Tiêu đề 3. Hernia.pdf ✅

Hernia ABU SAMN & MEERA Epidemiology - 10% in population. - More in males (M:F = 7:1). General - Hernia: abnormal protrusion through a muscle or tissue weakness. - Hernia consists of 3 parts: 1. Sac: • Mouth: opening of the sac. • Neck: narrow constriction which passes across the wall. • Body. • Fundus. 2. Covering: • Layers of abdominal wall (skin, fat, etc.). 3. Content: • Omentocele: omentum. • Enterocele: intestine. • Amayand’s: appendix. • Litter’s: Meckel’s diverticulum. • Sliding: viscus (colon). • Richter’s: anti-mesentric border of the intestine. • Cystocele: urinary bladder. - Divided into: 1. External hernia: • Inguinal (MC). • Femoral. • Epigastric. • Umbilical. • Spigelian. • Obturator. • Lumber. 2. Internal hernia: • Congenital diaphragmatic: Morgagni, Bochdalek. • Acquired diaphragmatic: sliding, paraoesophageal. - Terminology: 1. Reducible hernia: can be returned into its site either spontaneously or manually. 2. Irreducible hernia: cannot be returned to it’s site. • Due to: narrow neck, adhesions, overcrowding content. • Incarcerated: irreducible due to adhesions. • Obstructed: intestinal obstruction, intact blood supply. • Strangulated: ischemia, very tender and painful, TOP EMERGENCY! → More risk in femoral and Richter’s hernia.
Hernia ABU SAMN & MEERA Etiology - Natural weakness: • Inadequate muscle strength. - Acquired weakness: • ↑ intraabdominal pressure: pregnancy, ascites, chronic cough, chronic constipation, obesity. • Trauma and scars. - Congenital weakness: • Patent processes vaginalis. • Familial weakness of collagen. • Incomplete obliteration of umbilicus. Types Inguinal Hernia - Abnormal bulge that occurs in your groin region, the area between the lower part of your abdomen and your thigh. - Divided into direct and indirect according to Hesselbach’s triangle: • Medial border: rectus sheath. • Lateral border: inferior epigastric artery. • Inferior border: inguinal ligament. - Inguinal canal: • Borders: → Anterior wall: superficial inguinal ring (weakest point), external oblique aponeurosis (medial 1/3), internal oblique aponeurosis (lateral 2/3). → Posterior wall: deep inguinal ring (weakest point), conjoint tendon (medial 1/3), transversalis fascia. → Roof: internal oblique, transverse abdominis. → Floor: inguinal ligament. • Midpoint of inguinal ligament: surgical landmark for deep inguinal ring. External oblique Internal oblique Transversalis fascia Conjoint tendon
Hernia ABU SAMN & MEERA • Contents: → Females: round ligament of uterus. → Maled: ilioinguinal nerve, spermatic cord. • Spermatic cord: → 3 arteries: artery to the vas deference, testicular artery, cremasteric artery. → 3 nerves: genital branch of genitofemoral nerve, sympathetic nerves, branch of ilioinguinal nerve (the MC injured nerve during hernia repair). → 3 layers: external spermatic fascia (external oblique), cremasteric fascia (internal oblique), internal spermatic fascia (transversalis fascia). → 3 structures: pampiniform plexus, vas deferens, testicular lymphatics. 1. Direct inguinal hernia: • Inside the triangle, medial to the inferior epigastric. • Enters the inguinal canal “directly” through a weakness in the posterior wall of the canal (transversalis fascia). • Doesn’t descend to the scrotum. • The content is usually fat, less commonly bowel. • Acquired, ↑ risk in: old age, males, ↑ intraabdominal pressure, previous hernia. • Wide neck, cannot be controlled on deep ring occlusion test. 2. Indirect inguinal hernia: • The most common hernia in both males and females. • Outside the triangle, lateral to the inferior epigastric. • Enters the inguinal canal via the deep inguinal ring. • Descend through the scrotum. • The content is usually bowel or omentum. • Congenital due to patent processes vaginalis, found in the age groups. • Higher risk for strangulation. • Controlled on deep ring occlusion test. • Types: → Bubonocele: limited to the inguinal canal. → Funicular: pass beyond the superficial inguinal ring. → Complete/vaginal: reach down to the scrotum. 3. Pantaloon hernia: • Direct and indirect inguinal hernias together.
Hernia ABU SAMN & MEERA - History: • A bulge/lump: MC presentation. • Severe pain. • Past medical history is very important. - Physical exam: • Ask the patient to cough or do valsalva maneuver. → Positive cough impulse. • Try to reduce it. • Obliteration test. - Complications: • Incarceration, obstruction, strangulation - Differential diagnosis for a groin mass: • Lipoma, varicocele, hydrocele, lymphadenopathy. - Management: • Treat the underlying cause first. • Truss: → If not fit for surgery. → Can cause adhesions, muscle atrophy. • Surgery: → Herniotomy: hernia repair, done in children. → Herniorrhaphy: herniotomy plus repair of the posterior wall of the inguinal canal. → Hernioplasty: herniotomy plus reinforcement of the posterior wall of the inguinal canal with a synthetic mesh. ➢ All can be done either open or laparoscopic, laparoscopic is done in case of bilateral or recurrent hernia. • In case of strangulated hernia: → This is a top emergency. → Analgesia, put the patient in trendelenburg position, surgery. • What happens if you cut the ilioinguinal nerve? Femoral Hernia - Hernia through the femoral canal. - More common in females. - Very narrow neck! Highest risk for strangulation. - Below and lateral to pubic tubercle. → Inguinal hernia: above and medial to pubic tubercle. - Femoral canal: • Medial border: lacunar ligament. • Lateral borders: femoral vein. • Superior border: inguinal ligament. • Inferior border: pectineus muscle.
Hernia ABU SAMN & MEERA - Femoral triangle: • Medial border: adductor longus muscle. • Lateral border: sartorius muscle. • Superior border: inguinal ligament. - Cooper’s hernia: a femoral hernia made up of two sacs, one in the femoral canal and the other is in another defect. Umbilical Hernia - Congenital: almost all cases, in children. • Self limited. • Do surgery if: persists after 3 years of life, >1.5 cm. - Acquired: very rare, in adults, due to increased intraabdominal pressure. Paraumbilical Hernia - Defect in linea alba. - More common in females. - Crescentic in shape, within 5 cm around the umbilicus. - Content: MC omentum. - Very high risk for strangulation→ immediate surgery. Epigastric Hernia - Defect in linea alba. - > 5cm above the umbilicus. - Content: fat. - Painful. Incisional Hernia - Risk factors: old age, obesity, ascites, wound infection, wound hematoma, poor suturing techniques. Obturator Hernia - Howship-Romberg sign: an indication of obturator nerve irritation resulting in inner thigh pain that may extend to the knee on internal rotation of the hip. - https://www.youtube.com/watch?v=hIbzZ6mKoUo Spigelian Hernia - Defect in linea semilunaris. - Lateral to the rectus sheath. Lumber Hernia - In lumbar triangle.