Hernia

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Hernia PR

• Dr.AbdulWAHID M Salih
• M.D. Surgery

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Hernia

• protrusion of an organ or the fascia of an organ
  through the
• wall of the cavity that normally contains
• Congenital, acquired
• Most have an expansile cough impulse

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a Hernia composed of

• Sac a folding of peritoneum consisting of a
  mouth, neck, body and fundus.
• Body which varies in size and is not necessarily
  occupied.
• Coverings derived from layers of the abdominal
  wall.
• Contents which could be anything from the
  omentum, intestines, ovary or urinary bladder.

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• In children,
• Specifically in infants, the parents"
• observation of a swelling or protusion
• may be the only positive feature.
• In the infancy may beTransilluminable

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Inguinal

• Superficial inguinal ring1.25 cm above and
  lateral to the pubic tubercle
• Deep inguinal ring1.25 cm above and medial to
  the mid point of inguinal ligament
• Length of the inguinal canal3.25cm

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Ingiunal canal Boundaries MALT 2M
2A, 2L, 2T Superior wall roof 2 Muscles
Internal oblique Muscle Transverse abdominus
Muscle Anterior wall 2 Aponeuroses
Aponeurosis of external oblique Aponeurosis of
internal oblique Lower wall floor 2
Ligaments Inguinal Ligament Lacunar Ligament
Posterior wall 2Ts Transversalis fascia
laterally Conjoint Tendon medially
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Ingiunal canal
Contents Ilioinguinal nerve. Spermatic cord,
which contains3 arteries Testicular a.
Ductus deferens a. Cremasteric a.3 nerves
Cremasteric n. Genital branch of the
genitofemoral n. Autonomics3 other things
Ductus deferens Pampiniform plexus Lymphatics
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Types of indirect inguinal
hernia 1. Incomplete     Bubonocelelimited
within the inguinal canal    Funicularlimited
just above the epididymis 2.Complete
traverses to the bottom of the scrotum
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• Introduce yourself
• Wash hands
• Chaperone
• Standing up
• Undressed from waist down
• Look for an visible lumps
• Any scars, overlying skin changes.
• The lump extends into the scrotum

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• position
• Pt. stands, exposed area visible.
• best performed with the patient standing and
  in supine
• the physician seated on a stool

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prepare

• Stand at the side of the patient,
• one hand on the patients back to support him.
• hand and arm should be roughly parallel to the
  inguinal ligament when palpating the lump.

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Mass

• Observation of the groin area in oblique light
• Visible swelling. Examine as a mass (STEM
  site,skin,size,shape,)

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Most important

• Can you get above it?
• Reducibility test
• Expansile Cough Impulse
• Invagination test
• Three finger test
• Ziemans technique
• 6. Ring occlusion test

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Also Asses

• Intra or extra abdominal
• Tension
• Composition
• Percussion and auscultation
• Bowel Sounds
• Always examine both groins
• Tranillumination

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• 1-Cough Impulse
• Pt. coughs to highlight hernia.
• May not if the neck is blocked by adhesions
• Visible Palpable cough impulse.
• Reappear on straining,
• standing or coughing
•  

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2-Reducibility test

• Ask pt. to reduce hernia himselves
• usually done in lying position.
• The thigh of the affected side should be flexed,
  adducted and internally rotated.
• Finger guard of the inguinal canal by thumb and
  index finger and then the scrotum is gently
  squeezed.

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Relation to Pubic Tubercle

• INGUINAL HERNIA The neck above and medial to the
  pubic tubercle
• FEMORAL HERNIA The neck below and lateral to
  pubic tubercle

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• 3-Get above the swelling test
• Done in standing position
• At the root of the scrotum place the thumb in
  front and the index behind
• Try to reach above the swelling.
• Inguinal hernia cannot get above
• Pure scrotal swelling will get above

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• 4-Invagination test
• The scrotum on each side is inverted
• with the examining index finger
• Entering the inguinal canal along
• the course of the cord structures.
• The size of the external ring.
• The finger push up to the
• superf inguinal ring.
• The pulp should feel the ring.
• Pat is asked to cough,
• A palpable impulse will confirm the hernia
• felt on the pulp then direct
• felt on the tip then indirect hernia.

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5-Three finger test / Ziemans technique Index
finger deep inguinal ring (indirect hernia)
Middle finger superficial ing. Ring (direct
hernia) Ring finger saphenous opening (femoral
hernia) The patient is asked to cough.
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• 6-Ring occlusion test
• Reduce the hernia
• Occlusion of the deep ring by thumb.
• Then holding the thumb in position ask
• The pt to stand
• then cough
• If no bulging
• indirect
• If bulging
• direct .

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Beside

• Beside at the level of inguinal region at the
  affected side
• Notice a small bulge
• Compare to the other side.
• Stand beside the pt your shoulder behind the
  opposite shoulder of pt
• Reduce the hernia.
• Ask the pt to cough

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Search predisposing factors

• Examine the abdomen
• Causes Of raised intraabd. pressure
• Enlarged bladder (BPH)
• Ascites

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describe the hernia 1.  Site (inguinal) 2. 
Right/Left 3.  Reducible/Irreducible 4. 
Complete/Incomplete 5.  Direct/Indirect
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Strangulation

• Any hernia that is tender
• Nausea and vomiting
• No attempt to
• reduce it manually.
• An acute surgical
• emergency.

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• indirect summary
• Relation to epigastric vessels Lataral
• Processus vaginalis Present
• congenital
• Unilateral (usually).
• always descends
• the scrotum
• prone to obstruction
• and strangulation

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• Direct summary
• Bilateral
• Acqiured
• Processus vaginalis Absent
• Rarely strangulate
• medial to
• epigastric vessels

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Femoral Hernia (cont..)

• Femoral hernias are more common in women,
• present as a groin lump.
• the cause of unexplained small bowel obstruction.
• an absent Cough impulse
• globular lump than the pear shaped lump of the
  inguinal hernia.
• Differential Diagnoses
• Inguinal Hernia.
• Femoral Artery Aneurism.
• Femoral Lymphadenopathy.
• Psoas Abscess.

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Umbilical Hernia

• In infants children.
• Boys more than girls.
• Tend to resolve without any treatment by around
  the age of 5 years.
• Obstruction and strangulation is rare.

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Paraumbilical Hernia

• Affects adults.
• either supra or infraumbilical through the linea
  alba.
• The female to male ratio is 201.
• Clolicky pain and/or irreducibilty due to omental
  adhesions.

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Incisional Hernia

• weakness is the result of an incompletely healed
  surgical wound.
• more along a straight line from the sternum down
  to the pubis.
• Swelling at the
• incisional site /- pain.

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Epigastric Hernia

• a defectin the linea alba between the xiphoid
  process and umbilicus
• Starts as a protrusion of the extraperitoneal fat
  
• Swelling /- pain
• similar to a peptic ulcer pain.

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Rare external Hernias

• Spiglian Hernia
• spaces of the semilunar line and the lateral edge
  of the rectus muscle (inferior to the arcuate
  line).
• The posterior rectus sheath is weak
• Preoperative diagnosis is diffucult
• u/s c.t are helpful
• tools in the diagnosis

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2-Lumbar Hernias

• broad bulging hernia
• not vulnerable to incarceration.
• A. Petits hernia inferior lumbar triangle.
• B. Grynfeltts Herniasuperior lumbar triangle
  and is less common than Petits.

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