Waqas Khan

INGUINAL HERNIA

LAYOUT• Definition• Prevalence• Anatomy• Etiology• Types• Clinical Features• Differential Diagnosis• Management

DEFINITION

The word hernia is derived from a Greek word  "hernios" meaning a bud," related to hira "intestine“.Hernia: A general term referring to a protrusion of a tissue through the wall of the cavity in which it is normally contained. Also known as rupture.

PREVALANCE

• 150,000-500,000 hernias repaired annually in U.S

Anatomy Composition:• The Sac• The Coverings• The Contents

Continued…

Myopectineal Orifice of Fruchaud

The Myopectineal Orifice is bordered: • Superiorly: Fibers of Internal• Oblique and Transversus

Abdominus Muscles (conjoint tendon).

• Medially: Rectus Abdominus Muscle and Rectus Sheath

• Inferiorly: Coopers Ligament

Continued…

• Laterally: Illeopsoas Muscle Contents:

The inguinal ligament runs diagonally through the orifice

Continued…

Hesselbach's triangle

ETIOLOGY

Predisposing factors :• Smoking • Age • Steroids • Immunosuppressive Medication • Collagen disorders • Surgical Wounds

Continued…

• Heavy object lifting • Obesity • Constipation • Coughing • Difficulty urinating

Types of Inguinal Hernias

It has three main types

1. Direct Inguinal Hernia2. Indirect Inguinal Hernia3. Pantaloon

Hernia(combination of both direct and indirect type)

DIRECT INGUINAL HERNIA

INDIRECT INGUINAL HERNIA

CLINICAL FEATURES

• Bulge in the inguinal region• Pain or vague discomfort • Extreme pain in strangulation• Paresthesias if inguinal nerves

are compressed

Clinical Examination

Physical exam:• The patient should be standing

and facing the examiner• Visual inspection may reveal a

loss of symmetry in the inguinal area or bulge

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• Valsalva’s maneuver or cough may accentuate the bulge

• Then ring occlusion test is performed to differentiate between direct and indirect hernia.

Differences

COMPLICATIONS

• Incarceration • Strangulation • Erosion of hernia sac through

weak skin

DIFFERNTIAL DIAGNOSIS

In Males• Hydrocele • Encysted hydrocele of cord• Spermatocele • Femoral hernia • Undescended testis• Lipoma of the cord

Continued…

In Females• Hydrocele of the canal of Nuck • Femoral Hernia

MANAGEMENT

Available options• Conservative Treatment• Surgical Treatment

Conservative TreatmentSupport• Truss• Binder

Not used commonlyss, binder)

Surgical Treatment

• Hernias have been documented throughout history with varying success at either reduction or repair

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It includes• Open Repair • Laparoscopic Repair

Specific Open Surgical Procedures

• Lichenstein (Tension Free) Repair

• McVay (Cooper’s Ligament) Repair• Halstead’s Repair

• Shouldice (Canadian) Repair

• Bassini Repair

Lichtenstein Repair

McVay Repair

Shouldice Repair

Bassini Repair

Laparoscopic Hernia RepairCurrent techniques include

• Transabdominal pre-peritoneal repair (TAPP)

• Totally extra peritoneal approach (TEPA)

TAPP Repair

TEPA Repair

Contraindications to Laproscopy

Contraindications:• large inguinoscrotal hernias• previous abdominal surgeries

MESH

Types of Mesh: A. Synthetic: • Absorbable: Vicryl® & Dexon® • Non-absorbable: Prolene® &

Gortex®

Continued…Biologic:

B. Biologic:

MESH LOCATIONS

INTRA-OP COMPLICATIONS

• Injury to Vas deferens• Injury to viscus ( Colon ad

bladder)• Bleeding

POST-OP COMPLICATIONS

Classified into three type• Immediate• Early• Delayed

Immediate Complications

• Primary hemorrhage• Basal atelectasis• Shock• Complications of Anasthesia

Early Complications• Secondary hemorrhage• Wound dehiscence• Urinary tract infection• Postoperative wound infection• Bowel obstruction due to fibrinous

adhesions

Delayed• Bowel obstruction due to fibrous

adhesions• Persistent sinus• Recurrence • Keloid formation

Take Home Message• Early diagnosis and prompt

treatment should be done in order to avoid complications

• Education of the patients so that they can get themselves treated in time

THANK YOU