INGUINAL HERNIAINGUINAL HERNIAAYU WULAN ANGGRENI

DEFINITIONDEFINITION

A protrusion of the intestines into an opening between the deep epigastric artery and the edge of the rectus muscle; (indirect) involves the internal inguinal ring and passes into the inguinal canal.

ETIOLOGYETIOLOGY

abdominal hernias can be present at birth, others develop later in life. Some involve pathways formed during fetal development, existing openings in the abdominal cavity, or areas of abdominal-wall weakness

ETIOLOGYETIOLOGY

Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia. Examples include :

obesity

heavy lifting

coughing

straining during a bowel movement or urination,

chronic lung disease, and

fluid in the abdominal cavity

CLASSIFICATIONCLASSIFICATION

There are two types of inguinal hernia direct and indirect, which are defined by their relationship to the inferior epigastric vessels

Direct inguinal hernias occur medial to the inferior epigastric vessels when abdominal contents herniate through the external inguinal ring.

Indirect inguinal hernias occur when abdominal contents protrude through the deep inguinal ring, lateral to the inferior epigastric vessels; this may be caused by failure of embryonic closure of the processus vaginalis.

SIGN AND SYMPTOMPSSIGN AND SYMPTOMPS

Hernias present as bulges in the groin area that can become more prominent when coughing, straining, or standing up. They are rarely painful, and the bulge commonly disappears on lying down. The inability to "reduce", or place the bulge back into the abdomen usually means the hernia is 'incarcerated' which is a surgical emergency.

Significant pain is suggestive of strangulated bowel (an incarcerated indirect inguinal hernia).

As the hernia progresses, contents of the abdominal cavity, such as the intestines, can descend into the hernia and run the risk of being pinched within the hernia, causing an intestinal obstruction. If the blood supply of the portion of the intestine caught in the hernia is compromised, the hernia is deemed "strangulated," and gut ischemia and gangrene can result, with potentially fatal consequences

PATOPHISIOLOGYPATOPHISIOLOGY

In men, indirect hernias follow the same route as the descending testes, which migrate from the abdomen into the scrotum during the development of the urinary and reproductive organs. The larger size of their inguinal canal, which transmitted the testicle and accommodates the structures of the spermatic cord, might be one reason why men are 25 times more likely to have an inguinal hernia than women. Although several mechanisms such as strength of the posterior wall of the inguinal canal and shutter mechanisms compensating for raised intra-abdominal pressure prevent hernia formation in normal individuals, the exact importance of each factor is still under debate

COMPLICATIONCOMPLICATION

Most inguinal hernias enlarge over time if they're not repaired surgically. Large hernias can put pressure on surrounding tissues — in men they may extend into the scrotum, causing pain and swelling.

But the most serious complication of an inguinal hernia occurs when a loop of intestine becomes trapped in the weak point in the abdominal wall (incarcerated hernia). This may obstruct the bowel, leading to severe pain, nausea, vomiting and the inability to have a bowel movement or pass gas.

It can also diminish blood flow to the trapped portion of the intestine — a condition called strangulation — that may lead to the death of the affected bowel tissues. A strangulated hernia is life-threatening and requires immediate surgery

MORTALITY/MORBIDITYMORTALITY/MORBIDITY

Morbidity is secondary to missing the diagnosis of the hernia or complications associated with management of the disease.

A hernia can lead to an incarcerated and often obstructed bowel.

The hernia also can lead to strangulated bowel with a compromised blood supply. Reduced strangulated bowel leads to persistent ischemia/necrosis with no clinical improvement. Surgical intervention is required to prevent further complications such as perforation and sepsis.

Ensuing surgery to repair the hernia or its complications may leave the patient at risk for infection, future hernias, or intra-abdominal adhesions

DIAGNOSISDIAGNOSIS

In a patient with a large hernia, physical examination reveals an obvious swelling or lump in the inguinal area. In the patient with a small hernia, the affected area may simply appear full. Palpation of the inguinal area while the patient is performing Valsalva’s maneuver confirms the diagnosis.

DIAGNOSISDIAGNOSIS

A patient history of sharp or “catching” pain when lifting or straining may help confirm the diagnosis. Suspected bowel obstruction requires X-rays and a white blood cell count (may be elevated).

MANAGEMENTMANAGEMENT

If your hernia is small and isn't bothering you, your doctor may recommend a watch-and-wait approach. But enlarging or painful hernias usually require surgical repair to relieve discomfort and prevent serious complications. There are two general types of hernia operations:

Herniorrhaphy. In this procedure, your surgeon makes an incision in your groin and pushes the protruding intestine back into your abdomen, then repairs the weakened or torn muscle by sewing it together. After the operation, you'll be encouraged to move about as soon as possible, but it may be as long as four to six weeks before you're able to fully resume your normal activities.

Hernioplasty. In this procedure, which is something like patching a tire, your surgeon inserts a piece of synthetic mesh to cover the entire inguinal area, including all potential hernia openings. The patch is usually secured with sutures, clips or staples.

PREVENTIONPREVENTION

We can't prevent the congenital defect that may lead to an inguinal hernia, but the following steps can help reduce strain on your abdominal muscles and tissues:

Maintain a healthy weight Emphasize high-fiber foods Lift heavy objects carefully or avoid

heavy lifting altogether. Stop smoking

REFERENCESREFERENCES

Eubanks S. Hernias. In: Sabiston DC Jr, ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 1997.

Katz DA. Evaluation and management of inguinal and umbilical hernias. Pediatr Ann. Dec 2001;30(12):729-35. 

Levine BJ, Nabha S, Bouzoukis JK. Chronic inguinal hernia. J Emerg Med. May-Jun 1999;17(3):515-6. 

Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. Apr 2008;45(4):261-312. 

Scherer LR 3d, Grosfeld JL. Inguinal hernia and umbilical anomalies. Pediatr Clin North Am. Dec 1993;40(6):1121-31. 

Bobrow RS. The hernia. J Am Board Fam Pract. Jan-Feb 1999;12(1):95-6. 

Wants GE. Abdominal wall hernias. In: Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery. 6th ed. 1994.