Inguinal Herniorrhaphy Group 7

Submitted to : Mrs. Therisita Cruz Submitted by : Atienza,Ma. Ana Bantuas,Sahara L. Bernardo,Sittie Areej

Inguinal herniorrhaphy is a common day care surgical procedure and can be performed safely under regional or general anaesthesia. 1 Since inguinal hernia is rarely associated with serious complications, it is an ideal surgical procedure for ambulatory settings. Outpatient inguinal herniorrhaphy has been associated with remarkable reductions in cost without any obvious increase in complication rates or recurrence of hernia. An ideal outpatient anaesthetic technique would provide for excellent operating conditions, a rapid recovery, no postoperative side effects and high patient satisfaction. In addition to increasing the quality and improving the operating room efficiency, the ideal anaesthetic technique would also decrease the costs of the anaesthetic services in the form of rapid turnover of the patients and provide for an early discharge. About 75% of all hernias are classified as inguinal hernias, which are the most common type of hernia occurring in men and women as a result of the activities of normal living and aging. Because humans stand upright, there is a greater downward force on the lower abdomen, increasing pressure on the less muscled and naturally weaker tissues of the groin area. Inguinal hernias do not include those caused by a cut (incision) in the abdominal wall (incisional hernia). According to the National Center for Health Statistics, about 700,000 inguinal hernias are repaired annually in the United States. The inguinal hernia is usually seen or felt first as a tender and sometimes painful lump in the upper groin where the inguinal canal passes through the abdominal wall. The inguinal canal is the normal route by which testes descend into the scrotum in the male fetus, which is one reason these hernias occur more frequently in men. Herniorrhaphy (Hernioplasty, Hernia repair) is a surgical procedure for correcting hernia. A hernia is a bulging of internal organs or tissues, which protrude through an abnormal opening in the muscle wall. Hernias can occur in the abdomen, groin, and at the site of a previous surgery. An operation in which the hernia sac is removed without any repair of the inguinal canal is described as a 'herniotomy'. When herniotomy is combined with a reinforced repair of the posterior inguinal canal wall with autogenous (patient's own tissue) or heterogeneous (like steel or prolene mesh) material it is termed Hernioplasty as opposed to herniorrhaphy in which no autogenous or heterogeneous material is used for reinforcement. We therefore, conducted this case analysis study for daycare inguinal hernia repair, with respect to preparation and discharge times as well as cost effectiveness in patients’

They are very common (lifetime risk 27% for men. and their repair is one of the most frequently performed surgical operations. also known as herniorrhaphy. .Inguinal hernia (pronounced /ˈɪŋɡwɨnəl ˈhɜrniə/) is a protrusion of abdominal-cavity contents through the inguinal canal. weakness. or bulge in the lining tissue (peritoneum) of the abdominal wall in the groin area between the abdomen and the thigh. the repair is called hernioplasty. Inguinal hernia repair. using an instrument with a camera attached (laparoscope) and a video monitor to guide the repair. An inguinal hernia is an opening. When the surgery involves reinforcing the weakened area with steel mesh. is the surgical correction of an inguinal hernia. 3% for women[1]). The surgery may be a standard open procedure through an incision large enough to access the hernia or a laparoscopic procedure performed through tiny incisions.

Type Description Covered Relationship to by internal inferior spermatic epigastric vessels fascia? Usual onset indirect inguinal hernia protrudes through the inguinal ring and is ultimately the result of the failure of embryonic closure of the internal Lateral inguinal ring after the testicle passes through it enters through a weak point in the fascia of the abdominal wall (Hesselbach triangle)less common 25%-30% of inguinal hernia . Direct inguinal hernias occur medial to the inferior epigastric vessels when abdominal contents herniate through the superficial inguinal ring. the possibility for hernias through the inguinal canal in males is much greater because they have a larger opening and therefore a much weaker wall for the intestines to protrude through. Yes Congenital direct inguinal hernia Medial No Adult . which are defined by their relationship to the inferior epigastric vessels. direct and indirect. As a result.There are two types of inguinal hernia. lateral to the inferior epigastric vessels. this may be caused by failure of embryonic closure of the processus vaginalis. the opening of the superficial inguinal ring is smaller than that of the male. In the case of the female. most occur in men at 40 years and above . Indirect inguinal hernias occur when abdominal contents protrude through the deep inguinal ring.

000 inguinal hernias are repaired annually in the United States. about 700. Because humans stand upright. which are the most common type of hernia occurring in men and women as a result of the activities of normal living and aging. Nearly 25% of men and only 2% of women in the United States will develop inguinal hernias. there is a greater downward force on the lower abdomen.000 live births. increasing pressure on the less muscled and naturally weaker tissues of the groin area. Inguinal hernias occur nearly three times more often in African American adults than in Caucasians. Indirect inguinal hernias will occur in 10–20 children in every 1. Demographics The majority of hernias occur in males. According to the National Center for Health Statistics. The inguinal hernia is usually seen or felt first as a tender and sometimes painful lump in the upper groin where the inguinal canal passes through the abdominal wall. which is one reason these hernias occur more frequently in men. the risk of groin hernia is greater in premature infants or those of low birth weight. Inguinal hernias do not include those caused by a cut (incision) in the abdominal wall (incisional hernia).Purpose Inguinal hernia repair is performed to close or mend the weakened abdominal wall of an inquinal hernia. . Among children. Description About 75% of all hernias are classified as inguinal hernias. The inguinal canal is the normal route by which testes descend into the scrotum in the male fetus.

In fact. influenced by the same causes as direct hernia. women will more likely have an indirect inguinal hernia than direct. also called direct hernias. and 84% of all femoral hernias occur in women. About 60% of hernias found in children. About 3% of all hernias are femoral. Indirect inguinal hernias can occur in women. Direct or acquired inguinal hernias occur when part of the large intestine protrudes through a weakened area of muscles in the groin. occurring when the inguinal canal entrance fails to close normally before birth. but occur most often on the right side. and acquired. A femoral hernia is another type of hernia that appears in the groin. A congenital indirect inguinal hernia may be diagnosed in infancy. 50% are indirect or congenital hernias. This condition is found in 2% of all adult males and in 1–2% of male children. and 10% on both sides. also called indirect hernias. this combined hernia is called a pantaloon hernia. but they can sometimes confusethe diagnosis of inguinal hernias because they curve over the inguinal area.Hernias are divided into two categories: congenital (from birth). or excessive weight gain. too. about 30% on the left. The indirect inguinal hernia pushes down from the abdomen and through the inguinal canal. coughing. These are not inquinal hernias. Among the 75% of hernias classified as inguinal hernias. when abdominal pressure pushes folds of genital tissue into the inquinal canal opening. A direct and an indirect inguinal hernia may occur at the same time. will be on the right side. or later in adulthood. pregnancy. childhood. The weakening results from a variety of factors encountered in the wear and tear of life. for example. . causing a bulge of tissue. There is evidence that a tendency for inguinal hernia may be inherited. straining during urination or bowel movements. Inguinal hernias may occur on one side of the groin or both sides at the same or different times. The muscular weak spots develop because of pressure on the abdominal muscles in the groin area occurring during normal activities such as lifting. occurring when abdominal organs and tissue press through the femoral ring (passageway where the major femoral artery and vein extend from the leg into the abdomen) into the upper thigh. They are more often accompanied by intestinal obstruction than inguinal hernias. Internal organs such as the intestines may then push through this weak spot.

These conditions. blood supply to the intestines may be cut off (intestinal ischemia) and the hernia is said to be strangulated. A hernia may become incarcerated. which means that it is trapped in place and cannot slip back into the abdomen. or urinary obstruction. fluid retention. Groin hernias occur more frequently in smokers than nonsmokers.Because inguinal hernias do not heal on their own and can become larger or twisted. Anatomy . A relationship between smoking and hernia development has also been shown. other medical conditions complicate the presence of a hernia by adding constant abdominal pressure. If the herniated intestine becomes twisted. constipation. which may require the removal of affected parts of the intestines (bowel resection) as well as hernia repair. Protruding intestines can sometimes be pushed back temporarily into the abdominal cavity. or an external support (truss) may be worn to hold the area in place until surgery can be performed. Sometimes. must be treated simultaneously to reduce abdominal pressure and the recurrence of hernias after repair. which may close off the intestines. This causes bowel obstruction. the prevailing medical opinion is that hernias must be treated surgically when they cause pain or limit activity. including chronic coughing. especially in women. a condition causing severe pain and requiring immediate surgery.

Pathophysiology .

This initially impairs the lymphatic and venous drainage. The Hesselbach triangle is defined inferiorly by the inguinal ligament. Strangulation is more common with indirect hernia. Because of the wide neck of a direct hernia. The normal pinkish and shining color of the bowel wall is lost and replaced with a dull congested bowel segment. it carries with it fascial linings of the tissue it transverses. or follows the round ligament in females. As segments of the intestine prolapse through the defect in the anterior abdominal wall. . which leads to extravasations of blood into the hernia sac. The increased intraluminal pressure causes the wall of the affected segment to become congested. perforation occurs. if left untreated. Peritonitis occurs initially within the sac and then spreads to the peritoneal cavity. They typically affect middle-aged or elderly patients. This favors bacterial proliferation and subsequent infection of the blood-stained fluid in the hernia sac. Contents of this hernia then follow the tract of the spermatic cord down into the scrotal sac in men. A direct inguinal hernia occurs because of degeneration and fatty changes in the aponeurosis of the transversalis fascia in the Hesselbach triangle area. which further compounds the swelling. Direct hernias are always acquired and therefore unusual in the young. As the hernia emerges through the deep internal ring.Indirect inguinal hernias usually occur because of a persistent process vaginalis. and over time the arterial supply becomes involved. it rarely strangulates. they cause sequestration of fluid within the lumen of the herniated bowel. Gangrene ensues and. The hernia courses along the inguinal canal lateral to the epigastric arteries and emerges through the external ring slightly lateral to the pubic tubercle. followed by loss of tone within the bowel wall. which has a narrow neck. laterally by the inferior epigastric arteries and medially by the lateral border of rectus abdominus.


Surgical (Direct Inguinal Hernia) .


(Indirect inguinal hernia) After Surgical procedures .

called a herniorrhaphy or hernioplasty.Surgical incision in groin after inguinal hernia operation. type of anesthesia. The exposed inguinal canal is examined for any other trouble spots that may need reinforcement. with an incision made in the same location above the thigh. as in the repair of the indirect hernia. Local or regional anesthetics may be given to some patients. The surgeon will look for and palpate (touch) the bulging area of the hernia and will reduce it by placing sutures in the fat layer of the abdominal wall. Closing the underlayers of tissue (subcutaneous tissue) with fine sutures and the outer skin with staples completes the procedure. A sterile dressing is then applied. The weakened section of tissue is dissected (cut and removed) and the inguinal canal opening is sutured closed (primary closure). making sure that no abdominal organ tissue is within the sutured area. appropriateness of bilateral repair. The subcutaneous tissue and skin will be closed and a sterile dressing applied. Laparoscopic procedures . An open repair of a direct hernia begins just as the repair of an indirect hernia. There are various surgical strategies which may be considered in the planning of inguinal hernia repair. the patient will be asked to cough and strain during the procedure to help in demonstrating that the repair is "tension free" and sound In open inguinal hernia repair procedures. Surgical correction of inguinal hernias. just large enough to allow visualization of the hernia. Open surgical repair of an indirect hernia begins with sterilizing and draping the inguinal area of the abdomen just above the thigh. type of open repair. These include the consideration of mesh use. The repair will be checked for sturdiness and for any tension on the new sutures. the patient is typically given a light general anesthesia of short duration. etc. An incision is made in the abdominal wall and fatty tissue removed to expose the inguinal canal and define the outer margins of the hole or weakness in the muscle. by using a series of sutures from one end of the weakened hernia defect to the other. The hernial sac itself will be closed. is now often performed as outpatient surgery. During surgery conducted under local anaesthesia. use oflaparoscopy.

It is not usually possible to determine whether the hernia is direct or indirect until surgery is performed. A laparoscope. The surgeon will ask when the patient first noticed a lump or bulge in the groin area. the mesh makes a bridge over the hole and as normal healing take place. with little restrictions in activity. the mesh is incorporated into normal tissue without resulting tension. The doctor will palpate the area. The surgeon will view the movement of the instruments on a video monitor. Instead of the tension that develops between sutures and the skin in a conventionally repaired area. The risk of infection is also reduced because of the small incisions required in laparoscopic surgery. This may be all that is needed to diagnose an inguinal hernia. The ultrasound scan will allow the doctor to visualize the hernia and to make sure that the bulge is not another type of abdominal mass such as a tumoror enlarged lymph gland. The procedure is often performed in an outpatient facility withlocal anesthesia and patients can walk away the same day. Diagnosis Reviewing the patient's symptoms and medical history are the first steps in diagnosing a hernia. whether or not it has grown larger. hernioplasty using mesh patches has been shown to virtually eliminate tension. The use of surgical (prosthetic) steel mesh or polypropylene mesh in the repair of inguinal hernias has been shown to help prevent recurrent hernias. although general anesthesia is usually used. Signs and symptoms . and how much pain the patient is experiencing. an ultrasound examination may be performed.are conducted using general anesthesia. Rather than pulling the hole closed as in conventional repair. Laparoscopic surgery is believed to produce less postoperative pain and a quicker recovery time. The surgeon will make three tiny incisions in the abdominal wall of the groin area and inflate the abdomen with carbon dioxide to expand the surgical area. the mesh is placed so that it overlaps the healthy skin around the hernia opening and then is sutured into place with fine silk. will be inserted in one incision and surgical instruments inserted in the other incisions. In either open or laparoscopic procedures. Tension-free repair is also quick and easy to perform using the laparoscopic method. as the hernia is pushed back into place and the hernial sac is repaired with surgical sutures or staples. To confirm the presence of the hernia. which is a tube-like fiber-optic instrument with a small video camera attached to its tip. looking for any abnormal bulging or mass. and may ask the patient to cough or strain in order to see and feel the hernia more easily.

or standing up. If the blood supply of the portion of the intestine caught in the hernia is compromised. "elective" procedures. called Saphena varix Vascular aneurysm or pseudoaneurysm Hydrocele Varicocele . and the bulge commonly disappears on lying down. with potentially fatal consequences. Hernias present as bulges in the groin area that can become more prominent when coughing. such as the intestines. Some hernias remain static for years. As the hernia progresses. Significant pain is suggestive of strangulated bowel (an incarcerated indirect inguinal hernia). patients are advised to get the hernia repaired surgically at the earliest convenience after a diagnosis is made. can descend into the hernia and run the risk of being pinched within the hernia. They are rarely painful. or place the bulge back into the abdomen usually means the hernia is 'incarcerated' which requires surgery to correct. contents of the abdominal cavity. others progress rapidly from the time of onset. The timing of complications is not predictable. the hernia is deemed "strangulated. Emergency surgery for complications such as incarceration and strangulation carry much higher risk than planned. Provided there are no serious co-existing medical problems." and gut ischemia and gangrene can result. causing an intestinal obstruction. The inability to "reduce". Differential diagnosis of the symptoms of inguinal hernia mainly includes the following potential conditions:[2]           Femoral hernia Epididymitis Testicular torsion Lipomas Inguinal adenopathy (Lymph node Swelling) Groin abscess Saphenous vein dilation.Frontal view of an inguinal hernia (area shaved prior to hospitalisation and surgical repair procedure). straining.

anelectrocardiogram.sneezing -family history of hernias and premature birth. especially aspirin or anticoagulant (blood-thinning) drugs. a tube may be placed into a vein in the arm (intravenous line) to deliver fluid and medication during surgery. medications may be discontinued. and a chest x ray to make sure that the heart. lungs. Management . Cryptorchidism (Undescended testes) Causes: The weakness in the abdominal wall can be congenital injures and certain abdominal operation may increase hernia. A sedative may be given to relax the patient. Starting the night before surgery. A week or so before surgery. and major organ systems are functioning well. -pregnancy chronic -coughing chronic. Once in the hospital. -Excess weight. Preparation Patients will have standard preoperative blood and urine tests. -Heavy lifting. patients must not eat or drink anything. Other Factors: -Chronic constipation leading during bowel movements of urination.

as many individuals with small. they have been described by users as providing greater confidence and comfort when carrying out physically demanding tasksTheir popularity is likely to increase. and men should report any pain or swelling of the testicles. It is not considered to provide a cure. Although there is as yet no proof that such devices can prevent an inguinal hernia from progressing. Activities may be limited to non-strenuous movement for up to two weeks. To allow proper healing of muscle tissue. The postoperative activities of patients undergoing repeat procedures may be even more restricted. Aftercare The hernia repair site must be kept clean and any sign of swelling or redness reported to the surgeon. and if the pads are hard and intrude into the hernia aperture they may cause scarring and enlargement of the aperture. hernia repair patients should avoid heavy lifting for six to eight weeks after surgery. In addition. most trusses with older designs are not able effectively to contain the hernia at all times. Surgical Herniorrhaphy What to Expect After Surgery For adults. The more modern variety of truss (medicine) is made with non-intrusive flat pads and comes with a guarantee to hold the hernia securely during all activities.Medical The hernia truss is intended to contain a reducible inguinal hernia within the abdomen. open surgery for hernia repair usually involves a recovery period of up to 4 weeks before resuming normal strenuous activities. depending on the type of surgery performed and whether or not the surgery is the first hernia repair. because their pads do not remain permanently in contact with the hernia.Series: Aftercare . But this varies depending on the individual. Patients should also report a fever. Inguinal Hernia Repair . The surgeon may remove the outer sutures in a follow-up visit about a week after surgery. This device fell out of favour with the advent of hernia surgery. painless hernias are now delaying hernia surgery due to recently published reports on the incidence of Post Herniorrhaphy Pain Syndrome.

If you think you may be overweight. Stop smoking. Don't rely on a truss for support. emphysema and heart disease. talk to your doctor about the best exercise and diet plan for you.Prevention You can't prevent the congenital defect that may lead to an inguinal hernia. A truss won't protect against complications or correct the underlying problem. wearing a truss isn't the best long-term solution for an inguinal hernia. always bend from your knees. Lift heavy objects carefully or avoid heavy lifting altogether. not from your waist. smoking often causes a chronic cough that can lead to or aggravate an inguinal hernia. Fresh fruits and veget ables and whole grains are good for your overall health. They're also packed with fiber that can help prevent constipation and straining. although your doctor may recommend wearing one for a short time before surgery. . If you have to lift something heavy. Contrary to what you may have heard. Emphasize high-fiber foods. In addition to increasing your risk of serious diseases such as cancer. but the following steps can help reduce strain on your abdominal muscles and tissues: • • • • • Maintain a healthy weight.

most in the 7–12% range.Risks Hernia surgery is considered to be a relatively safe procedure. severing or entrapping nerves. Premature babies are at risk for heart and lung complications during surgery. present the same circumstance of combined scar tissue and hernia and even greater risk of recurrence. Postoperative complications include infection of the surgical incision (less in laparoscopy). Certain specialized clinics report markedly fewer complications. Each time a repair is performed. causing hemorrhage. representing about 100. Unfortunately. Recurrence and infection rates for mesh repairs have been shown in some studies to be lower than with conventional surgeries. Males with hydrocele and hernia may have both problems repaired at the same time to avoid the risks of a second surgery. 10–15% of hernias may develop again at the same site in adults. injuries to veins or arteries. The surgery usually is done on an outpatient basis. reactions toanesthesia. the surgery is less likely to be successful. . Infection and bleeding at the site. Recurrent hernias can present a serious problem because incarceration and strangulation are more likely and because additional surgical repair is more difficult than the first surgery. this practice involves putting both testicles at risk at the same time. Complications that can occur during surgery include injury to the spermatic cord structure. it may be repaired during the same surgery to avoid the risks of a second surgery. Adults and children who have a hernia repair are at risk for: • • Reaction to anesthesia (main risk). which are hernias that occur at the site of a prior surgery. This means that about 10% of the 700. pulmonary (lung) problems.000 recurrences annually. although complication rates range from 1–26%. which can cause paralysis. and systemic complications such as cardiac arrythmias. Incisional hernias. In males. cardiac arrest. One of the greatest risks of inquinalhernia repair is that the hernia will recur. Healthy children who have a hernia repair have few risks. • • • The surgeon may check to see whether a child younger than 1 year also has a hernia on the other side of the groin. injuries to the bladder or bowel. The risk of recurrence in children is only about 1%. or death. If there is one.000 inguinal hernia repairs each year will have complications. and urinary retention or urinary tract infection. When the first hernia repair breaks down. often related to whether open or laparoscopic technique is used. the formation of blood clots at the site that can travel to other parts of the body. the surgeon must work around scar tissue as well as the recurrent hernia.

or who are taking anticoagulant medicines. such as bronchopulmonary dysplasia Normal results . Damage to the femoral artery or vein. Very large hernias. Infants with the following conditions may need to be hospitalized for hernia surgery: • Lung problems. resulting in an inability to father children. Hernias on both sides (bilateral hernias). Inpatient surgery is sometimes recommended for people who have: • • • • Unusual. This lowers costs (as much as 50% lower than inpatient surgery. What To Think About The following people need special preparation before surgery to reduce the risk of complications: • • • • Those with a history of blood clots in large blood vessels (deep vein thrombosis) Smokers Those taking large doses of aspirin Those taking anticoagulation medicines (such as warfarin or heparin) Most inguinal hernia repair surgery on adults of all ages and healthy children is done on an outpatient basis. Outpatient surgery takes about 1 hour. which requires a stay in the hospital) and may reduce infection. recurrent hernias. Damage to the cord that carries sperm from the testicles to the penis (vas deferens).• • • Nerve damage. numbness of skin. Severe illnesses (such as heart or lung disease). loss of blood supply to scrotum or testicles resulting in testicular atrophy (all infrequent).

Points to Remember . Alternatives If a hernia is not surgically repaired. How Well It Works Open surgery for inguinal hernia repair is safe. an incarcerated or strangulated hernia can result. Most first-time hernia repair procedures will be one-day surgeries. Recovery times will vary. with recurrence rates for indirect hernias from less than 1–7% and 4–10% for direct. in which the patient will go home the same day or in 24 hours. sometimes involving life-threatening bowel obstruction or ischemia. deaths do occur. and the underlying condition of the patient. Patients undergoing open surgery will experience little discomfort and will resume normal activities within one to two weeks. Only the most challenging cases will require an overnight stay. but with advanced age or severe underlying conditions. Laparoscopy patients will be able to enjoy normal activities within one or two days. The chance of a hernia coming back after open surgery ranges from 1 to 10 out of every 100 open surgeries done. Synthetic patches are now widely used for hernia repair in both open and laparoscopic surgery. The recurrence rate (hernias that require two or more repairs) is low when open hernia repair is done by experienced surgeons using mesh patches. depending on the size of the hernia.Inguinal hernia repair is usually effective. with the exception of heavy lifting and contact sports. returning to a normal work routine and lifestyle within four to seven days. Morbidity and mortality rates Mortality related to inguinal hernia repair or postoperative complications is unlikely. depending on the type of surgery performed. Recurrence is a notable complication and is associated with increased morbidity. how much time has gone by between its first appearance and the corrective surgery.

also called the small bowel. the technique used. and the age and health of the patient. is a serious condition and requires immediate medical attention. sudden pain that worsens quickly. An inguinal hernia can occur any time from infancy to adulthood and is much more common in males than females. and vomiting. An incarcerated inguinal hernia is a hernia that becomes stuck in the groin or scrotum and cannot be massaged back into the abdomen.• An inguinal hernia is a condition in which intra-abdominal fat or part of the small intestine. discomfort or sharp pain. A strangulated hernia. Symptoms include extreme tenderness and redness in the area of the bulge. Inguinal hernias may be repaired through surgery. • • • • • • • Surgery for inguinal hernia is usually done on an outpatient basis. An inguinal hernia occurs in the groin—the area between the abdomen and thigh. in which the blood supply to the incarcerated small intestine is jeopardized. Recovery time varies depending on the size of the hernia. and they have different causes. or aching feeling at the bulge. bulges through a weak area in the lower abdominal muscles. and a burning. . rapid heart rate. An inguinal hernia is diagnosed through a physical examination. nausea. fever. Direct and indirect hernias are the two types of inguinal hernia. Symptoms of an inguinal hernia usually appear gradually and include a bulge in the groin. a feeling of weakness or pressure in the groin. Surgery is performed through one incision or with a laparoscope and several small incisions. gurgling.