Download inguinal hernias

Subsec D2
2.
A 25-year old male waiter comes to the Emergency
Room because of a R inguinal mass. Since two years
ago, the mass would appear when lifting heavy
objects, coughing, or sneezing and spontaneously
disappear upon lying down aided by gentle manual
manipulation
SALIENT FEATURES
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25 y/o
Male
Waiter
Right inguinal mass
2 years ago, the mass would appear when lifting heavy
objects, coughing, or sneezing
 Spontaneously disappear upon lying down aided by
gentle manual manipulation
a. What is your diagnosis?
Inguinal Hernia
INGUINAL HERNIAS
 Inguinal hernias are classified as either direct or indirect.
 INDIRECT

The sac passes from the internal inguinal ring obliquely toward the
external inguinal ring and ultimately into the scrotum
 DIRECT

The sac protrudes outward and forward and is medial to the internal
inguinal ring and inferior epigastric vessels
 Although it sometimes can be difficult to distinguish between an
indirect and a direct inguinal hernia, this distinction is of little
importance because the operative repair of these types of hernias is
similar
 Pantaloon-type hernia
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Occurs when there is an indirect and direct hernia component
INCIDENCE
 Hernias are a common problem; however, their true
incidence is unknown.
 It is estimated that 5% of the population will develop an
abdominal wall hernia, but the prevalence may be even
higher
 About 75% of all hernias occur in the inguinal region
 Two thirds of these are indirect, and the remainder are
direct inguinal hernias
 Men are 25 times more likely to have a groin hernia than
are women
 INDIRECT INGUINAL HERNIA
 Most common hernia, regardless of gender
 In men, indirect hernias predominate over direct hernias at a ratio
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of 2 : 1
Direct hernias are very uncommon in women
The female-to-male ratio in femoral and umbilical hernias,
however, is about 10 : 1 and 2 : 1, respectively
Although femoral hernias occur more frequently in women than in
men, inguinal hernias remain the most common hernia in
women.
Femoral hernias are rare in men. Ten percent of women and 50% of
men who have a femoral hernia either have or will develop an
inguinal hernia
 Both indirect inguinal and femoral hernias occur more
commonly on the right side
 This is attributed to a delay in atrophy of the processus
vaginalis after the normal slower descent of the right
testis to the scrotum during fetal development
 The predominance of right-sided femoral hernias is
thought to be due to the tamponading effect of the
sigmoid colon on the left femoral canal
 The prevalence of hernias increases with age,
particularly for inguinal, umbilical, and femoral
hernias
 Strangulation, the most common serious
complication of a hernia, occurs in only 1% to 3%
of groin hernias and is more common at the
extremes of life
 The likelihood of strangulation and need for
hospitalization also increase with aging
 Most strangulated hernias are indirect inguinal hernias;
however, femoral hernias have the highest rate of
strangulation (15%-20%) of all hernias, and for this
reason, it is recommended that all femoral hernias be
repaired at the time of discovery
Anatomy of the important preperitoneal structures in the right inguinal space. (From Talamini MA, Are C: Laparoscopic hernia repair. I
n Zuidema GD, Yeo CJ [eds]: Shackelford's Surgery of the Alimentary Tract, 5th ed. Philadelphia, WB Saunders, 2002, vol 5, p 140.)
SIGNS AND SYMPTOMS
A bulge in the area on either side of your pubic bone
2. Pain or discomfort in your groin, especially when
bending over, coughing or lifting
3. A heavy or dragging sensation in your groin
4. Occasionally, in men, pain and swelling in the
scrotum around the testicles when the protruding
intestine descends into the scrotum
1.
CAUSES
• Some inguinal hernias have no apparent cause. But
many occur as a result of:
a.
b.
c.
•
Increased pressure within the abdomen
A pre-existing weak spot in the abdominal wall
A combination of the two
The abdominal wall weakness that leads to an
inguinal hernia occurs at birth when the abdominal
lining (peritoneum) doesn't close properly.
• Other inguinal hernias develop later in life when
muscles weaken or deteriorate due to factors such as
aging, strenuous physical activity or coughing that
accompanies smoking.
• In men, the weak spot usually occurs along the
inguinal canal. This is the area where the spermatic
cord, which contains the vas deferens, the tube that
carries sperm, enters the scrotum.
• In the male fetus, the testicles form within the
abdomen and then move down the inguinal canal into
the scrotum. Shortly after birth, the inguinal canal
closes almost completely, leaving just enough room for
the spermatic cord to pass through, but not large
enough to allow the testicles to move back into the
abdomen.
• Sometimes, however, the canal doesn't close properly,
leaving a weakened area.
• In women, the inguinal canal carries a ligament that
helps hold the uterus in place, and hernias sometimes
occur where connective tissue from the uterus attaches
to tissue surrounding the pubic bone.
– There's less chance that the inguinal canal won't close
after birth in female babies. In fact, women are more
likely to develop hernias in the femoral canal, an
opening near the inguinal canal where the femoral
artery, vein and nerve pass through.
• Weaknesses can also occur in the abdominal wall later
in life, especially after an injury or certain operations
in the abdominal cavity.
• Whether or not you have a pre-existing weakness,
extra pressure in your abdomen can cause a hernia.
This pressure may result from:
Straining during bowel movements or urination
ii. Heavy lifting
iii. Fluid in the abdomen (ascites)
iv. Pregnancy
v. Excess weight
vi. Even chronic coughing or sneezing can cause
abdominal muscles to tear.
i.
 Six hours prior to admission, upon lifting a case of beer,
the mass protrudes to its largest size and cannot be
pushed back anymore even with manipulation. The
mass this time becomes painful and tender rendering
him unable to walk.
b.
What would you recommend for him?
 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.
– Hernioplasty can be performed conventionally, with a
single long incision over the hernia. But it's often done
laparoscopically, using several small incisions rather
than one large one.
– A fiber-optic tube with a tiny camera is inserted into
your abdomen through one incision, and miniature
instruments are inserted through the other incisions.
Your surgeon then performs the operation using the
video camera as a guide.
LAPAROSCOPIC REPAIR
 ADVANTAGES
 Less discomfort and scarring after surgery and a quicker
return to normal activities
 DISADVANTAGES
 Increased risk of complications and of recurrence
following surgery. These risks are reduced if the
procedure is performed by a surgeon with extensive
experience in these kinds of repairs
He is given a muscle relaxant – sedative
parenterally after which he falls asleep. One hour
later, you come back and re-evaluate him. The mass
has now disappeared and he has become completely
asymptomatic. He now wants to go home.
COMPLICATIONS
• 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.
3. What would you advise the patient?
 The patient should be advised to undergo elective
surgery because most groin hernias when left
unrepaired can further enlarge and can result into
further surgical failure rates.
 The patient’s occupation demands strenuous activities
which he is constantly exposed to. This can increase
the incidence of recurrent Inguinal hernia
 Furthermore, delaying surgical management can
increase the incidence of incarceration as well as
strangulation
Strangulated Inguinal Hernia
Patient will present with acute, painful, non-reducible inguinal hernia. It's worth
mentioning that in spite of rapid diagnosis and prompt surgical exploration, gangrenous bowel was
identified. This highlights the potential seriousness of this condition.
4. Do you agree with how the patient was managed in the ER? Why
or Why not?
 The patient is presents with incarcerated hernia,
which is a constriction of the hernial sac rendering the
hernia irreducible.
 This condition is initially managed with sedation,
Trendelenberg position, ice packs and taxis (Manual
Manipulation).
 The patient should be further observed, if there is
failure of taxis with no progress within 6-8 hrs, or if
signs of complete bowel obstruction, peritonitis or
sepsis happened, immediate surgery is recommended
Trendelenburg position
THANK YOU
REFERENCES
Sabiston Textbook of Surgery, 18th ed.
2. Mayoclinic.com
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