Category: Education

Presentation Description

No description available.


By: umar550 (74 month(s) ago)

very good

By: drbhaskar1974 (83 month(s) ago)

very nice presentation

By: tazammul (87 month(s) ago)


Presentation Transcript

Hernia & PR : 

Hernia & PR Dr.Mukhtar Ali Mukhtar Surgical depart: Mr.Yasir Mr.Mahmoud Ahmed National Ribat hospital

Hernia : 

Hernia protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains Congenital, acquired Most have an expansile cough impulse

a Hernia composed of; : 

a Hernia composed of; Sac: a folding of peritoneum consisting of a mouth, neck, body and fundus. Body: which varies in size and is not necessarily occupied. Coverings: derived from layers of the abdominal wall. Contents: which could be anything from the omentum, intestines, ovary or urinary bladder.

Slide 5: 

In children, Specifically in infants, the parents" observation of a swelling or protusion may be the only positive feature. In the infancy may beTransilluminable

Inguinal : 

Inguinal Superficial inguinal ring—triangular opening in EOA 1.25 cm above and lateral to the pubic tubercle Deep inguinal ring—oval opening 1.3 cm above and medial to the mid point of inguinal ligament Length of the inguinal canal—3.25cm

Slide 7: 

Ingiunal canal Boundaries MALT: 2M 2A, 2L, 2T: Superior wall [roof]: 2 Muscles:• Internal oblique Muscle• Transverse abdominus Muscle Anterior wall: 2 Aponeuroses:• Aponeurosis of external oblique• Aponeurosis of internal oblique Lower wall [floor]: 2 Ligaments:• Inguinal Ligament• Lacunar Ligament Posterior wall: 2Ts:• Transversalis fascia [laterally]• Conjoint Tendon [medially]

Slide 8: 

Ingiunal canal Contents Ilioinguinal nerve. Spermatic cord, which contains:3 arteries:• Testicular a.• Ductus deferens a.• Cremasteric a.3 nerves:• Ilioinguinal nerve .• Genital branch of the genitofemoral n for cremasteric m• Autonomics{sympathatic}3 other things:• Ductus deferens• Pampiniform plexus• Lymphatics

Covering of the spermatic cord: : 

Covering of the spermatic cord: Internal spermatic fascia(from transversalis fascia) Cremasteric fascia(from internal olique transversus abdominus). External spermatic fascia( from external oblique)

Indirect inquinal hernias : 

Indirect inquinal hernias 60% of adult male inguinal hernia are indirect. 4% of male infants have indirect inguinal herias. {Indirect inguinal hernia most common type in children groin hernia caused by the congenital failure of the process vaginalis to close }

Predisposing factors for indirect hernia: : 

Predisposing factors for indirect hernia: Males:bigger process vaginalis than women. Premature twins or low birth weight: process vaginalis not closed. Africans: the lower arch in the more oblique African pelvis means the internal oblique origin does not protect the deep ring. On the right side: right testis descends later than the left. Testicular feminization syndrome: genotypic male but androgen insensitive so phenotypic female. Young men: direct hernia become more common with age. Increased intra-peritoneal fluid: whatever the cause cardiac, cirrhotic, carcinomatosis, dialysis tend to open the processus vaginalis.

Direct inguinal hernias : 

Direct inguinal hernias 35% of adult male inguinal hernias are direct. 5% of adult male inguinal hernias are a combination of direct & indirect. The direct inguinal hernia is an acquired weakness in the abdominal wall which tends to develop in adult in adulthood (unlike indirect hernias which are common in childern)& mostd are therefore most common groin hernias in old men

Predisposing factors for direct hernia: : 

Predisposing factors for direct hernia: Males Old age. Increased intra-abdominal pressure{chronic cough,obesity,constipation,prostatism}. Aortic aneurysm (associated with a collagen defect) Anatomical variant(10% of adult white males have no lateral extension of the conjoint tendon)

Slide 14: 

The direct inguinal hernia sac lies behind the cord. The inferior epigastric artery lies lateral to the neck. The hernia passes directly forward through the defect in posterior wall (fascia transversalis) of the inguinal canal. The hernia doesn't typically run down along side the cord to the scrotum, but may do so.

Femoral sheath: : 

Femoral sheath: Downward protrusion into the thigh of the fascial envelop lining the abdominal walls.it surrounds the femoral vessels &lymphatica for about 2.5 cm below the inguinal ligment .it ends by fusing with the tunica adventitia of the femoral vessels. This occur close tp the saphenous opening in the deep fascia of the thigh.

Content of the femoral sheath: : 

Content of the femoral sheath: Femoral artery laterlly. Femoral veins intermediate. Lymphatics in medial compartment. Femoral branch l1 of genito-femoral nerve:pierce the ant wall of the femoral sheath running on the ant surface of external iliac artery.

Slide 17: 

Femoral canal Lying in the medial compartment of the femoral sheath contain lymphatic's about 1.3 cm with an upper opening called the femoral ring contains: Fatty connective tissue. Efferent lymph vessels from deep inguinal nodes. Deep ingunial node of Cloquet (drain penis /clitoris)

Slide 18: 

Femoral ring Boundaries of the femoral ring: Anterioly: inguinal ligament Posterioly:superior ramus of pubis & pectineal ligment. Medi ally:lacunar ligament or ilio-pubic tract. Laterally:f emoral vein.

Femoral Hernia (cont..) : 

Femoral Hernia (cont..) Femoral hernias are more common in women, present as a groin lump. the cause of unexplained small bowel obstruction. an absent Cough impulse globular lump than the pear shaped lump of the inguinal hernia. Differential Diagnoses: Inguinal Hernia. Femoral Artery Aneurism. Femoral Lymphadenopathy. Psoas Abscess. Lipoma Ectopic testis Obturator hernia. Psoas bursa Psoas abscess.

Indication for groin repair: : 

Indication for groin repair: Nonmandatory:Small,easily reducible direct. Elective :indirect ,symptomatic direct. Prompt :irreducible inguinal hernia,history >4 weeks. Urgent: All femoral hernias. Emergency: Painful irreducible hernia Follow up in 1 year. Rate of strangulation of ihguinal hernia is 0.3 -3.9% icreased risk if irreducible. Gerater risk of strangulation in first 3 months after apperance. 50% strangulate within 1 month.

Diagnosis: : 

Diagnosis: Usually clinical . imaging to confirm diagnosis: U/S CT Contrst herniogram

Slide 22: 

Types of indirect inguinal hernia 1. Incomplete;     Bubonocele—limited within the inguinal canal    Funicular—limited just above the epididymis 2.Complete; traverses to the bottom of the scrotum

Clinical Examintion: : 

Clinical Examintion: Introduce yourself Wash hands Chaperone Standing up Undressed from waist down Look for an visible lumps Any scars, overlying skin changes. The lump extends into the scrotum

Slide 24: 

position Pt. stands, exposed area visible. best performed with the patient standing and in supine the physician seated on a stool

Prepare : 

Prepare Stand at the side of the patient, one hand on the patients back to support him. hand and arm should be roughly parallel to the inguinal ligament when palpating the lump.

Slide 26: 

Observation of the groin area in oblique light Visible swelling. Examine as a mass; (STEM; site,skin,size,shape,…) Mass

Most important : 

Most important Can you get above it? Reducibility test Expansile Cough Impulse; Invagination test Three finger test Zieman’s technique 6. Ring occlusion test

Also Asses : 

Also Asses Intra or extra abdominal Tension Composition Percussion and auscultation; Bowel Sounds Always examine both groins Tranillumination

Slide 29: 

1-Cough Impulse Pt. coughs to highlight hernia. May not ;if the neck is blocked by adhesions Visible & Palpable cough impulse. Reappear on straining, standing or coughing

2-Reducibility test : 

2-Reducibility test Ask pt. to reduce hernia himselves usually done in lying position. The thigh of the affected side should be flexed, adducted and internally rotated. Finger guard of the inguinal canal by thumb and index finger and then the scrotum is gently squeezed.

Relation to Pubic Tubercle : 

Relation to Pubic Tubercle INGUINAL HERNIA; The neck above and medial to the pubic tubercle FEMORAL HERNIA; The neck below and lateral to pubic tubercle

Slide 32: 

3-Get above the swelling test Done in standing position At the root of the scrotum place the thumb in front and the index behind Try to reach above the swelling. Inguinal hernia; cannot get above Pure scrotal swelling; will get above

Slide 33: 

4-Invagination test The scrotum on each side is inverted with the examining index finger Entering the inguinal canal along the course of the cord structures. The size of the external ring. The finger push up to the superf inguinal ring. The pulp should feel the ring. Pat is asked to cough, A palpable impulse will confirm the hernia; felt on the pulp then direct felt on the tip then indirect hernia.

Slide 35: 

5-Three finger test / Zieman’s technique Index finger; deep inguinal ring (indirect hernia) Middle finger; superficial ing. Ring (direct hernia) Ring finger; saphenous opening (femoral hernia) The patient is asked to cough.

Slide 36: 

6-Ring occlusion test Reduce the hernia Occlusion of the deep ring by thumb. Then holding the thumb in position ask The pt to stand then cough If no bulging; indirect If bulging; direct .

Beside : 

Beside Beside; at the level of inguinal region at the affected side; Notice a small bulge Compare to the other side. Stand beside the pt; your shoulder behind the opposite shoulder of pt; Reduce the hernia. Ask the pt to cough

Slide 38: 

Examine the abdomen; Causes Of raised intraabd. pressure; Enlarged bladder (BPH) Ascites Search; predisposing factors;

Slide 39: 

Describe the hernia: 1.  Site (inguinal) 2.  Right/Left 3.  Reducible/Irreducible 4.  Complete/Incomplete 5.  Direct/Indirect

Slide 40: 

Any hernia that is tender Nausea and vomiting; No attempt to reduce it manually. An acute surgical emergency. Strangulation

Main approches: : 

Main approches: Shlulidice technique Mesh repair. Laparoscopic repair. Macvay Cooper ligamrnt operation.

Post operative advice after repair: : 

Post operative advice after repair: Often home the same day. Eat v,drink & moilise on waking. Back to sedentary job within 2 weeks. Back to heavy lifting ,sternous sports & manual labour in 6 weeks. Safe to drive wafter 3 weeks. Oral analgesia for few days.

Complication of open repair if inguinal hernia: : 

Complication of open repair if inguinal hernia: Haematoma. Wound infection and mesh infection. Recurrence. Testicular atrophy or ishemic orchitis due to cord damage in males. Temporary post –operative urinary retention due to pain in elderly or those with ore existing prostatic symptoms.

Slide 44: 

indirect summary Relation to epigastric vessels; Lataral Processus vaginalis; Present congenital Unilateral (usually). always descends the scrotum prone to obstruction and strangulation

Slide 45: 

Direct summary Bilateral Acqiured Processus vaginalis; Absent Rarely strangulate; medial to epigastric vessels;

Umbilical Hernia: : 

Umbilical Hernia: In infants & children. Boys more than girls. Tend to resolve without any treatment by around the age of 5 years. Obstruction and strangulation is rare.

Paraumbilical Hernia: : 

Paraumbilical Hernia: Affects adults. either supra or infraumbilical through the linea alba. The female to male ratio is 20:1. Clolicky pain and/or irreducibilty due to omental adhesions.

Incisional Hernia : 

Incisional Hernia weakness is the result of an incompletely healed surgical wound. more along a straight line from the sternum down to the pubis. Swelling at the incisional site +/- pain.

Epigastric Hernia : 

Epigastric Hernia a defectin the linea alba between the xiphoid process and umbilicus Starts as a protrusion of the extraperitoneal fat Swelling +/- pain similar to a peptic ulcer pain.

Rare external Hernias : 

Rare external Hernias Spiglian Hernia: spaces of the semilunar line and the lateral edge of the rectus muscle (inferior to the arcuate line). The posterior rectus sheath is weak Preoperative diagnosis is diffucult u/s & c.t are helpful tools in the diagnosis

2-Lumbar Hernias: : 

2-Lumbar Hernias: Broad bulging hernia not vulnerable to incarceration. A. Petit’s hernia: inferior lumbar triangle. B. Grynfeltt’s Hernia:superior lumbar triangle and is less common than Petit’s.

Slide 54: 

Thank for attension

authorStream Live Help