DEPARTMENT

DEPARTMENT OF OF SURGERY
SURGERY
OSPITAL NG
OSPITAL NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards
“Towards Patient
Patient Safety in Surgery”
Safety in Surgery”
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Case Management Presentation,

Discussion and Sharing of
Information on
INDIRECT INGUINAL HERNIA

JUNIOR INTERN
MONTEVERDE, NUNEZ, OCAMPO
 DEPARTMENT
DEPARTMENT OF OF SURGERY
SURGERY
OSPITAL NG
OSPITAL NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards
“Towards Patient
Patient Safety in Surgery”
Safety in Surgery”
Avoid complaints
Promote customeratdelight.
all times, promote
Avoid customer
complaints at alldelight!
times!

General Data

B.S.
22/M
Filipino
Currently residing in Manila
Admitted for the first time at OMMC last Nov.
24, 2017
 DEPARTMENT
DEPARTMENT OF OF SURGERY
SURGERY
OSPITAL NG
OSPITAL NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards
“Towards Patient
Patient Safety in Surgery”
Safety in Surgery”
Avoid complaints
Promote customeratdelight.
all times, promote
Avoid customer
complaints at alldelight!
times!

Chief Complain:

Bulging Inguinal Mass

 DEPARTMENT
DEPARTMENT OF OF SURGERY
SURGERY
OSPITAL NG
OSPITAL NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards
“Towards Patient
Patient Safety in Surgery”
Safety in Surgery”
Avoid complaints
Promote customeratdelight.
all times, promote
Avoid customer
complaints at alldelight!
times!

History of Present Illness

2 years  Noted bulging mass on the right inguinal
area. No pain and redness noted
 Patient noted palpability of the mass upon
lifting heavy objects and reduction of mass
upon lying down.
 No associated
Bleeding
Fever
Abdominal pain
Nausea and vomiting
Changes in urinary or bowel movements
Significant weight loss/gain
 DEPARTMENT
DEPARTMENT OF OF SURGERY
SURGERY
OSPITAL NG
OSPITAL NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards
“Towards Patient
Patient Safety in Surgery”
Safety in Surgery”
Avoid complaints
Promote customeratdelight.
all times, promote
Avoid customer
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History of Present Illness

2 weeks  Persistence of bulging mass with associated

intermittent pain at inguinal area prompted
consult at our institution

Schedule
for elective
OR
 DEPARTMENT
DEPARTMENT OF
OF SURGERY
SURGERY
OSPITAL
OSPITAL NG
NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards Patient Safety
“Towards Patient Safety in
in Surgery”
Surgery”
Promote customer delight. Avoid complaints at all times!

Past Medical History

• Not known HPN, DM, BA

• No history of PTB, cancer or radiation
therapy, HIV infection, other abdominal
diseases
• No history of trauma
• No known allergies to food and
medications
• No previous hospitalization
 DEPARTMENT
DEPARTMENT OF
OF SURGERY
SURGERY
OSPITAL
OSPITAL NG
NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards Patient Safety
“Towards Patient Safety in
in Surgery”
Surgery”
Promote customer delight. Avoid complaints at all times!

Family History

No known PTB, DM, BA, CA in the family

(+) HTN, father
 DEPARTMENT
DEPARTMENT OF
OF SURGERY
SURGERY
OSPITAL
OSPITAL NG
NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards Patient Safety
“Towards Patient Safety in
in Surgery”
Surgery”
Promote customer delight. Avoid complaints at all times!

Personal Social History

4.5 pack year smoker

occasional alcoholic beverage drinker
denies illicit drug use
no intake of medications
 DEPARTMENT
DEPARTMENT OF
OF SURGERY
SURGERY
OSPITAL
OSPITAL NG
NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards Patient Safety
“Towards Patient Safety in
in Surgery”
Surgery”
Promote customer delight. Avoid complaints at all times!

Review of Systems
no generalized weakness
no cough, colds, difficulty of breathing
no chest pain, palpitations, dyspnea
no dysuria, polyuria, nocturia, changes in color
of urine
no nervousness, anxiety
no easy bruising, prolonged bleeding
 DEPARTMENT
DEPARTMENT OF
OF SURGERY
SURGERY
OSPITAL
OSPITAL NG
NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards Patient Safety
“Towards Patient Safety in
in Surgery”
Surgery”
Promote customer delight. Avoid complaints at all times!

Physical Examination
conscious, coherent, not in cardio-pulmonary
distress
120/70 74 17 36.9 98%O2 sat

SHEENT: good skin turgor, anicteric sclerae, pink

conjunctivae, no cervical lymphadenopathies, no
tonsillopharyngeal congestion, no naso-aural
discharge
 DEPARTMENT
DEPARTMENT OF
OF SURGERY
SURGERY
OSPITAL
OSPITAL NG
NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards Patient Safety
“Towards Patient Safety in
in Surgery”
Surgery”
Promote customer delight. Avoid complaints at all times!

Physical Examination
Chest and Lungs: symmetric chest expansion,
no retractions, clear breath sound, no crackles,
no wheezes

Heart: adynamic precordium, distinct hearts

sound, normal rate, regular rhythm, no
murmurs
 DEPARTMENT
DEPARTMENT OF
OF SURGERY
SURGERY
OSPITAL
OSPITAL NG
NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards Patient Safety
“Towards Patient Safety in
in Surgery”
Surgery”
Promote customer delight. Avoid complaints at all times!

Physical Examination
Abdomen: flat, normoactive bowel sounds, no
direct or rebound tenderness; bulging inguinal
mass, Right, non erythematous, non-tender,
reducible, external inguinal ring ~ 2cm

Extremities: grossly normal, no edema, full and

equal pulses
 DEPARTMENT
DEPARTMENT OF
OF SURGERY
SURGERY
OSPITAL
OSPITAL NG
NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards Patient Safety
“Towards Patient Safety in
in Surgery”
Surgery”
Promote customer delight. Avoid complaints at all times!

Salient Features
• 22 year-old male
• 2 years history of bulging mass at inguinal mass
• bulging inguinal mass, Right, non erythematous,
non-tender, reducible, external inguinal ring ~ 2cm
• No changes in urination or defecation
• No bleeding
• No abdominal pain
• No significant weight loss/gain
 DEPARTMENT
DEPARTMENT OF SURGERY
OF SURGERY
OSPITAL NG
OSPITAL NGMAYNILA MEDICAL
MAYNILA MEDICAL CENTER
CENTER
“Towards
“TowardsPatient
Patient Safety
Safety ininSurgery”
Surgery”
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Bulging Inguinal Mass

Neoplastic Non Neoplastic

Testicular Pathology Abdominal Wall defect

Varicocele Hernia
Epididymitis
Torsion Indirect Direct
Undescended testicle
Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th
edition. Mc Graw Hill: New York, USA. Pg 1495-1516
 DEPARTMENT
DEPARTMENT OF
OF SURGERY
SURGERY
OSPITAL
OSPITAL NG
NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards Patient Safety
“Towards Patient Safety in
in Surgery”
Surgery”
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Clinical Diagnosis

Diagnosis Certainty Treatment

Hernia 90% Surgical

Testicular 10% Surgical

Problem
 DEPARTMENT
DEPARTMENT OF OF SURGERY
SURGERY
OSPITAL NG
OSPITAL NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards
“Towards Patient
Patient Safety in Surgery”
Safety in Surgery”
Avoid complaints
Promote customeratdelight.
all times, promote
Avoid customer
complaints at alldelight!
times!

Paraclinical Diagnostic Procedures

Do I need additional paraclinical diagnostic procedure?

Yes, in case of ambiguous diagnosis, imaging studies

can help in making final decisions; such as
Ultrasonography, CT Scan and MRI.

Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th

edition. Mc Graw Hill: New York, USA. Pg 1495-1516
 DEPARTMENT
DEPARTMENT OF OF SURGERY
SURGERY
OSPITAL NG
OSPITAL NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards
“Towards Patient
Patient Safety in Surgery”
Safety in Surgery”
Avoid complaints
Promote customeratdelight.
all times, promote
Avoid customer
complaints at alldelight!
times!

Goals of Treatment

•Resolution of symptoms
•Prevention of complications – Recurrence,
Urinary retention, infection
 DEPARTMENT
DEPARTMENT OF OF SURGERY
SURGERY
OSPITAL NG
OSPITAL NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards
“Towards Patient
Patient Safety in Surgery”
Safety in Surgery”
Avoid complaints
Promote customeratdelight.
all times, promote
Avoid customer
complaints at alldelight!
times!
 DEPARTMENT
DEPARTMENT OF OF SURGERY
SURGERY
OSPITAL NG
OSPITAL NG MAYNILA
MAYNILA MEDICAL
MEDICAL CENTER
CENTER
“Towards
“Towards Patient
Patient Safety in Surgery”
Safety in Surgery”
Avoid complaints
Promote customeratdelight.
all times, promote
Avoid customer
complaints at alldelight!
times!

Benefits Risk Cost Availabilit

y
Herniorrhaphy • Provide relief of symptoms • Higher recurrence rate ~ Available
• Low Wound and non wound (10%)
complications (P= 0.07) • Higher reoperation rate
within 30 day (P=0.27)
• Post operative pain
after 6 months
(P=12.26), 12times that
of Hernioplasty
Hernioplasty • Relief of signs and 30- Available
symptoms 50,000
• Lower recurrence rate (0- php
1%)
• Low reoperation rate within
30 days (P=0.13)
• Low Wound and non wound
complications (P= 0.06)

Weltz, AS et al. Operative Outcomes after Abdominal Wall Reconstruction with Mesh Fixation versus
Transfascial suture. Am Surg 2017; Sept 1;83(9) PMI:28958271
 DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
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Treatment of Choice

Hernioplasty
 DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
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PREOPERATIVE PREPARATION

• Optimizing patient’s physical condition prior

to operation
• Proper prophylactic antibiotic coverage
• Informed consent for operation secured
• Psychosocial preparation
• Preparation of OR needs
 DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
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OPERATIVE TECHNIQUE

•Patient placed on supine position under

SAB
•Asepsis-antisepsis technique done
•Sterile drapes placed
•Time out done
•Skin incision is made at lowest skin
crease
•External oblique identified and its fibers
 DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
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OPERATIVE TECHNIQUE
•Spermatic cord identified
•Hernial sac identified, dissection done
•Purse string technique done
•Mesh in place
•External muscle repaired with 2.0 round
•Initial counting of needles, sponges and
instruments done
•Hernioplasty done
• Final counting of needles, sponges and
instruments done
•Skin closure done with 4.0 cutting
 DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
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INTRAOPERATIVE FINDINGS
Noted hernia sac at the
anteromedial to the
spermatic cord with no
noted Incarcerated
bowel and omentum
 DEPARTMENT
DEPARTMENT OF SURGERY
OF SURGERY
OSPITAL NG
OSPITAL NGMAYNILA MEDICAL
MAYNILA MEDICAL CENTER
CENTER
“Towards
“TowardsPatient
Patient Safety
Safety ininSurgery”
Surgery”
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FINAL DIAGNOSIS

Indirect Inguinal Hernia, Right

s/p Hernioplasty, Right (OMMC,2017)
 OSPITAL NG MAYNILAOF
DEPARTMENT MEDICAL
SURGERY CENTER
“Towards Patient Safety in Surgery”
OSPITAL NG MAYNILA MEDICAL CENTER
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“Towards Patient Safety in Surgery”

Sharing of Information
 OSPITAL NG MAYNILA MEDICAL CENTER
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INGUINAL HERNIA
• Most common abdominal wall hernia (75%)
• Majority in males
• More common on the right side

Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th

edition. Mc Graw Hill: New York, USA. Pg 1495-1516
 OSPITAL NG MAYNILA MEDICAL CENTER
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Diagnosis
• Pattern of signs and symptoms
– Bulging mass
– Reducible
– Irreducible (Incarcerated/ strangulated)
• Common complaint: pressure or heaviness in
the groin area

Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th

edition. Mc Graw Hill: New York, USA. Pg 1495-1516
 OSPITAL NG MAYNILA MEDICAL CENTER
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PHYSICAL EXAMINATION
• Patient should be examined in a standing
position to increase intra-abdominal
pressure, with the groin and
scrotum fully exposed
INGUINAL OCCLUSION TEST

Entails the examiner blocking the internal inguinal ring

with a finger as the patient is instructed to cough
INDIRECT DIRECT

Controlled impulse Persistent herniation

Transmission of the cough An impulse palpated on

to the tip of the finger the dorsum of the finger
Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th edition. Mc
Graw Hill: New York, USA. Pg 1495-1516
 OSPITAL NG MAYNILA MEDICAL CENTER
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ANATOMY
• Inguinal Canal
– 4 to 6 cm long
– Cone like shape

Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th edition. Mc

Graw Hill: New York, USA. Pg 1495-1516
 OSPITAL NG MAYNILA MEDICAL CENTER
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LIGAMENTS CONTRIBUTING TO INGUINAL

CANAL

Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th

edition. Mc Graw Hill: New York, USA. Pg 1495-1516
 OSPITAL NG MAYNILA MEDICAL CENTER
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DIRECT VS INDIRECT HERNIA

• INDIRECT • DIRECT
– It is the remains of the processus – It is common in old men with weak
vaginalis and therefore,congenital in abdominal muscles and is rare in
origin women.
– It is much more common in males – The hernial sac bulges forward through
– right side the posterior wall of
– It is most common in children and the inguinal canal medial to the inferior
young adults epigastric vessels
– The hernial sac enters the inguinal canal – The neck of the hernial sac is wide
through the deep
inguinal ring and lateral to the inferior
epigastric vessels. The
neck of the sac is narrow
– the hernial sac may extend through the
superfcial inguinal
ring above and medial to the pubic
tubercle. (Femoral hernia
is located below and lateral to the pubic
tubercle.)
– The hernial sac may extend down into
the scrotum or labium majus

Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th

edition. Mc Graw Hill: New York, USA. Pg 1495-1516
 OSPITAL NG MAYNILA MEDICAL CENTER
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TREATMENT
• Open
– Tissue
– Mesh
• Laparoscopic
– TAPP (Transabdominal Preperitoneal Repair)
– TEP ( Total Extraperitoneal Repair)

Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th

edition. Mc Graw Hill: New York, USA. Pg 1495-1516
 OSPITAL NG MAYNILA MEDICAL CENTER
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Tissue Repair
• suitable alternative when
prosthetic material cannot be used safely

• BASSINI REPAIR
• SHOULDICE REPAIR
• MCVAY REPAIR

Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th

edition. Mc Graw Hill: New York, USA. Pg 1495-1516
 OSPITAL NG MAYNILA MEDICAL CENTER
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Prosthetic Repair
• Tension free mesh repair

• LICHTENSTEIN TENSION-FREE REPAIR

• PLUG AND PATCH REPAIR
• PROLENE HERNIA REPAIR

Brunicardi, Charles, editor. 2015. Schwartz’s Principles of Surgery, 10th

edition. Mc Graw Hill: New York, USA. Pg 1495-1516
 DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Promote customer delight. Avoid complaints at all times!
References:
Brunicardi, Charles, editor. 2015. Schwartz’s Principles
of Surgery, 10th edition. Mc Graw Hill: New York, USA.

Weltz, AS et al. Operative Outcomes after Abdominal

Wall Reconstruction with Mesh Fixation versus
Transfascial suture. Am Surg 2017; Sept 1;83(9)
PMI:28958271