CLINICAL INFORMATION OF INGUINAL HERNIA
(Live operations on direct, indirect & recurrent inguinal hernia surgery)
Bubonocele / Inguinal Hernia
Bubon = groin
Bubonocele is a type of inguinal hernia which is limited in its extent to the inguinal canal.
Epidemiology :
· Occurs at all ages; M > F
· In 1st decade - right > left ( because of late descent of right testis)
· After that R = L
· Bilateral in 1/3 of cases
· Etiology :
1) Increased Intra Abdominal Pressure due to straining :-
· In children - Measles, whooping cough
· In adults - Smoking, chronic bronchitis, emphysema, hard physical labor, Intra Abdominal malignancy,
· Stricture urethra, chronic constipation
2) Increased Intra Abdominal Pressure due to stretching muscles :-
· Ascites
· Pregnancy
· Complaints
o dull dragging pain referred to the testis - increases on work
o If obstructed may have constipation, vomiting, pain
o If strangulated may have severe pain, shock, collapse.
· Clinical Findings
o piriform swelling - in the inguinal canal
o bubonocele does not come into scrotum
o Cough impulse + Reducibility +
o Neck of the hernia is supero-medial to pubic tubercle
· Special tests
o Deep ring occlusion - hernia does not appear
o Finger Invagination - impulse at tip of finger
o Dr.Desarda's test - Sliding of contents from ring finger to index finger indicates indirect and from middle to index finger indicates direct hernia
· Types :
1. Reducible
2. Irreducible (complication of (1))
3. Obstructed -------"---------
4. Strangulated ------"----------
5. Inflamed (the viscus in the hernia is inflamed - e.g. appendicitis, salpingitis)
· Differential Diagnosis:
· Males
1. Femoral hernia
2. Direct inguinal
3. Vaginal hydrocele
4. encysted hydrocele of cord
5. Undescended testis
6. Spermatocele
7. Varicocele
8. Diffuse lipoma of cord.
· Females
1. Femoral hernia
2. Hydrocele of
· Treatment
[1] Principles of treatment :
1. Restore the disrupted anatomy
2. Repair using fascia / aponeurosis NOT muscle
3. NO tension
4. Suture material used should hold until natural support is formed over it. ( i.e. monofilament nylon or polyethylene)
[2] Management
*** Described by DEVLIN
1. Resuscitation - in case of strangulated hernia with gangrene with shock or with intestinal obstruction.
2. Reduction of hernia - includes taxis, & reduction under anesthesia.
3. Repair - of the defect - may be herniorrhaphy or hernioplasty.
· Strangulated hernia -
o treat as emergency
o treat shock if any. Start IV antibiotics
o Incision over the most prominent part of swelling - sac carefully identified & dissected out. Sac opened.
o Aspirate all fluid ( highly infectious)
o Resect any unviable intestine or omentum
o EO aponeurosis & external ring divided. Sac opened throughout the length upto deep ring & a little inside.
o Viable contents reduced. Definite repair carried out - any prosthetic repair is contra-indicated.
- Non - Operative approach - in elderly, unfit / unwilling for surgery.
- Use of truss is advised in such cases- Truss must be applied with hernia reduced. Must prevent reappearance of the hernia on straining.
- Surgery - treatment modality of choice.
1 - Herniotomy - may be sufficient in young,, muscular individuals and in children.
2 - Herniorrhaphy - in adults with good musccular tone.
3 - Hernioplasty - in elderly with poor musccular tone.
C/I in strangulated hernia - may get infected leading to wound sinuus.
· Herniorrhaphy -
o Dr. Desarda's repair: Giving physiologically dynamic and strong posterior wall should be the principle of any type of inguinal hernia repair to give 100% success rate. Undetached strip of the external oblique aponeurosis is sutured between the muscle arch and the inguinal ligament to give a strong posterior wall which is kept physiologically dynamic by the additional muscle strength provided by the external oblique muscle to the weakened muscle arch.
o Lytle's repair (syn : Marcie's repair)- narrowing of the deep ring by suturing medial wall - Tight enough so that cord & little finger just fit in.
o Bassini's repair - Suturing of conjoint tendon to the incurved part of inguinal ligament - medial most stitch through the pubic periosteum - sutures taken with non-absorbable sutures - originally done by Bassini using black silk - now monofilament nylon used. - Chances of femoral hernia increased.
o
Shouldice repair - Double breasting of transversalis fascia - best tissue repair - at
the Shouldice clinic in
o Ogilvie's repair - plication of transversalis fascia
o McVay's repair / Cooper's repair - Conjoint tendon sutured to the Cooper's ligament - also prevents Femoral hernia formation -- closes off the Fruchaud's orifice.
o Condon's repair - Conjoint tendon sutured to the ilio-pubic tract.
o Halsted's repair - repaired at 3 levels (6 layer repair) - Bassini's + Shouldice + double breasting of external oblique - cord becomes subcutaneous
o NYHUS / Cheatle - Henry repair - pre-peritoneal repair - may be combined with prostatectomy. Used for large double hernias (direct + indirect), bilateral hernias, & Recurrent hernias.
o Inguinoclysis - only in elderly men with recurrent / very large hernias - obliteration of the inguinal canal with bilateral orchidectomy.
o Pantaloon hernia - Treated by 1st converting the hernia into one giant indirect hernia & then treating it as indirect hernia
· Complications :
1] Of the hernia -
· Irreducibility
· Obstruction
· Strangulation
· Toxic shock
· Peritonitis
2] Of the surgery -
· Sepsis ( most common ) - may lead to formation of incisional hernia.
· Hematoma
· 2ndary hydrocele - damage to lymphatics
· Testicular ischemia & atrophy
· Division of the vas deferens - especially in children
· Sinus formation - use of non-absorbable sutures
· Nerve entrapment - ilioinguinal N.
· Lymphocele - common after operations for femoral hernnia
· Recurrence of hernia.
Hernia
- General information
Hernia - General
·
Common
Hernias : Inguinal, Incisional, Femoral, Umbilical
·
Acquired
Hernia - Incisional
·
Hernias
due to obesity - Direct inguinal,
Classification:-
Internal
·
Diaphragmatic
hernia - congenital or acquired
·
Duodenum
herniating in the
·
Intestine
herniating into the lesser sac or hole in mesentery or hole in transverse
mesocolon or defect
in the broad ligament or Ileocaecal fossae - superior & inferior or
retrocaecal fossa
External
·
Anterior
o Inguinal - indirect, direct,
pantaloon
o Femoral
o Umbilical - Exomphalos (major
& minor), & child umbilical hernia.
o
o Epigastric
o Divarication of Rectii
o Spigelian-occurs at lateral border
of rectus sheath at level of arcuate line.
o Obturator
o Interstitial / Interparietal - 4
types
§
Pro-peritoneal
- diverticulum from inguinal or femoral heernia.
§
Intermuscular
- common in obese patients - spreads betweeen External Oblique & Internal
Oblique - narrow neck - tendency to strangulation.
§
Inguinosuperficial
- hernia into the superficial inguinal pouuch - associated commonly with an
ectopic testis in the pouch.
·
Posterior
o Lumbar - superior & inferior.
May be a phantom hernia - due to local muscular paralysis e.g. polio.
o Gluteal - through greater sciatic
foramen.
o Sciatic - through lesser sciatic
foramen.
·
Perineal hernia - 4 types
o Post - operative - after AP
resection of rectum.
o Median sliding hernia - complete
rectal prolapse.
o Antero-lateral - in females -
swelling of one side labium majus.
o Postero-lateral - through levator
ani muscle into the ischiorectal fossa.
·
Para-ileostomy hernia
· Para-colostomy hernia
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