Opera&veApproachestoStrangulatedInguinalHernias

LouisFerrariMD,PGY4September1st,2016

TheCase

-  HPI:-  75Mpresentswith48hoursofabdominalpain,disten&onandobs&pa&onassociatedwithnauseaandbiliousvomi&ng.

-  AknownreducibleleRinguinalherniahasnowbecomefixed,firmandissignificantlypainful.

TheCase

•  PMH:HTN,BPH;NormalC-scopein2011.•  PSH:None

•  Exam:-150s/80s;90-100s;97.8-A&Ox3,uncomfortableandlethargic-SoR,distended,minimallytenderabdomen-Firm,tenderleRgroinmasswithnoskinchanges-RectalExamNega&ve

TheCase

LabarotoryResults:– CBC15>17/53<252– Electrolytes140/4.1/95/19/42/3.89<115– VBG7.319/45/28/20.4/-2.4– Lactate6.1

TheCasePreopera&veCourse:-  NGTplaced:500ccfeculentfluidini&allydrained-  Appropriatefluidresuscita&onOpera&veCourse–  Induc&oncomplicatedbyvomi&ng/aspira&on.–  ExploratoryLaparotomy

•  Revealedsignificantlydilatedloopsofedematous,congested,ischemicsmallbowelsecondarytoincarceratedloopofdistalileum.Sigmoidcolonandbladderappearedalsoinvolved.Notreducible.4Lfeculentmaterialmilkedretrograde.

–  Groinincision•  StandardIncisionanddissec&on•  Revealedlargepantaloonhernia.Withminimaldissec&onandtrac&onfromwithin,Contentswerereduced.

TheCase

•  Opera&veCourseCon&nued– Necro&c15cmpor&onofincarceratedsmallbowelwasresected.Anastomosiswasperformed.

– BassiniRepair– Reinforcedwithmeshpatch– Pa&entbecameunstable

•  Acido&c,Hypoxic,hypotensive,tachycardic– SkinofAbdomenClosedExpedi&ously– Pa&entTransferredtoICU.

TheCase

-  Postopera&vecourse

-  Increasinglyhypoxic,acido&candhypotensive-  LeRIJTLCwasplacedaRerarrivalinICU-  LeRBreathsoundsweredecreased-  EmergentLeRTubeThoracostomyPerformed-  ACLSini&ated-  Pa&entexpired

InguinalAnatomy1

InguinalAnatomy2

InguinalAnatomy3

InguinalAnatomy4

Epidemiology

•  Incidencenotknown•  75%ofallherniasoccurinthegroin•  Inguinalhernia25Xmorelikelyinamale•  Indirectalwaysmostcommon(2:1inmales)•  Femoralherniasfarmorecommoninfemales•  1-3%willbecomestrangulated.

Diagnosis1

KeyConcept:-  REDUCIBLE

-  IRREDUCIBLE/INCARCERATED

-  STRANGULATED

AnteriorRepairs-  Incision

-  OpeningofExternalObliqueAponeurosis

-  Protec&onofIlioinguinalNerve

-  Isola&onofCordStructures

-  Dissec&onofHerniasac

-  Reduc&onvsHighLiga&on.

-  ClosureofExternalOblique

BassiniRepair

•  InciseFloorofInguinalCanal.

•  InternalOblique/AponueurosisofTransversalistoInguinalLigament

DrChesterMcVay

1911-1987

McVayRepair-  Cooper’sLigamentRepair

-  MedialTransi&onS&tch-  FemoralSheath&Inguinal

Ligament

-  RelaxingIncision

-  Indirect,DirectandFemoralDefects

EdwardEarleShouldice

1890-1965

LichtensteinRepair

Plug&Patch

-  Excludedonlythosewithfeculentor

purulentcontamina&on

-  LichtensteinRepair

-  Periopera&veAn&bio&cs

-  Allresec&onsrepairedintheGroinField

Conclusions

•  RepairofStrangulatedInguinalHerniasshouldbeperformedusinganopen/anteriortechnique.

•  Laparotomyisindicatedwhenpa&enthasevidenceofcompromisedintra-abdominalviscera.

•  Theuseofmeshinaclean-contaminatedfieldduringstrangulatedinguinalherniarepairisnotcontra-indicated.

THANKYOU