hernia surgery

8/12/2019 Hernia Surgery

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HERNIA

RAQUIZA/RAYEL/RICALDE/VENGCO

JI


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HERNIA Latin for r upture

an abnormal protrusion of an organ or tissuethrough a defect in its s urrounding wall

occur only at sites where the aponeurosis andfascia are n ot covered by striated muscle

TERMINOLOGY REDUCIBLE HERNIA - can be replaced

within the surrounding m usculature- can be r eturned t o the ab domen

IRREDUCIBLE OR INCARCERATED

HERNIA cannot be reduced into the abdomen


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STRANGULATED HERNIA - hascompromised b lood supply t o its contents, whichis a serious a nd potentially fatal complication

EXTERNAL HERNIA - protrudes through alllayers of the a bdominal wall

INTERNAL HERNIA - a protrusion ofintestine through a defect within the peritonealcavity

INTERPARIETAL HERNIA - occurs when thehernia sac is contained within amusculoaponeurotic layer of the a bdominal wall


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ETIOLOGY risk factors a re likely multifactorial, the

common denominator being a w eakness in theabdominal wall musculature

ACQUIRED

inguinal hernias i n the a dultsacquired defects i n the a bdominal wall

CONGENITALmake u p the m ajority of pediatric herniasconsidered an impendance of normaldevelopment


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NORMAL COURSE OF DEVELOPMENT the testes descend from the intra-abdominal

space i nto t he sc rotum in the t hird trimester

their descent is preceded by the gu bernaculumand a diverticulum of peritoneum whichprotrudes through the inguinal canal andultimately becomes t he p rocessus va ginalis

between 36 and 40 weeks - the processusvaginalis closes a nd eliminates t he peritonealopening at the i nternal inguinal ring

failure o f the peritoneum to close resu lts inPATENT PROCESSUS VAGINALIS (PPV)


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ANATOMY OFINGUINAL REGION

GROIN REGION a complex network of muscles,

ligaments and fascia that areinterwoven in a multiplanar fashion

INGUINAL CANAL 4 to 6 cm long, shaped like a coneand situated in the anteroinferiorportion of the pelvic b asin

Canal begins intra-abdominally onthe deep aspect of the abdominalwall, where the spermatic cordpasses through a hiatus in thetransversa lis fascia (in females, is

the r ound ligament)


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POUPARTS LIGAMENT comprised of the inferior bers of theexternal oblique a poneurosis

st retches from the anterior su perior i liacspine t o t he p ubic t ubercle

LACUNAR LIGAMENT OF GIMBERNAT is the triangular fanning out of theinguinal ligament as it joins the pubictuberclefusion of the inferior bers o f the internaloblique and transversus abdominusaponeurosis, at the p oint where t hey i nserton the p ubic tuberclemedial border of the femoral canal


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COOPERS OR PECTINEAL LIGAMENTlateral portion of the l acunar l igament that is f usedto t he p eriosteum of the p ubic t ubercle

include bers from the transversus abdominus,iliopubic tract, internal oblique and rectusabdominus

CONJOINED TENDON

a combination of the transversus abdominusaponeurosis, transversalis f ascia, lateral edge of therectus sheath and internal oblique muscles or itsbers

ILIOPUBIC TRACTan aponeurotic band that begins at the ASIS andinserts i nto C oopers l igamentforms on the DEEP side of the inferior margin ofthe t ransversus ab dominus an d transversalis f ascia


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INNERVATION ILIOINGUINAL NERVE (L1)

supplies t he sk in of the u pper and medial thighmales: penis and upper scrotum; females: monspubis and labium majus

ILIOHYPOGASTRIC NERVE (T12-L1)supplies the internal oblique and transversus

abdominus GENITOFEMORAL NERVE (L1-L2)

a. Genital branchMales - scrotum and cremaster muscle

Females - mons pubis and labia m ajorab.Femoral branch supplying the sk in anterior t o

the u pper p art of the femoral triangle LATERAL FEMORAL CUTANEOUS NERVE (L2-L3)

supply the l ateral aspect of the t high


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TRIANGLE OF DOOMBOUNDARIES:

Medial: vas d eferens Lateral: spermatic vessels (testicular arteryand vein)

I nferior: external iliac v essels


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CONTENTS ex ternal iliac a rtery and vein

deep circumex iliac vei n genital branch of genitofemoral nerve femoral nerve

MOST IMPORTANT STRUCTURES Arteria corona mortis Obturator vessels E xternal iliac v essels

Staple should not be applied in this triangleotherwise; chances of mortality are there ifthese great vessels a re i njured


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TRIANGLE OF PAINBOUNDARIES:

Medial: Testicular artery a nd vein Base: iliopubic t ract


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CONTENTS genitofemoral nerve lateral femoral cutaneous nerve femoral nerve

Staple should be less because n erve en trapmentcan cause n euralgia

CIRCLE OF DEATH is a vascular continuation formed by the

common iliac, internal iliac, obturator, aberra nt

obturator, inferior e pigastric a nd external iliacvessels


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DIAGNOSIS OF INGUINALHERNIA

H istory a nd Physical exam P rocedure

examiner place the t ip of the index nger a tthe most dependent part of the scrotum anddirect it into the external inguinal ring

d irect hernia will push against the p ulp of the nger if a bulge progresses f rom deep to su percial

through the inguinal oor indirect hernia

will push against the ngertip a bulge moving lateral to medial in the

inguinal canal


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CLINICAL PRESENTATION groin bulge often asymptomatic dull feeling of discomfort or h eaviness FOCAL PAIN

raise suspicion for incarceration orstrangulation

symptoms of bowel obstruction

IMAGING p lain x-ray: Herniography u ltrasonography MRI CT

Laparoscopy


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HESSELBACHS TRIANGLE h elps i dentify type of inguinal hernia

BOUNDARIES: Medial: rectus abdominis L ateral: inferior e pigastric a rtery

I nferior: inguinal ligament of Poupart


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CLASSIFICATION


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CLASSIFICATION


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TYPES OF INGUINALHERNIA

DIRECT INGUINAL HERNIAMedial to t he i nferior ep igastric a rtery andwithin hesselbachs t riangle

Acquired weakness in the inguinal oor 2 major f actors: increased intra-abdominal pressureassociated with a variety of conditions

relative weakness of the posterioringuinal wall


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INDIRECT INGUINAL HERNIA inguinal hernias that protrude lateral tothe inferior e pigastric vessels t hrough thedeep inguinal ring incomplete or defective obliteration ofprocessu s v aginalis d uring the fetal period remnant layer of peritoneum forms a sac inthe i nternal ringdenervation of the internal oblique muscleby adjacent incisions ( e.g., appendectomy)


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VARIANTS OF INGUINAL HERNIARICHTERS HERNIA

more common in premature infants

partial circumference on small bowel in hernial saconly the antimesenteric border of small intestine isincarcerated in the deep inguinal ring thereforeintestinal obstruction may be absent but gangrenemay occur

LITTRES HERNIAhernia contains M eckels d iverticulum

PETTIT HERNIAhernia at inferior l umbar t riangle

GRYNFELT HERNIAhernia at superior l umbar t riangle

AMYANDS HERNIAcontent of the hernial sac is the vermiform

appendix


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FEMORAL HERNIA more common in females passes m edial to the femoral vessels an d nerve

in the femoral canal through the em pty spa ce

FEMORAL TRIANGLESuperior: inguinal ligament

Lateral: sartorius m uscleMedial: adductor longus muscle

CONTENT: NAVEL

N: femoral nerve A: femoral artery V: femoral vein

E: empty sp ace, site of herniaL: lymphatics of Cloquet

hernia surgery

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