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Hernia Abnormal protrusion of an organ or tissue, through a defect in its surrounding walls Various sites of the body Most commonly abdominal wall hernia.

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Presentation on theme: "Hernia Abnormal protrusion of an organ or tissue, through a defect in its surrounding walls Various sites of the body Most commonly abdominal wall hernia."— Presentation transcript:

1 Hernia Abnormal protrusion of an organ or tissue, through a defect in its surrounding walls Various sites of the body Most commonly abdominal wall hernia

2 Hernia External – protrudes through all layers of abdominal wall
Internal – protrusion of the intestine through a defect within peritoneal cavity

3 Abdominal wall hernias
Groin Inguinal Femoral Anterior Umbilical Epigastric Spigelian Pelvic Obturator Perineal Posterior Lumbar Superior triangle Inferior triangle

4 Hernia Reducible – content can be replaced within the surrounding musculature Irreductible or incarcerated – cannot be reduced Strangulated – compromised blood supply - complications

5 Hernia strangulation Large hernia – small orificies
Small neck obstructs blood flow, venous drainage or both Adhesions between content and peritoneum – obstruction and strangulation of the intestine

6 Hernia – incidence 600.000/y hernia repairs in US
Most common operation performed by general surgeons 5% of population will develope abdominal wall hernia

7 Hernia incidence 75% of all hernias occur in the inguinal region
2/3 – indirect hernias Men – 25 times more likely to have groin hernia then woman Female – femoral and umbilical hernias more often then inguinal (10/1 and 2/1 respectively)

8 Hernia incidence Both inguinal indirect and femoral – more commonly on the right side Delay in atrophy of right processus vaginalis peritonei Slower decent of thr right testis to the scrotum Tamponading effect of sigmoid colon on the left femoral canal

9 Hernia – inguinal canal
4 cm lenght, 2 – 4 cm up to inguinla ligament Extends between internal (deep) and external (superficial) inguinal ring Contain spermatic cord or round ligament of the uterus

10 Hernia – inguinal canal
Spermatic cord Cremasteric muscle fibres Testicular artery Pampiniform plexus Genital branch of genitofemoral nerve Vas deferens Cremasteric vessels Lymphatics Processus vaginalis

11 Hernia – inguinal canal
Superficial – external oblique aponeurosis Upper (cephalad) – intermnal oblique and transversus muscle Inferior – inguinal and lacunar ligament Posterior – transversalis fascia

12 Hernia – diagnosis Bulge in the inguinal region
Pain or discomfort (groin hernias are not extremely painful) Paresthesias (compression or irritation of inguinal nerves)

13 Hernia – differential diagnosis
Inguinal hernia Femoral hernia Hydrocele Inguinal adenitis Varicocele Ectopic testes Lipoma Hematoma

14 Hernia – differential diagnosis
Psoas abscess Femoral adenitis Lymphoma Metastatic nepolasm Epididymitis Testicular torsion Femoral artery aneurysm or pseudoaneurysm Hydradenitis of inguinal apocrine glands

15 Hernia – physical examination
Both supine and standing position Visual and palpative inspection for mass in inguinal region Ask patient to cough or perform Valsalva maneuver Fingertip OVER inguinal canal Finally fingertip into inguinal canal – small hernia

16 Hernia – physical examination
PROBLEM – bulge of the groin described by the patient not demonstrated during examination??? Ask patient to stand for a period of time Repeat examination (sometimes another visit)

17 Hernia – examination USG – high degree of sensitivity and specificity in detection of occult direct, undirect and femoral hernias CT – abdomen and pelvis – to diagnose unusual hernias or atypical groin masses

18 Hernia – nonoperative management
Opertaion recomended on discovery!!! Progressive enlargement and weakening Potential for incarceration and strangulation Exclusions: Short life expectancy patients Significant comorbid ilnesses Minimal symptoms

19 Hernia – nonoperative management
Trusses – provide symtomatic relief Correct measurement and fitting are the key Hernia control in 30% patients Complications: Testicular atrophy Ilioinguinal or femoral neuritis Hernia incarceration

20 Hernia – nonoperative management
NOT RECOMMENDED IN FEMORAL HERNIAS!!! High incidence of complications, particulary strangulation

21 Hernia – operative repair
Anterior repairs: Most common technique Tension – free techniqes are standard Older types – indicated for small hernias

22 Hernia – operative repair

23 Hernia – operative repair

24 Hernia – operative repair

25 Hernia – operative repair

26 Hernia – operative repair

27 Hernia – operative repair

28 Hernia – operative repair

29 Hernia – operative repair

30 Hernia – Bassini repair

31 Hernia – Bassini repair

32 Hernia – Bassini repair

33 Hernia – Bassini repair

34 Hernia – Halstead repair

35 Hernia – Shouldice repair

36 Hernia – Lichtenstein repair

37 Hernia – Lichtenstein repair

38 Hernia – Lichtenstein repair

39 Hernia – Lichtenstein repair

40 Hernia – other methods Girard Kirschner Marcy Mc Arthur Mc Vay Wolfer

41 Hernia – laparoscopic management
Minimal invasive ??? Tension – free mesh repair Less pain Quicker recovery Better visualisation of anatomy Fixing all hernia defects Decreased surgical site infections

42 Hernia – laparoscopic management
Complication rate – less then 10% Reccurrence rate 0 – 3%

43 Hernia – laparoscopic management
TAPP – transabdominal preperitoneal approach TEP – total extraperitoneal approach – without entering peritoneal cavity

44 Hernia – laparoscopic management
Infraumbilical incision Dissecting baloon inflated under vision Created space is insuflated, aditional trocars are placed Reduction of hernia (hernias) Traction Large sac shoud be cautered to inguinal ring

45 Hernia – laparoscopic management
10x15 cm mesh inserted through a trocar and unfolded Mesh should cover direct, indirect and femoral area It’s secured with a tacking stapler

46 Hernia – femoral canal Superficial – inguinal ligament
Lateral – femoral vein Posterior – Cooper’s ligament

47 Hernia – femoral canal

48 Femoral hernia

49 Femoral hernia - diagnosis
Mass or bulge occursbelow inguinal ligament If it’s over inguinal ligament – it still could be femoral hernia (hernia sac is ascending) It’s usually more painful then inguinal

50 Femoral hernia - repair
Dissection and removal of hernia sac Obliteration of the femoral canal defect Cooper’s method Mesh In case of strangulation, hernia sac content should always be examined for viability

51 Femoral hernia - repair

52 Femoral hernia - repair

53 Femoral hernia - repair

54 Hernia – special problems
Sliding hernia Internal organ comprises a portion of the hernia sac Mostly indirect inguinal hernias Bowel (sigmoid) or urinary bladder DANGER – recognize visceral component of hernia sac during operation, to avoid damage of the organ)

55 Hernia – special problems
Recurrent hernias Challenging Higher incidence of secondary recurrence Placing of the mesh required for succes Recurrences after anterior mesh repairs require posterior approach and placement of second prothesis

56 Hernia – special problems
Strangulated hernias Hernia sac content must be visualised for viability Constricting ring can be incised to reduce tension Sometimes it’s necessery to resect strangulated intestine

57 Hernia – postopertaive complications
Wound infection – 0,58% Haematoma – 0,43% Pulmonary embolus – 0,07% Haemorrhage – 0,02% Ischemic orchitis – 0,61% Testicular atrophy – 0,34%

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