CSS HERNIA INGUINAL

LATERAL (HIL)

Ayu Niendar Puspita

1210011
Program Pendidikan Profesi Do
Fakultas Kedokteran Universitas Islam Ban

Pres
Liza Nursanty, dr., SpB., M
Bagian Bedah Umum Rumah Sakit Al-Islam Ban

ANATOMY

Inguinal Canal
Because the vast majority of inguinal hernias occur in men, general
descriptions of groin anatomy contained herein will pertain to males.
The inguinal canal is approximately 4 to 6 cm long and is situated in the
anteroinferior portion of the pelvic basin.
Shaped like a cone, its base is at the superolateral margin of the basin,
with its apex pointed inferomedially toward the symphysis pubis.
The canal begins intra-abdominally on the deep aspect of the abdominal
wall, where the spermatic cord passes through a hiatus in the transversalis
fascia (in females, this is the round ligament).
This hiatus is termed the deep or internal inguinal ring. The canal then
concludes on the superficial aspect of the abdominal wall musculature at
the superficial or external inguinal ring, the point at which the spermatic
cord crosses the medial defect of the external oblique aponeurosis.

Indirect inguinal hernia

DEFINITION

An indirect inguinal hernia is an inguinal hernia

that results from the failure of embryonic closure
of the deep inguinal ring after the testicle has
passed through it. Like other inguinal hernias, it
protrudes through the superficial inguinal ring.

EPIDEMIOLOGY

75% percent of all abdominal wall hernias occur in

the groin. Indirect outnumber direct by about 2:1,
with femoral hernias making up a much smaller
proportion. Right sided groin hernias are more
common than those on the left. The male : female
ratio for inguinal hernias is 7 : 1.

AGE (YEARS)

2534

3544

45-54

55-64

65-74

75+

Current
prevalence (%)

12

15

20

26

29

34

Lifetime
prevalence (%)

15

19

28

34

40

47

RISK FACTORS AND ETIOLOGY

Inguinal hernias may be considered congenital or acquired diseases.
In adult patient with a groin hernia include old age, short duration, femoral hernia, and coexisting medical illness.
In children, the risk factors are very young age, male sex, short duration and right sided hernia.
PRESUMED CAUSES OF GROIN HERNIATION
1. Coughing
2. COPD
3. Obesity
4. Straining (Constipation , prostatism)
5. Pregnancy
6. Birthweight less than 1500g
7. Family history of a hernia
8. Valsava maneuvers
9. Ascites
10. Upright position
11. Congenital connective tissue disorders
12. Defective collagen synthesis
13. Previous right lower quadrant incision
14. Arterial aneurysms
15. Cigarette smoking
16. Heavy lifting
17. Physical exertion (?)

PRESUMED CAUSES OF GROIN HERNIATION

Coughing
2. COPD
3. Obesity
4. Straining
(Constipation ,
prostatism)
5. Pregnancy
6. Birthweight less than 1500g
7. Family history of a hernia
8. Valsava maneuvers
9. Ascites
10. Upright position
1.

11.

Congenital connective tissue disorders

12.

Defective collagen synthesis

13.

Previous right lower quadrant incision

14.

Arterial aneurysms

15.

Cigarette smoking

16.

Heavy lifting

17.

Physical exertion

CLINICAL MANIFESTATION

diagnosis
History
Patients who present with a symptomatic groin hernia will frequently present with groin pain.
Less commonly, patients will present with extrainguinal symptoms such as change in bowel
habits or urinary symptoms. Regardless of size, an inguinal hernia may impart pressure onto
nerves in the proximity, leading to a range of symptoms. These include generalized pressure,
local sharp pains, and referred pain. Pressure or heaviness in the groin is a common complaint,
especially at the conclusion of the day, following prolonged activity. Sharp pains tend to
indicate an impinged nerve and may not be related to the extent of physical activity performed
by the patient. Lastly, neurogenic pains may be referred to the scrotum, testicle, or inner thigh.

Physical
The patient should be examined in a standing position, with the groin and scrotum fully
exposed. The standing position has the advantage over the supine position in that intraabdominal pressure is increased, and thereby, the hernia can be more easily elicited.
Inspection is performed first, with the goal of identifying an abnormal bulge along the groin or
within the scrotum. If an obvious bulge is not detected, physical examination is performed to
confirm the presence of the hernia.

DIAGNOSIS
Palpation is performed by placing the index finger into the scrotum, aiming it toward the external inguinal
ring. The patient is then asked to cough or bear down (i.e., Valsalva's maneuver) to protrude the hernia
contents.

Imaging

The most common radiologic modalities include ultrasonography (US), computed tomography (CT), and
magnetic resonance imaging (MRI).

Clinical grading
GRADE

REDUCTIO
N

PAIN

OBSTRUCT
ION

TOXIC

Reponible

Irreponible

Incarceratio
n

Colic

Strangulati
on

Steady
increase

++
leucocytosi
s

Differential diagnosis

Malignancy (lymphoma, retroperitoneal sarcoma, metastasis, testicular tumor)

Primary testicular (varicocele, epididymitis, testicular torsion, hydrocele,
ectopic testicle, undescended testicle)
Femoral artery aneurysm or pseudoaneurysm
Lymph node
Sebaceous cyst
Hidradenitis
Cyst of the canal of nuck (female)
Saphenous varix
Psoas abscess
Hematoma
Ascites

Nyhus Classification System

Type I
Indirect hernia; internal abdominal ring normal; typically in infants, children,
small adults
Type II
Indirect hernia; internal ring enlarged without impingement on the floor of the
inguinal canal; does not extend to the scrotum
Type IIIA
Direct hernia; size is not taken into account
Type IIIB
Indirect hernia that has enlarged enough to encroach upon the posterior inguinal
wall; indirect sliding or scrotal hernias are usually placed in this category
because they are commonly associated with extension to the direct space; also
includes pantaloon hernias
Type IIIC
Femoral hernia
Type IV
Recurrent

Gilbert Classification System

Type 1

Small, indirect

Type 2

Medium, indirect

Type 3

Large, indirect

Type 4

Entire floor, direct

Type 5

Diverticular, direct

Type 6

Combined (pantaloon)

Type 7

Femoral

TREATMENT

treatment
The definitive treatment of all hernias is surgical repair. A hernia defect will not decrease in size,
but likely increase and possibly progress to incarceration or strangulation of the sac's contents.
Surgery can be delayed or avoided in situations where the patient's medical status prohibits
operative treatment. Conservative management is aimed at alleviating symptoms related to the
inguinal hernia, such as pain, pressure, and protrusion of abdominal contents. Simple maneuvers
include assuming a recumbent position, which aids in self-reduction of the hernia.
CONSERVATIVE
Reposition
Injection
Belt
OPERATIVE
Herniotomy
Hernioraphy
Hernioplasty

Eduardo Bassini Herniorhhapy :

Chester B McVay,MD,PhD 1940 (Coopers ligament repair):

S EE Shouldice, 1945

Tension Free =Mesh Graft

1987 : Gilbert

Complication

Recurrence
Chronic groin pain (nociceptive, somatic, visceral)
Neuropathic (iliohypogastric, iliolinguinal, genitofemoral, lateral cutaneous, femoral)
Cord and testicular (hematoma, ischemic orchitis, testicular atrophy, dysejaculation, division of vas
deferens, hydrocele, testicular descent)
Bladder injury
Wound infection
Seroma
Hematoma (wound, scrotal, retroperitoneal)
Osteitis pubis
Prosthetic complication (contraction, erosion, infection, rejection, fracture)
Laparoscopic (vascular injury, intra abdominal, retroperitoneal, abdominal wall, gas embolism
Visceral injury (bowel perforation, bladder perforation
Trocar site complications (hematoma, hernia, wound infection, keloid)
Bowel obstruction (trocar or peritoneal closure site hernia, adhesion)
Miscellaneous (diaphragmatic dysfunction, hypercapnia)
General (urinary, paralytic ileus, nausea and vomiting, aspiration pneumonia, cardiovascular and
respiratory insufficiency)

PROGNOSIS
Traditionally, the most important measure of success was the recurrence rate of the
hernia, although newer measures focus on quality of life and return to normal activities.
Surgeons who perform a large volume of the Shouldice repair are able to demonstrate
recurrence rates around 1%.
In less experienced hands, such low recurrence rates are not demonstrated, yet
overall, recurrence rates for the Shouldice repair are consistently lower than those of
the Bassini or McVay repair. Other comparative studies have demonstrated that the
Shouldice repair, even with a recurrence rate near 6%, is superior to the Bassini repair
(8.6% recurrence rate) and McVay repair (11.2%).
Common causes of hernia recurrence postrepair include patient, technical, and tissue
factors. Patient factors that affect tissue healing include malnutrition,
immunosuppression, diabetes, steroid use, and smoking. Technical factors include
mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors
include wound infection, tissue ischemia, and increased tension within the surgical
repair. Most recurrences are of the same type as the original hernia.

THANK YOU FOR THE

ATTENTION