CLINICAL SCIENCE SESSION

INGUINAL HERNIA

PRESEPTOR:
Disusun oleh: DR. LIZ A NURSANT Y,
ELSHA SASKIA SP.B, M.KES., FINACS
12100118021 SMF ILMU BEDAH
RS AL-ISLAM BANDUNG
2019
 ANATOMY OF
ABDOMINAL WALL
AND INGUINAL
REGION
ABDOMINAL WALL

• Skin
• Subcutaneous fat
• Scarpa’s fascia
• External oblique muscle
• Internal oblique muscle
• Transversus abdominis
• Transveralis fascia
• Preperitoneal fat
• Peritoneum
 ANATOMY INGUINAL REGION
• Inguinal region disebut juga groin.
• The inguinal canal starts at the internal
inguinal ring and ends at the superficial
ring, containing the spermatic cord in
men and the round ligament in women.
• The integrity of the abdominal wall
depends on the orientation of the
inguinal canal, the transversalis fascia, and
the sphincter-like function of the internal
ring
INGUINAL LIGAMENT AND ILIOPUBIC
TRACT
6
 INGUINAL CANAL
– The canal begins on the posterior abdominal wall,
where the spermatic cord passes through the deep
(internal) inguinal ring.
– The canal concludes medially at the superficial
(external) inguinal ring.
– 4-6 cm long
• Situated in Anterior portion of pelvic basin
• Cone-shaped
BOUNDARIES

• Anterior
– external oblique aponeurosis
• Lateral
– Internal oblique muscle
• Posterior
– fusion of the transversalis fascia and transversus abdominus muscle,
• Superior
– arch formed by the fibers of the internal oblique muscle.
• Inferior
– inguinal ligament
 HESSELBACH’S TRIANGLE
• Medial aspect of Rectus abdominis muscle
• Lateral: Inferior epigastric vessels
• Base: Inguinal ligament
INGUINAL HERNIA
DEFINITION
• Inguinal hernia is a condition in which intra-abdominal fat or part of the small intestine, also
called the small bowel, bulges through a weak area in the lower abdominal muscles

HERNIA’S STRUCTURE
•Consist of sac, ring,
covering, dan content.
EPIDEMIOLOGI

our
office

Hernia inguinal
Approximately 75% of abdominal wall hernias occur in the
groin.
The lifetime risk of inguinal hernia is 27% in men and 3% in
women.
The male:female ratio for inguinal hernias is 7:1
There are approximately 750,000 inguinal herniorrhaphies 12
ETIOLOGI:

• Coughing. • Congenital connective tissue

• Chronic obstructive pulmonary disorders.
disease. • Defective collagen synthesis.
• Obesity. • Previous right lower quadrant
• Straining (constipasi, incision.
prostatism). • Arterial aneurysms.
• Pregnancy. • Heavy listing.
• Birthweight < 1500g • Physical excertion.
• Family history of a hernia.
CLINICAL MANIFESTATION

• a small bulge in one or both sides of the groin that may increase in size and disappear when
lying down; in males, it can present as a swollen or enlarged scrotum
• discomfort or sharp pain—especially when straining, lifting, or exercising— that improves
when resting
• a feeling of weakness or pressure in the groin
• a burning, gurgling, or aching feeling at the bulge
CLASSIFICATION
HERNIA TYPES

Direct
• Direct inguinal hernias are caused by connective tissue degeneration of the abdominal muscles,
which causes weakening of the muscles during the adult years.

• Dua faktor utama dalam perkembangan direct inguinal hernia:

1. Peningkatan tekanan intraabdominal yang ditandai dengan induksi-induksi yang meningkatkan
hernia.
2. Kelemahan dari dinding inguinal posterior.
Indirect
• Indirect inguinal hernias are congenital hernias and are much more common in males than
females
• In a male fetus, the spermatic cord and both testicles—starting from an intra-abdominal
location—normally descend through the inguinal canal into the scrotum, the sac that holds the
testicles  Sometimes the entrance of the inguinal canal at the inguinal ring does not close as
it should just after birth  leaving a weakness in the abdominal wall  Fat or part of the
small intestine slides through the weakness into the inguinal canal  causing a hernia
HERNIA DIRECT AND
INDIRECT Indirect Direct
Patient’s age Any age but ussualy young Older

Cause Maybe congenital Acquired

Bilateral 20% 50%
Protusion on coughing Oblique Straight
Appearance on standing Does not reach full size Reach full size
immediately immediately

Reduction on lying down May not reduce Reduce immediately

immediately

Descent into scrotum Common Rare

Occlution of internal ring Controls Does not control
Neck of sac Narrow Wide
Strangulation Not uncommon Unusual
Relation to inferior epigastric vessels Lateral Medial
20
CLASSIFICATION BY SEVERITY:

– Hernia Reponible
• The protruding mass can be placed back into the abdominal cavity
– Hernia Irreponible
• The protruding mass cannot be placed back into the abdominal cavity
– Hernia Incarcerated
• An irreducible hernia in which he intestinal flow is completely obctructed
– Hernia Strangulated
• An irreducible hernia in which the blood an intestinal flow are completely obstructed;
develops when the loop of intestine in the sac become twisted or swollen and a constriction
is produced at the neck of the sac
 DIAGNOSIS - ANAMNESIS
• Groin pain
• Extrainguinal symptoms
– Change in bowel habits
– Urinary symptoms
• Pressure on nerves
– Generalized pressure
– Local sharp pains
– Referred pain
• Scrotum, testicle or inner thigh
• Duration
• Progressiveness
DIAGNOSIS – PHYSICAL EXAMINATION
DIAGNOSIS - IMAGING

• USG
• CT scan
• MRI
DIFFERENTIAL DIAGNOSIS

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MANAGEMENT

• Non Operative
• Nonoperative inguinal hernia treatment targets pain, pressure, and protrusion of abdominal
contents in the symptomatic patient population

• Operative
• Surgical repair is the definitive treatment of inguinal hernias
 HERNIORAPHY TECHNIQUE
Basini
• The Bassini repair was an historic
advancement in operative technique. Its
current use is limited, as modern
techniques reduce recurrence.
• The original repair includes dissection of
the spermatic cord, dissection of the
hernia sac with high ligation, and extensive
reconstruction of the floor of the inguinal
canal
 Shouldice
• The Shouldice repair recapitulates
principles of the Bassini repair, and
its distribution of tension over
several tissue layers results in lower
recurrence rates
 McVay repair
• The McVay repair addresses both inguinal and femoral ring defects. Once the spermatic cord
has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal
space.
 Prosthetic repair (Lichtenstein
Tension-free repair)
• The Lichtenstein technique expands the
domain of the inguinal canal by
reinforcing the inguinal floor with a
prosthetic mesh, thereby minimizing
tension in the repair
COMPLICATION
RECURRENCE

• Around 1% for Shouldice repair

• Most recurrences are of the same type as the original hernia

• Recurrence Factors
• Patient
• Technical
• Tissue
RECURRENCE FACTORS

• Patient factors
– malnutrition, immunosuppression, diabetes, steroid use, and smoking.
• Technical factors
– mesh size, prosthesis fixation, and technical proficiency of the surgeon.
• Tissue factors
– wound infection, tissue ischemia, and increased tension within the surgical repair
REFERENSI
Schwartz Principle of Surgery 10th edition

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