy
bassini
shouldice
3. herniplasty
4. laparoscopy herniotomy
FEMORAL HERNIA
herniation of intra-abdominal
contents through the femoral
canal
contents:
fat
fascia
lymphatics:lymph node of cloquet
BOUDARIES of femoral ring
anterior : inguinal ligament
posterior : ligament of cooper, iliopectineal ligament
medial : lacunar ligament
lateral : thin septum which separates the femoral canal from femoral vein

CAUSES for femoral hernia

pregnancy
wide femoral canal
NEVER CONGENITAL
CLINICAL FEATURES

females between age of 20-40 years are commonly affected

Gaur sign
right side is more commonly affected
to start with,there is a small swelling below the inguinal, which goes
unnoticed very often
expansile impulse is often not present due to the narrow canal
TYPICALLY, the swellig is below and lateral to the pubic turblecle
TREATMENT
low operation of lockwood
inguinal operaition
combined approach : high
operation of McEvedy
henry's approach
UMBILICAL HERNIA & PARAUMBILICAL HERNIA
1. umbilical hernia of newborn
1. it is call as Omphalocele- exomphalos
2. found 1 in 6000 live births
3. failure of midgut as a whole or part into coellomic cavity during
embryonic life

2. umbilical hernia of infants and children

1. occurs as a complication of umbilical sepsis, which weakens
the umbilical scar
3. paraumbilical hernia of adults
not a true umbilical hernia but it is a para-umbilical
CLINICAL FEATURES
swelling in the umbilical region
expansile impulse present
dragging pain

TREATMENT
1. reduction of weight
2. anatomical repair
3. mesh repair-lparoscopic
method
4. Mayo's repair
INCISIONAl HERNIA
called as VENTRAL HERNIA

FACTORS which precipitate incisional hernia

infection
anatomical site
obesity
faulty technique
ascites
TREATMENT
anatomival repair
mesh repair
laparoscopic mesh repair
keel operation
REFERENCES
manipal manual of surgery ,third edition
schwatz's principle of surgery,ninth edition
bedside clinics in surgery, academic publishers
THANK YOU