hernia hernia begashaw m (md). introduction common surgical problem adequate knowledge is important...
TRANSCRIPT
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HERNIA
Begashaw M (MD)
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Introduction
Common surgical problem Adequate knowledge is important Prevent serious complications
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Definition
– Is a protrusion of a viscus through an opening in the wall of the cavity
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Component
Sac -Out pouch of the peritoneum-
-Four parts-Mouth,Neck,Body&Fundus
Content-viscus/organ inside a sac
- Small bowel and omentum – the commonest
- Large bowel appendix
- Bladder
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CLASSIFICATION
Reducible - viscus can be returned back Irreducible - contents can’t be returned backObstructed - intestineis occluded but no
impairment of vascular supplyStrangulated - vascularity of viscus is impairedRichter’s - only one side of wall is herniatedSliding - extra peritoneal structure form part of
wall of the sac
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HERNIAS
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Risk factors
Increased intra abdominal pressure
- Chronic cough
- Straining at urination or defecation
- Heavy wt lifting
- Abdominal distension
Weakened abdominal wall
- Advanced age
- Malnutrition
- Congenital defect – ppv
- Trauma/surgery
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Clinical features
History
- Lump
- Pain, local aching, discomfort
- Factors predisposing to increased intra abdominal pressure
- Symptoms of int. obstruction/strangulation
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Physical examination
- Examine Standing & Lying
- Lump – reducible, cough impulse with bowel sound
- Reduced on lying & increases in size _coughing/ straining
- Obstruction – tense, tender, irreducible with absent cough impulse
- Strangulation – more tenderness, with warm indurated, and inflamed overlying skin
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Examination
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Investigation
a clinical diagnosis investigation is rarely needed
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Complications
1. Irreducibility
2. Obstruction
3. Strangulation is a surgical emergencyRisk of obstruction and strangulation is
very high in femoral hernia, paraumblical hernia and indirect inguinal hernia with narrow neck
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Principles of management
1. Herniotomy - removal of the sac and closure of the neck
- in infants and children
2. Herniorrhaphy - Herniotomy and repair of the wall to prevent recurrence
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Obstruction
Non operative
-Gentle reduction
- Put patient in head down position
- Sedative is given
- Gentle manipulation to reduce the hernia Urgent Surgery
- Failed reduction
- All strangulated hernia
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Strangulation
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Anatomy-inguinal canal
Boundary
Anteriorly: External oblique apponeurosis
Posteriorly: Fascia transversalis
Inferiorly: Inguinal ligament
Superiorly: Conjoined tendon and internal oblique M Runs in antero inferior (InternalExternal ring)
_Internal ring -2cm above & 2cm medial to mid inguinal ligament
_External ring -just above pubic crest & tubercle
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Anatomy
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Anatomical site of groin hernia
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Contents of inguinal canal
Male Spermatic vessels Vas deference Ileo inguinal nerve Genito femoral nerve
Female Round ligament
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Anatomy of Femoral canal
Is a narrow rigid space Boundary
- Inguinal ligamentsuperiorly- Pectineal posteriorly- Lacunar mediallyF- Femoral veinlaterally prone to obstruction & strangulation
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Inguinal hernia
- accounts for 80%
- commonest is all ages & sexes
- 20 x more common is males than women
- more common on right side
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Classification
1-Indirect_passes through internal inguinal ring along the inguinal canal
-May extend down to the scrotum
2 -Direct_Bulges through post wall of inguinal canal
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Classification
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Hernia
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Indirect inguinal hernia
- 60% on right- 40% Lt side - 20% bilateral- Due congenital defect
patent processes vaginalis
- 20 times more common in men
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Direct inguinal hernia
- due to wear and tear associated - advanced age- increased intra abdominal pressure
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Femoral Hernia
- acquired downward protrusion of intestinal contents into the femoral canal
- 4 times more common in females
- rare in children
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Clinical features
History
- Elderly or middle aged woman
- lump on anterior and upper thigh
- may present with complaints associated with int. obstruction or strangulation
Physical examination
- Small lump on lower groin, lateral and below pubic tubercle
- Reducible/irreducibility
- Bowel sound/cough impulse – usually absent
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Femoral hernia
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Management
- surgical repair without delay
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Umbilical Hernia
Umbilicus is one of the weak sites of the abdomen A hernia can occur at this potential site Risk factors
Female sex
Multiparity
Obesity
Ascites Complications
Obstruction
Strangulation
Rupture
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Umblical hernia
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Treatment
Expectant - Spontaneous closure is expected in 80% cases of umbilical hernia in under five children
SurgeryBeyond five years
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Incisional Hernia
Risk Factors
-Wound infection
-Poor surgical technique (
-Chronic cough
-Straining
-Obesity
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Clinical features
Risk of obstruction and strangulation is very rare
Local discomfortCosmetic problemsDifficulties with micturation and bowel
movement when very largeTreatment
Hernioplasty
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Incisional hernia