2DirectHernia. occur between 10-15% of inguinal hernia , half of them bilateral. . Always acquired. . The sac passes through weakness or defect of transversalis fascia in post . wall of canal . . Often pt. has poor abdominal musculature as shown by presence of elongated bulging called “malgaigne’s bulgings . . Woman never develop direct hernia practically (by brown). . Predisposing factors . Chronic cough . Heavy work (heavy lifting) . Damage to ileoinguinal N. mainly in previous appendicectomy (motor branch) lead to weakness of conjoined tendon .
3Rarely large enough to descend to scrotum , not attain a large size . Rarely large enough to descend to scrotum , not attain a large size. . The hernia mass consist mainly of extra peritoneal fat & neck of sac wide & so rarely get strangulation , the sac is smaller than hernia mass. . Prevesical hernia , funicular direct hernia pass through small defect in conjoined tendon (apponeurosis of 2 muscles int. oblique & tansversus ) . . Dual or saddle bag or pantaloon hernia means there is both direct & indirect hernia & usually seen intra operatively .
4The most medial to inf. epigastric A. is direct & most lat. to A The most medial to inf. epigastric A. is direct & most lat. to A. is indirect hernia.This is most common cause of true or false recurrence.. Direct inguinal hernia lies behind the spermatic cord.. Direct ing. H. once treated, it usually not need removal of sac & only retained it ‘s content & herniorrhaphy & no herniotomy .. But sometime in very large sac that it’s returned into peritoneal cavity difficult so may need herniotomy.. Strangulation occur rarely because of wide neck but occur especially in pt. wearing a truss that are unfit for anesthesia or refuse surgery.
5. Constricting agents in strangulation:- - neck of sac.- external ring in children.- Rarely adhesion within the sac.. Rx. Should be urgently (of strangulated hernia) because strangulation within short time may develop septicemia.IV. Fluid.Analgesia & sedation & AB.NG tube for gastric decompression to prevent vomiting & inhalation pneumonia.Urethral catheterization due to full bladder from volume over load.
6.Recurrence a)) true recurrence - within 1st 2 yrs.- same hernia return onb)) false recurrencethere is other type of hernia that is over looked .Exp:- direct & indirect, femoral with inguinal.. To prevent recurrence remove spermatic cord as it is barrier & called complete excision of cord & testes & complete closure of canal.. Operation motioned above. Complication (for herniorrhaphy mainly )
7General. Retention. Respiratory. Cardiovascular & thromboembolic * General . Retention . Respiratory . Cardiovascular & thromboembolic * Local 1- wound sepsis mainly due to poor & septic technique or towel may not so aseptic. 2- hematoma, bruising 3- lymphocele specially after repair of femoral hernia 4- wound sinus when foreign mesh T. used for repair that continually discharging. 5- division of spermatic cord especially in infancy because it is very thin &small 0.2,mn
86- testicular ischemia especially after large or recurrent repair 7- testicular atrophy because of ischemia & pressure effect 8- hydrocele 9- nerve genito femoral branch (sensory) entrapment pain, numbness or parasthesia 10- recurrence especially after large hernia
9Strangulated Inguinal Hernia . Occur at any time & both sex. Commonly occur in case of indirect , rarely direct. Commonly following hernia for long time especially in those wearing truss or in irreducible. Constrictive agents as mentioned aboveStrangulation during infancy- incidence 4%- F\M \1 contain ovary or ovary with fallopian tubesShould be treated urgentlyMay Rx conservatively by Iv fluid , AB, analgesia, sedation & NG tube with elevation of pelvis or buttock & manual reduction without vigorous manipulation.Strangulated Inguinal Hernia
10Note conservative Rx & manual reduction used with caution in adult Note conservative Rx & manual reduction used with caution in adult * Vigorous manipulation 1- contusion or rupture of intestinal wall 2- reduction en masse this mean that mass with obstructing agents &sac become intraperitonealy complain continue not relieve 3- reduction into a loculus of a sac 4- ruptured of sac & passed into extra peritoneal space
11(Hernia-en-glissade). Is a result of slipping of post ... (Hernia-en-glissade) . Is a result of slipping of post. parietal peritoneum on underlying retro peritoneal structure . Post . wall of sac is not formed of peritonium alone but by:- L. Sigmoid colon & it’s mesentry R. Cecum either side portion of bladder & rarely small intestine (1-2000) . Occur mainly ( almost always) in male & 5\6 on L side . Bilateral sliding hernia is rare . Age > 40 years . Is very large & globular descending well into the scrotum . Should not be treated by truss because part of sac is part of intestine &should be operated by excision of sac &marsupelization . Cecum . appendix or portion of colon wholly in the sac is not a sliding hernia.Sliding Hernia
12Third most common type [ incisional is 2nd most common]. 20% of H . Third most common type [ incisional is 2nd most common] . 20% of H. in woman 5% in men FIM 2\1 . More liable for strangulation it is the initial presentation in 40% of cases because of narrowness of neck & rigidity of canal . Femoral canal is most medial compartment of femoral sheath extend from femoral ring above into saphenous opening below cm 1.25 cm wide at the base which is directed upward .Femoral Hernia
13The space contain fat, lymph v. , L. N. of cloquet . The space contain fat, lymph v., L.N. of cloquet. . It can not be controlled by truss . The canal is closed above by septum crurale , a conden sation of extraperitonel tissue pierced by lymphatic vessels and below by cribriform fascia. * boundaries Ant. Inguinal lig. post. . ileopectineal lig. (Astley cooper’s lig) . Pubic bone . Fascia over pectinus m . Med. Lacunar lig. Gumbernat ‘s lig. Lat. Femoral vein separated by thin septum. F\M 2\1 female are usually elderly while male from years.
14Rare before puberty & R. side twice the L. 2:1 . 20% bilateral. Usually passed unnoticed or may presented with obstruction or strangulation because it is small & it’s under underwear. Fully distended femoral H. has the shape of retort and it’s bulbous extremity may be above the inguinal ligament , usually irreducible ape to strangulate.
15DDx ....1- inguinal hernia the neck above and medial to inguinal ligament.2- saphena varix has pulse on cough saccular enlargement of large saphenous v with other signs of varix vein, disappear when pt. lie.3- enlargement of femoral L.N. with infected wound or abrasion4- lipoma5- femoral aneurysm6- psoas abscess fluctuating swelling7-rupture of adductor longus with hematoma by history8- distended psoas bursa the swelling decrease when the hip is flexed and there is osteoarthritis of the hip .. Truss C.I in femoral hernia .
16* Rx ..... Also there is a laparoscopic approach Operations of 3 types1)) High type opening above inguinal lig (Mc Evedy)2)) low type opening below inguinal lig. (Lockwood)3)) inguinal approach opening through inguinal canal ( Lotheissen)in all cases the bladder must be emptied by catheterization.N .B. Funicular hernia * narrow necked hernia* operation is usually advised* contain prevesical fat and portion of bladder* occurs through a small oval defect in the medial part of conjoined tendon just above the pubic tubercule* occur principally in elderly men, occasionally strangulated .
17N. B. Dual hernia. Two sacs that straddle the inf. epigastric A N.B. Dual hernia . Two sacs that straddle the inf. epigastric A. . The condition is not rare . One of the sacs have been overlooked during operation N.B. Repair of direct hernia is as the indirect except 1- hernial sac can usually be simply inverted after free dissection 2- transversalis fascia is simply reconstructed in front of it * The reconstruction should be done by shouldice repair or mesh implant according to Lichtenstein technique. * Bassini is not acceptable because of high recurrence rate and slow rehabilitation.