Hernia Inguinal

Lateral
Angeline Soeparto
12/335437/KU/15248

RSUD SLEMAN
2017
 Identitas Pasien
Nama : Bp. Y
Jenis kelamin : laki-laki
Usia : 35 tahun
Alamat : Jombor
Tanggal periksa : 19 September 2017
 Anamnesis
Keluhan Utama: nyeri dan benjolan
diselangkangan.
Riwayat penyakit sekarang: 2 thn yang lalu
muncul benjolan pada selangkangan kiri pasien,
namun jika ditekan masih bisa masuk kembali. 2
bulan terakhir pasien pasien mengeluh benjolan
sdh tidak dikembalikan dan terasa nyeri. Pasien
bekerja di ternak dan sering mengangkat benda
dengan beban berat. Demam (-), mual (-), muntah
(-), batuk (-), konstipasi (-).
Riwayat penyakit dahulu: Alergi (-), Asma (-), HT (-),
DM (-)
 Pemeriksaan fisik
Pemeriksaan tanggal 19 Septmber 2017
Kesan umum : compos mentis
VS :
TD : 140/85 mmHg
N : 82x/mnt, simetris, isi cukup, tegangan kuat
RR : 20x/mnt
T : 36.5 o C
VAS : 6
 Thorax-Pulmo
Thorax depan KANAN KIRI
Inspeksi Pengembangan dada Pengembangan dada
ka=ki, Retraksi (-) ka=ki, Retraksi (-)
tampak lesi luka tampak lesi luka
bakar . bakar .

Palpasi Fremitus taktil kanan=kiri

Perkusi Sonor (+) Sonor (+)
Auskultasi Vesikular
KANAN (+), ronchi Vesikular
KIRI (+), ronchi
(-), wheezing (-), (+), wheezing (-),
Inspeksi Pengembangan
krepitasi (-) dada Pengembangan
krepitasi (-) dada
ka=ki, Retraksi (-) ka=ki, Retraksi (-)
Palpasi Fremitus taktil kanan=kiri
Perkusi Sonor (+) Sonor (+)
Auskultasi Vesikular (+), ronchi Vesikular (+), ronchi
Thorax belakang (-), wheezing (-), (-), wheezing (-),
krepitasi (-) krepitasi (-)
 Pemeriksaan jantung
I : IC tidak tampak
P : IC dibelakang sternum
P : Batas jantung: kardiomegali (-)

SIC II LPS D SIC II LPS S

SIC IV LPS D S IV IC LMC S

A : S1 S2 reguler, bising (-), gallop (-)

 Abdomen
o Abdomen
Inspeksi : Dinding perut terlihat sejajar
dinding dada, tidak tampak lesi.
Auskultasi : peristaltik usus positif tidak ada
peningkatan
Perkusi : timpani, shifting dullness (-), ascites (-)
Palpasi
o Supel, nyeri tekan ulu hati (-), turgor/elastisitas
normal
o Hati : teraba 2 cm bac
o Lien: tidak teraba
 Anogenital
tampak benjolan di lipat paha kiri hingga ke scrotum,
lesi (-), nyeri (-).
Finger test (+)
 Ekstremitas
CRT < 2 detik
Akral hangat, nadi kuat
Ekstremitas atas : edema -/-,
Ekstremitas bawah : edema -/-
 KEPALA-LEHER
Mata : konjunctiva anemis (-/-) cairan (+)
Hidung : rhinorrhea (-), nasal flare (-)
Telinga : tidak ada sekret
Mulut : bibir pecah-pecah (+)
Faring : hiperemis (-)
Leher : limfonodi tidak teraba
 Pemeriksaan Dl tanggal 25Februari 2017
No Pemeriksaan Hasil Satuan Keterangan
1. Leukosit 6.9 10^3/L Normal
2. Eritrosit 5.12 10^6/L Normal
3. Hemoglobin 15.1 g/dL Normal
4. Hematokrit 44 % Normal
5. RDW-CV 13.3 % Normal
6. MCV 79.7 fL Normal
7. MCH 25.6 pg Normal
8. MCHC 32.1 g/dL Normal
9. Trombosit 225 10^3/L Normal
10. Neutrofil 68.8 % Normal
11. Limfosit 20.9 % Normal
12. Monosit 4.3 10^3/L Normal
13. Eosinofil 3.6 10^3/L Normal
14. Basofil 0.2 10^3/L Normal
15. HBSAG Non Non Reaktif Normal
Reakti
No. Pemeriksaan Hasil Satuan Keterangan
16. Ureum 27.7 mg/dl Normal
17. GDS 96 mg/dl Normal
 Hasil Foto Thorax
Kesan :
- Pulmo tak tampak kelainan
- Cor dalam batas normal
 Diagnosis
Hernia Inguinal lateralis
 Tindakan
Rencana op 22 september 2017
 Hernia
Suatu keadaan keluarnya jaringan/organ
tubuh dari suatu ruangan melalui
lubang/celah keluar di bawah kulit atau
menuju rongga lainnya (secara
kongenital atau aquisital)

Bagian-bagian hernia:
Pintu hernia LMR (Locus Minoris
Resistentiae) yang dilalui kantong
hernia
Kantong hernia peritoneum parietal
(tidak semua hernia punya kantong,
misal: hernia adiposa, hernia incisional)
Leher hernia bagian tersempit
Isi hernia gaster, usus, VU, ovarium,
omentum
 Tipe hernia
o EKSTERNA isi hernia berasal dari cavum abdominalis
melalui LMR keluar sampai subkutis, teridiri dari:
Hernia Inguinalis Lateral, Hernia Inguinalis Medial,
Hernia Umbilikalis, Hernia Epigastrika, Hernia Lumbalis,
Hernia Semilunaris, Hernia Pelvica (femoralis,
obturatoria, perinealis, ischiadica)
o INTERNA isi hernia dari cavum abdominalis masuk ke
rongga lain. Diagnosis ditentukan dengan Rontgen Foto
Intra-peritonealis (hernia epiploicum winslowi, hernia
bursa omentalis, hernia mesenterica)
Retro-peritonealis (hernia paraduodenalis, hernia
recessus illeocecalis, hernia recessus sigmoideus)
Hernia Diafragmatika Morgagni, Bochdalek, hiatal
 Tipe hernia
SECARA KLINIS
1. REPONABILIS dapat dimasukkan kembali
tanpa operasi
2. IRREPONABILIS tidak dapat dimasukkan, harus
Operasi
3. AKRETA mengalami perlengketan
4. INKARSERATA hernia irreponabilis disertai
gejala ileus
5. STRANGULATA Isi hernia tidak dapat
dikembalikan dan terjepit oleh
cincin hernia, terdapat
gangguan vaskularisasi, nyeri
hebat
 Etiologi
KONGENITAL
Sempurna proses intrauterin (terjadi sejak lahir, misal: hernia
umbilikalis, hernia epigastrika, omphalocele kongenital)
Tidak Sempurna waktu lahir tak tampak, setelah ada faktor
predisposisi baru nampak, misal: hernia inguinalis lateralis akibat
processus vaginalis abdominis persistens tak dapat masuk ke
skrotum
ACQUISITA
Tekanan intra abdominal yang tinggi
Konstitusi tubuh
Banyak preperitoneal fat
Distensi dinding perut
Sikatrik
Penyakit yang melemahkan otot-otot dinding perut
Faktor-faktor predisposisi Insiden Hernia
Herediter individu tipe asthenik (fascia transversa
abdominis lemah)
Umur dan pekerjaan usia > 50 tahun karena dinding
perut mulai melemah
Jenis kelamin
o HIL banyak terdapat pada laki-laki karna terdapat
processus vaginalis peritonii
o Hernia Femoralis banyak pada wanita karena:
Sering partus tekanan intra abdominal meningkat
dan anulus femoralis melemah
Bentuk pelvis lebih horizontal tekanan ligamentum
inguinale lebih besar anulus femoralis melemah
Keadaan Tubuh
Obesitas preperitoneal fat banyak fascia transversa
abdominis lemah hernia adiposa
 Faktor presipitasi
hernia
Peningkatan tekanan intra abdomen
Batuk
Muntah
Mengejan saat BAK atau BAB
Hamil dan melahirkan
Angkat berat maupun olahraga berat
Obesitas
Ascites
Gross organomegaly
 Inguinal Hernia
Inguinal hernia is the commonest hernia,
and is approximately 10 times more
common in males than females. It is more
common on the right than on the left, the
ratio being 2:1.
Two types of inguinal hernia (IH) are
recognised indirect (IIH) and direct (DIH),
but they can occur together.
 Direct inguinal hernia
Direct inguinal hernia (DIH)
A DIH protrudes directly through the posterior wall of the inguinal
canal, medial to the inferior epigastric artery and deep inguinal
ring. The essential fault with a DIH is weakness of the inguinal
canal, and is invariably associated with poor abdominal
musculature. Herniation occurs at a site where the transversalis
fascia is not supported by the conjoint tendon or the transversus
aponeurosis, an area known as Hesselbach's triangle. The neck of
a DIH is usually larger than the body and so strangulation is rare.
The hernia passes forwards as it enlarges, stretching muscle and
fascial layers. It rarely reaches a large size or approaches the
scrotum. Occasionally, the inferior epigastric vessels straddle the
hernia which is then known as a pantaloon hernia.
Direct IH is rare in females and does not occur in children. It is
more common on the right side after appendicectomy,
suggesting that damage to the iliohypogastric and ilio-inguinal
nerves with subsequent weakness of the internal oblique and
transversus abdominis muscles is an aetiological factor.
 Indirect inguinal hernia
It is five times more common than a direct inguinal
hernia, and is seven times more frequent in males,
due to the persistence of the processus vaginalis
during testicular descent.
In children, the vast majority of inguinal hernias are
indirect.
Indirect inguinal hernias arise lateral and superior to
the course of the inferior epigastric vessels, lateral to
the Hesselbach triangle, and then protrude through
the deep or internal inguinal ring into the inguinal
canal. An indirect hernia enters the inguinal canal
at the deep ring, lateral to the inferior epigastric
vessels. It passes inferomedially to emerge via the
superficial ring and, if large enough, extend into the
scrotum.
Direct vs indirect
Direct vs indirect
 Clinical presentation
Inguinal hernias present with inguinal discomfort, with or
without a lump. Discomfort is due to stretching of the
tissues of the inguinal canal and occurs typically when
IAP is increased. Pain may also be referred to the testis
because of pressure on the spermatic cord and ilio-
inguinal nerve. Severe inguinal or abdominal pain
suggests obstruction or strangulation. A lump is usually
obvious to the patient, is often precipitated by
increasing IAP, and may reduce completely with rest
and lying down.
 The patient initially is examined standing to demonstrate
the lump and possible cough impulse, and then lying
down to allow the hernia to be reduced. An IIH
protrudes along the line of the inguinal canal for a
variable distance towards the scrotum or labia; a DIH
appears as a diffuse bulge at the medial end of the
inguinal canal. The significance of a cough impulse, or
sudden bulging of the inguinal region with coughing,
must be interpreted carefully. A generalised weakness in
the inguinal region will result in a diffuse bulge appearing
with coughing, but this condition (known as a
Malgaigne's bulge) is not the same as a hernia in which
the cough impulse is discrete and confined to the area
of herniation. Abdominal examination is performed to
detect organomegaly, a mass or ascites.
 Complication #1
1. Irreducibility
A hernia is irreducible when the sac cannot be
emptied completely of contents. Irreducibility is caused
by (i) adhesions between the sac and its contents, (ii)
fibrosis leading to narrowing at the neck of the sac, or
(iii) a sudden increase in IAP that causes transient
stretching of the neck and forceful movement into the
sac of contents, which cannot subsequently return to
their original location.
Generally, irreducible hernias should be operated on
soon after presentation. Although irreducibility is not an
indication for urgent operation, it is the step before
obstruction supervenes. In addition, irreducible hernias
are usually painful.
 Complication #2
2. Obstruction
A hernia becomes obstructed when the neck is
sufficiently narrow to occlude the lumen of the intestine
contained within the sac. Obstructed hernias are nearly
always irreducible and, if not treated, may become
strangulated. Often, there is a history of a sudden
increase in IAP that has pushed intestine or other
contents into the sac. The patient presents with
symptoms and signs of intestinal obstruction (abdominal
colic, vomiting, constipation, abdominal distension),
together with a tender irreducible hernia. Failure to
examine the hernial orifices in a patient with intestinal
obstruction may lead to the wrong operative approach
being undertaken. It may be difficult to distinguish
obstruction from strangulation on clinical grounds, and
therefore obstructed hernias should be treated as a
matter of urgency.
 Complication #3
3. Strangulation
Strangulation means that the blood supply of the
contents has ceased due to compression at the hernial
orifice. Initially, lymphatic and venous channels are
obstructed, leading to oedema and venous congestion
but with continued arterial inflow. When the tissue
pressure equals arterial pressure, arterial flow ceases and
tissue necrosis ensues. Strangulation is a serious
complication and, if the intestine is involved, leads to
peritonitis which can be fatal. A strangulated hernia is
both irreducible and obstructed, and is very tense and
usually exquisitely tender. Erythema of the overlying skin
is a late sign. Strangulated hernias must be operated on
urgently. A strangulated Richter's hernia is not preceded
by intestinal obstruction and there may be few local
signs.
 HIL VS HIM VS Hernia
femoralis
Tes visibel: hernia tereposisi, penderita diminta
mengejan
o HIL: benjolan keluar dari kraniolateral ke
kaudomedial, keluar lambat, berbentuk lonjong
o HIM: benjolan keluar langsung pada daerah medial,
berbentuk bulat
o Hernia femoralis: benjolan keluar di bawah lig.
inguinalis, keluar lambat

Tes oklusi: hernia tereposisi, ibu jari menutup anulus

inguinalis, pasien diminta mengejan
o HIL: benjolan tidak keluar
o HIM: benjolan keluar
o Hernia femoralis: benjolan keluar
HIL VS HIM VS Hernia
femoralis
Tes taktil: hernia tereposisi, jari
telunjuk menyusuri canalis inguinalis,
pasien diminta mengejan
o HIL: dirasakan di ujung jari
o HIM: dirasakan di samping/sisi jari

Tes Zieman: hernia tereposisi, jari II di

anulus internus, jari III di anulus
eksternus, jari IV di fosa ovalis, pasien
diminta mengejan
HIL: dorongan pada jari II
HIM: dorongan pada jari III
Hernia femoralis: dorongan pada
jari IV
 Treatment
KONSERVATIF
Reposisi memasukan isi hernia ke dalam
cavum abdomen
Suntikan setelah reposisi berhasil, cairan
sklerotik (alkohol/kinin)
Sabuk hernia bila pintu hernia masih
kecil

DEFINITIF SURGERY
Hernia reponible --> elektif
Hernia inkarserata & strangulata -->
emergency

Teknik operasi:
Herniotomi (pada anak-anak)
Herniorrhaphy
Hernioplasty
 Teknik operasi
Herniotomy
o Removal of hernial sac only
Herniorraphy
o Herniotomy plus repair of the posterior wall of
inguinal canal
Hernoplasty
o Herniotimy plus reinforcement of the posterior
wall of the inguinal canal with synthetic mesh
Post surgical management
Patients require analgesia for the first few days.
They should avoid straining and lifting for about 4
weeks after surgery, and avoid very heavy physical
work for about 68 weeks.
The average length of stay off work is approximately
24 weeks after open repair and 12 weeks after
laparoscopic repair.
 Complications of surgery
Durante Op:
Nerve injury - injury to the ilio-inguinal nerve, which lies below the
spermatic cord in the inguinal canal and passes out through the
superficial inguinal ring, occurs in 1020% of inguinal hernia repairs,
resulting in paraesthesia or numbness below and medial to the
wound over the pubic tubercle and proximal scrotum. The lateral
cutaneous nerve of the thigh and the femoral nerve are at risk during
laparoscopic repair.
Injury to the vas deferens - a rare complication, is most likely to occur
when a recurrent hernia is repaired and with laparoscopic repair.
Visceral injury - viscera in a sliding hernia are at risk for injury when the
sac is being dissected away from them.
Testicular ischaemia and atrophy - interruption of the testicular
arterial supply (testicular artery and indirectly from the cremasteric
artery and the artery of the vas deferens) can occur during
dissection of an indirect sac from the cord. Ischaemia produces
testicular pain, tenderness and swelling. Testicular atrophy is
observed in 15% of males.
 Complications of surgery
Post Op:
Urinary retention - Elderly male patients are particularly susceptible to
retention of urine. Prostatic symptoms should be identified and
treated before the hernia is repaired.
Scrotal swelling and haematoma - Oedema, swelling and bruising of
the scrotum are common (especially with bilateral repairs) and
resolve spontaneously. Scrotal support may bring symptomatic relief.
Large haematomas require operative drainage.
Wound infection - A deep wound infection which does not settle with
antibiotocis requires removal of the prosthetic mesh.
Persisting wound pain - This is uncommon, and results from nerve
entrapment or damage, neuroma formation, osteitis pubis if sutures
have been inserted into the pubis, displacement of a mesh repair, or
pressure on the spermatic cord. Pain may be a symptom of recurrent
herniation. Local anaesthetic or phenol injections may help, and
surgical exploration is indicated for severe or persistent pain.
Post Op:
Recurrent hernia - Recurrence is related to
surgical technique and expertise, experience of
the operator, postoperative infection and
haematoma, and failure to correct factors
predisposing to hernia formation. Also, failure to
examine the spermatic cord for the presence
of an indirect inguinal sac when repairing a DIH
may lead to an apparent recurrence.
Recurrence rates should be less than 2%. About
50% of recurrences appear within 5 years after
the initial repair, and approximately 50% of
recurrences are indirect hernias.
Hydrocele - a long-term complication probably
resulting from the repair being too tight or
scarring, with subsequent compression of
lymphatics of the cord.
Terima Kasih