SURGERY Abdominal hernia Feb 11, 2008

• Differentials: a) Hydrocoele = differentiate thru TRANSILLUMINATION b) Hernia = no enlargement; w/ bulging **condition w/ hernia & hydrocoele is common in children Protrusion of visceral contents through the abdominal wall Important Components: a) Defect in the aponeurosis (size/neck, location & fascial opening) b) Hernia Sac – peritoneal outpouching that contains the abdominal viscera Examples: a) SLIDING HERNIA = retroperitoneal organs as the sigmoid, bladder/ ureter forms part of the wall b) RICHTERS HERNIA = anti-mesenteric portion of bowel protrudes into the sac c) LITTRES HERNIA = sac contains Meckel’s Diverticulum SITES OF HERNIATION: • occurs where the aponeurosis fascia are devoid of the protective support of striated muscles • sites include: a) groin  inguinal hernia b) umbilicus  umbilical hernia c) linea alba  epigastric hernia d) semilunar line of Espreghel  spigelian hernia e) diaphragm  hernia of Morgagni, hernia of Bochdalek f) surgical incisions  incisional hernia **Recommended to observe: until 2y/o specially if the defect is quite & small (circumference>5)



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Starts in the internal inguinal ring  inguinal canal  scrotum (complete indirect IH) Usually associated w/ patent PROCESSUS VAGINALIS Increase intra-abdominal pressure weaken the internal ring causing herniation a) Complete – end up in scrotum b) Incomplete – only in the area of inguinal canal c) Completely open processus vaginalis & testis with the sac-communicating hydrocoele (patient lies down, hernia disappears, stands up reappears) Lateral to the inferior epigastric vessels

• • Hernias located above the abdomino-crural areas Protrusion of peritoneal sac through the transversalis fascia spanning the myopectineal orifice of Fruchaud Sac passes obliquely or indirectly toward & ultimately into the scrotum
Marco, Fars, jassie, April, viki

B. DIRECT INGUINAL HERNIA o Sac protrudes directly outwards through the floor of the inguinal canal & passes the Hesselbach triangle o Rarely will it descend into the scrotum o MEDIAL to the inferior epigastric vessels o REPAIR: strengthening the floor of Inguinal Canal specially in elderly o MANUEVER: to differentiate 3 inguinal hernia to determine what type of surgical intervention ↓ Px is standing & Dr. is behind ↓ 3 Finger-test RT hand: middle(ext oblique) Index ( femoral) Thumb ( Hasselbach) Px: strain / cough a. Herniotomy – if there is no weakening of the inguinal floor b. Buttress repair – if there is recurrent hernia and weakness at the floor c. Mesh repair C. FEMORAL HERNIAS o Mass located at the medial base of scarpas’s femoral triangle or medial side of the femoral sheath o Iliopubic tract shifted medially widening the ring



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Absence of the posterior rectus sheath below the arcuate line Insubstantial transversalis fascia (strongest layer of the abdominal wall) Unsupported by muscles and aponeurosis

• • Cause of all groin hernias is the failure of the transversalis fascia to retain the peritoneum He further emphasized that the common origin of all groin hernias begin with a single weak area known as the MYOPECTINEAL ORIFICE
TYPES Indirect ring hernia Direct Ring hernia Femoral hernia Pantalon Sliding hernia Recurrent RUTLEDGE (n-1437) 60% 36% 4% 11.4% 2% 4% LICHUTENSTEIN (n-4000) 44.4% 43.4% UERM (n-49) 97%

PATENT PROCESSUS VAGINALIS  Primary cause of indirect inguinal hernia  Common in pediatric  Additional factors in adults SHUTTER MECHANISM  Maintains the integrity of sites with natural weakness by: a) Strengthens the arch & lie close to the Inguinal ligament b) Pulls up & tenses the crura causing closure of the internal ring c) Counter-pressure exerted by the external oblique muscle d) Inguinal ligament pulled upwards • Decrease pressure of myopectineal orifice **defined in the lower portion of internal oblique muscle, the shutter mechanism of the deep ring and expose the floor of inguinal canal RAISED INTRA-ABDOMINAL PRESSURE e.g. patients wit prostatic hyperplasia  excessive straining a) Patent processus vaginalis causes hernia b) Attenuated muscle (as patient gets older) c) Umbilical defect INTEGRITY OF TRANSVERSALIS FASCIA a) Ability to stand increase intra-abdominal pressure b) Strength rely on COLLAGEN FIBER o Ehlers Danlos Syndrome o Marfan’s syndrome o Hereditary & connective tissue disease CIGARETTE SMOKING • Investigation revealed abnormal metabolism of collagen • Presence of elastase and anti-protease • Impaired leukocyte response to oxidants GENETIC FACTORS a) Age b) Lack of exercise c) Multiparity d) Surgical procedures

**PANTALON = combination of direct and indirect hernia **INDIRECT INGUINAL HERNIA = most common **HERNIA is more common in the RIGHT than the left because: a) Delayed descent of the right testis & obliteration of processus vaginalis b) Tamponade effect of the sigmoid over the left side

SIGNS & SYMPTOMS 1) Non-specific discomfort – exquisite pain in
the scrotal area 2) Slow enlargement of the patient of irreducibility & disfigurement 3) Palpable impulse generated by the sac with its contents 4) Failure to transilluminate 5) Mass below the inguinal ligament Immediate Tx: cold compress to reduce swelling  taxis (return to original position  surgery

1) Herniography - Inject soluble dye in peritoneal cavity, if the dye descends into scrotal cavity 2) UTZ, Ct scan & MRI - Exclude other masses 3) IVP (intravenous pilography

Acceptable class should be: a) Blueprint for understanding the inguinal & femoral canal b) Aid in scientific appraisal of various surgical repairs c) Evaluation of special outcome

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d) Differentiate anatomic problems I. GILBERT CLASSIFICATION, 1988 a) Hernial Sac b) Size & competency of the internal ring c) Integrity of the posterior wall within the Hesselbach triangle Type 1(N) ,2(<4cm),3 (>4cm) = Indirect inguinal Hernia Type 4,5 = Direct Inguinal Hernia Rutkow & Robbins 6 = Pantalon Hernia 7 = Femoral Hernia Tx: 1-3  minimize by sutures 4-5  suture and buttress the inguinal hernia II. NYHUS CLASSIFICATION, 1991 - State of the internal Ring posterior wall of the Internal Canal
TYPE 1 2 3a 3b 3c 4 HERNIAS Indirect Hernia without dilation of Internal ring Indirect Hernia with dilation of Internal Ring Direct with backwall defect Indirect Hernia with backwall defect (combined) Femoral Hernia Recurrent

a) Anterior – dividing structure in & around the
inguinal canal 1. Open & prosthesis 2. Open anterior non prosthesis

b) Posterior/ Preperitoneal Herniography
Exposure of the orifice by entering the peritoneal space

TYPES 1,2 3 4,5 6 7 Sutures less hand-rolled mesh plug Same plug, single suture lateral to the cord for the incompetent sling shutter mechanism Circumscribed fusiform sac, invaginated with plug inserted through the defect & interrupted suture placed Multiple plugs. All direct & indirect are reinforced with only patch Plug through the growing of the femoral canal

TREATMENT BASED ON NYHUS CLASSIFICATION • Based on strict functional state of the inguinal ring & posterior wall of the canal
I II III IV Indirect Inguinal Hernia, high ligation & no facial repair High ligation of sac, ring is closed or strengthened with few sutures Shouldice, McVay & Stoppa’s GPRVS for femoral hernia – posterior iliopubic repair without mesh plug/ simply mesh plug Posterior iliopubic tract repair with on lay buttress of mesh

TREATMENT • Pressing cold compress= decreases swelling;
• reduce spontaneously Anesthesia for Repair = SPINAL anesthesia – relaxation of abdominal wall → decreases mass Check if there is: a) Reducibility? b) Recurrence? c) Strangulation? d) Bowel involvement? e) Gangrene? Small or serous sanguineous fluid? HERNIA DEVICES - Temporary Femoral = not used →compression→gangrene

GILBERTS MARCY, 1871 - High ligation of the sac - Closure of the ring by suturing the Transversalis Fascia to the inguinal ligament - Indicated in: pediatrics, female & puberty MARCUS SIMPLE RING CLOSURE - Few interrupted stitches approximating the transverse aponeurotic tract which will return the _____ to its normal size EDOARDO BASSINI, 1887 - Reconstruction of the floor by suturing: a) Internal oblique muscle b) Transverses abdominal muscle c) Transversalis fascia with iliopubic tract & the shelving edge of the inguinal ligament McVAY/ COOPER’S LIGAMENT REPAIR - Approximate of the transverses abdominal muscle(TAM) & transversalis fascia to Cooper’s ligament - McVay repair approximate the transverses aponeurotic arch to Cooper’s ligament and to the femoral sheath. The suture in the medial side of the femoral sheath is called the transition stitch. Excess tension is always present & relaxing is mandatory.

OBJECTIVE IN THE REPAIR = prevent peritoneal protrusion = restoration & closure of the myopectineal orifice TYPES OF REPAIR

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EARLE SHOULDICE, 1953 - Similar to Bassini but using running sutures to imbricate the several layers (not interlocking) - Repairs the innermost aponeurotic fascial layers by imbrication COMPARISON OF RESULTS - Multicenter prospective Randomized controlled Trial, Recurrence after 5year Bassini 8.6% McVay 11.2% Shouldice 6.5% ANTERIOR REPAIR WITH PROSTHESIS - Conceived in the 9th century A. Pierre Nicholas Gerdy o Conceptualized plugging the internal canal with folded skin using the scrotum skin B. C.W. Wutzer 1789-1869 o Wood plug pushing the scrotal skin C. Theodore Billroth, 1829-1894 o Prophesized effective resolution with artificial replacement of attenuated tissue D. IRVING LICHTENSTEIN, 1986 o Criticized suturing tendinous structure not normally in apposition o Creating tension, a violation of surgical principle o Attenuated structures o Impaired collagen metabolism (Ehler, Marfans) MESH PLUG - Gilbert 1980 - Cone shaped plug readily made from 6-8 cm square of polypropylene mesh that has been partially slit and then rolled around the apex if the slit Comparison of Results (Folis & Lindahl prospective studies, recurrence after 2 year foolow-up, 2000+) Lichtenstein 102(10%) Moray 53(3.8%) McVay 53(26%)


TAPP ( Transabdominal Preperitoneal) I POM ( intraperitoneal On-Lay Mesh) TEP ( Totally Extraperitoneal)

Recurrence  10% reported for groin hernia repair o Indirect 1-7% o Direct 4-10% o Femoral 1-7% o Recurrent 5-3%  50% of recurrence occur within 5years  75% becomes evident within 10years CAUSES OF RECURRENCE: 1) Failure to diagnose multiple hernia 2) Failure to close large internal ring 3) Breakdown of repair under tension 4) Missed bilateral hernia 5) Infection 50% of recurrence 6) Suture material 7) Suturing technique 8) Genetic Factor NERVE ENTRAPMENT (2%) - High in McVay & Shouldice repair - Numbness, pain - Paresthesia - Felt in 2weeks after surgery - Treatment: a) rest for 8weeks b) corticosteroid/ nerve block c) exploration & neurorectomy TESTICULAR COMPLICATION - orchitis, atrophy and vas deferens injury - secondary to venous thrombosis - swelling, hard cord & epididymis - fever & leucocytosis - precautions: a) avoid distal dissection beyond pubis b) avoid distal dissection in the sac c) delay control repair for 1year VASCULAR INJURY (1-8%) - inferior epigastric, femoral and testicular vessels - bowel of bladder in sliding hernia BOWEL OBSTRUCTION - in adhesive complications with the used of mesh WOUND INFECTION - case considered a clean wound - increase due to use of mesh - increase with length of operating time - prophylactic antibiotics

OTHER TYPES - Open preperitoneal, Lloyd Nyhus 1960 - Giant prosthetic reinforcement of visceral sac (GPRVS) LAPAROSPCOPIC REPAIR (1990)

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SEROMA – collection of serous fluid - tissue reaction to foreign body - increase incidence with mesh HEMATOMA – collection of blood - evacuation - closed by 2ndary intention VISCERAL INJURIES OSTEITIS PUBIS – accidential suture of Coopers ligament Conclusion: haaay huwag na 2! “ Considering all that is written about the medical tx of inguinal hernias up until now, it has been somewhat pushy to try to publish more about – Eduardo Bossini
GUYZ,compl2 na toh…sbrang effort kami mgcopy nila fars at jassie ng powerpoint n khit n22log n lahat ng mga kaklase nmn, todo kopya kmeng apat……at thanx sa notes ni April!!! Sana mak2long tong trans!!! Thanx din kay Paul kc pinhiram niya ung laptop nya skin….kaya natpos ko n 2ng trans at di ko n kailngan mgrent. Pasaway kc ang mga virus nasira ko 2loy computer nmn s bahay. Hehehe. Lagot tlga ako sa kuya ko!!! Anyways ang bagong MOTTO ngun sa buhay ay di bale nang BUMAGSAK pero MASAYA k nmn at my BUHAY!!!!hehehe Guys gud luck sa exams…kaya natin toh. Waaaahahaha. Nag adik din kami sa pagsususlat. Hahahahahaha MR and brim