Download Hernia – incidence

Hernia
►Abnormal
protrusion of an organ or
tissue, through a defect in its
surrounding walls
►Various
►Most
sites of the body
commonly abdominal wall hernia
Hernia
►External
– protrudes through all layers
of abdominal wall
►Internal
– protrusion of the intestine
through a defect within peritoneal
cavity
Abdominal wall hernias
► Groin
 Inguinal
 Femoral
► Anterior
► Pelvic
 Obturator
 Perineal
► Posterior
 Lumbar
 Umbilical
► Superior
 Epigastric
► Inferior
 Spigelian
triangle
triangle
Hernia
►Reducible
– content can be replaced
within the surrounding musculature
►Irreductible
or incarcerated – cannot
be reduced
►Strangulated
– compromised blood
supply - complications
Hernia strangulation
►Large
hernia – small orificies
►Small
neck obstructs blood flow,
venous drainage or both
►Adhesions
between content and
peritoneum – obstruction and
strangulation of the intestine
Hernia – incidence
►600.000/y
►Most
hernia repairs in US
common operation performed by
general surgeons
►5%
of population will develope
abdominal wall hernia
Hernia incidence
► 75%
of all hernias occur in the inguinal
region
► 2/3 – indirect hernias
► Men – 25 times more likely to have groin
hernia then woman
► Female – femoral and umbilical hernias
more often then inguinal (10/1 and 2/1
respectively)
Hernia incidence
► Both
inguinal indirect and femoral – more
commonly on the right side
► Delay in atrophy of right processus vaginalis
peritonei
► Slower
decent of thr right testis to the
scrotum
► Tamponading effect of sigmoid colon on the
left femoral canal
Hernia – inguinal canal
►4
cm lenght, 2 – 4 cm up to inguinla
ligament
► Extends
between internal (deep) and
external (superficial) inguinal ring
► Contain
spermatic cord or round ligament of
the uterus
Hernia – inguinal canal
►
Spermatic cord
 Cremasteric muscle fibres
 Testicular artery
 Pampiniform plexus
 Genital branch of genitofemoral nerve
 Vas deferens
 Cremasteric vessels
 Lymphatics
 Processus vaginalis
Hernia – inguinal canal
► Superficial
► Upper
– external oblique aponeurosis
(cephalad) – intermnal oblique and
transversus muscle
► Inferior
– inguinal and lacunar ligament
► Posterior
– transversalis fascia
Hernia – diagnosis
► Bulge
► Pain
in the inguinal region
or discomfort (groin hernias are not
extremely painful)
► Paresthesias
(compression or irritation of
inguinal nerves)
Hernia – differential diagnosis
► Inguinal
hernia
► Femoral
hernia
► Hydrocele
► Inguinal
adenitis
► Varicocele
► Ectopic
testes
► Lipoma
► Hematoma
Hernia – differential diagnosis
► Psoas
abscess
► Femoral
adenitis
► Lymphoma
► Metastatic
nepolasm
► Epididymitis
► Testicular
► Femoral
torsion
artery aneurysm or pseudoaneurysm
► Hydradenitis
of inguinal apocrine glands
Hernia – physical examination
► Both
supine and standing position
► Visual
and palpative inspection for mass in inguinal
region
► Ask
patient to cough or perform Valsalva
maneuver
► Fingertip
► Finally
OVER inguinal canal
fingertip into inguinal canal – small hernia
Hernia – physical examination
► PROBLEM
– bulge of the groin described by
the patient not demonstrated during
examination???
► Ask
patient to stand for a period of time
► Repeat
examination (sometimes another visit)
Hernia – examination
► USG
– high degree of sensitivity and specificity in
detection of occult direct, undirect and femoral
hernias
► CT
– abdomen and pelvis – to diagnose unusual
hernias or atypical groin masses
Hernia – nonoperative management
► Opertaion
recomended on discovery!!!
 Progressive enlargement and weakening
 Potential for incarceration and strangulation
► Exclusions:
 Short life expectancy patients
 Significant comorbid ilnesses
 Minimal symptoms
Hernia – nonoperative management
► Trusses
– provide symtomatic relief
► Correct
measurement and fitting are the key
► Hernia
control in 30% patients
► Complications:
 Testicular atrophy
 Ilioinguinal or femoral neuritis
 Hernia incarceration
Hernia – nonoperative management
► NOT
RECOMMENDED IN FEMORAL
HERNIAS!!!
► High
incidence of complications, particulary
strangulation
Hernia – operative repair
Anterior repairs:
► Most
common technique
► Tension
► Older
– free techniqes are standard
types – indicated for small hernias
Hernia – operative repair
Hernia – operative repair
Hernia – operative repair
Hernia – operative repair
Hernia – operative repair
Hernia – operative repair
Hernia – operative repair
Hernia – operative repair
Hernia – Bassini repair
Hernia – Bassini repair
Hernia – Bassini repair
Hernia – Bassini repair
Hernia – Halstead repair
Hernia – Shouldice repair
Hernia – Lichtenstein repair
Hernia – Lichtenstein repair
Hernia – Lichtenstein repair
Hernia – Lichtenstein repair
Hernia – other methods
► Girard
► Kirschner
► Marcy
► Mc
Arthur
► Mc Vay
► Wolfer
► Zimmerman
Hernia – laparoscopic management
► Minimal
invasive ???
► Tension – free mesh repair
► Less pain
► Quicker recovery
► Better visualisation of anatomy
► Fixing all hernia defects
► Decreased surgical site infections
Hernia – laparoscopic management
► Complication
rate – less then 10%
► Reccurrence
rate 0 – 3%
Hernia – laparoscopic management
► TAPP
► TEP
– transabdominal preperitoneal approach
– total extraperitoneal approach – without
entering peritoneal cavity
Hernia – laparoscopic management
► Infraumbilical
► Dissecting
incision
baloon inflated under vision
► Created
space is insuflated, aditional trocars
are placed
► Reduction
of hernia (hernias)
 Traction
 Large sac shoud be cautered to inguinal ring
Hernia – laparoscopic management
► 10x15
cm mesh inserted through a trocar
and unfolded
► Mesh
should cover direct, indirect and
femoral area
► It’s
secured with a tacking stapler
Hernia – femoral canal
► Superficial
► Lateral
– inguinal ligament
– femoral vein
► Posterior
– Cooper’s ligament
Hernia – femoral canal
Femoral hernia
Femoral hernia - diagnosis
► Mass
or bulge occursbelow inguinal
ligament
► If
it’s over inguinal ligament – it still could
be femoral hernia (hernia sac is ascending)
► It’s
usually more painful then inguinal
Femoral hernia - repair
► Dissection
and removal of hernia sac
► Obliteration
of the femoral canal defect
 Cooper’s method
 Mesh
► In
case of strangulation, hernia sac content should
always be examined for viability
Femoral hernia - repair
Femoral hernia - repair
Femoral hernia - repair
Hernia – special problems
► Sliding
hernia
 Internal organ comprises a portion of the hernia
sac
 Mostly indirect inguinal hernias
 Bowel (sigmoid) or urinary bladder
 DANGER – recognize visceral component of
hernia sac during operation, to avoid damage of
the organ)
Hernia – special problems
► Recurrent
hernias
 Challenging
 Higher incidence of secondary recurrence
 Placing of the mesh required for succes
 Recurrences after anterior mesh repairs require
posterior approach and placement of second
prothesis
Hernia – special problems
► Strangulated
hernias
 Hernia sac content must be visualised for
viability
 Constricting ring can be incised to reduce
tension
 Sometimes it’s necessery to resect strangulated
intestine
Hernia – postopertaive complications
► Wound
infection – 0,58%
► Haematoma
► Pulmonary
– 0,43%
embolus – 0,07%
► Haemorrhage
► Ischemic
– 0,02%
orchitis – 0,61%
► Testicular
atrophy – 0,34%