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Inguinal Hernia
Inguinal Hernia
The inguinal canal starts in the abdomen from the point that the
spermatic cord crosses the internal/deep inguinal ring in the
transversalis fascia (in women the Round ligament).
Femoral hernia in the elderly and in those who had a previous hernia repair is
more common.
A) Congenital
B) Acquired
A) Congenital Hernia:
ii. In the descent of the testes from the abdomen to the scrotom in the third trimester, a part of the
perituneum descends with it which is called the process vaginalis.
i. Lack of closure of process vaginalis results in a patent process vaginalis which is a reason for the high
prevalence of inguinal hernia in the preterm neonates.
i. A lot of the process vaginalises close in a few months after birth and its patency does not necessarily
mean that a hernia will be formed.
Etiology
B) Acquired Hernia:
It seems that most cases of hernia come from an acquired defect in the abdominal wall and
the reason for its formation is multifactorial:
1- Strenuous physical activity can be a factor but it is not known whether the hernia is just
from physical activity or in the setting of a patent process vaginalis.
4- Collagen deficiency associated diseases like collagen type I deficiency relative to type
III.
Being overweight is to some extent protective (maybe it is from the more difficult diagnosis
of hernia)
Symptoms
The symptoms are variable from a hernia with no symptoms to one
with stangulation.
The feeling of pressure and weight on the inguinal region especially after a
daily activity is common.
Important Point: The duration and the way the symptoms progress is
important
Usually the patient can reduce the hernia but the bigger the hernia, the
less likely it is to reduce.
B) We examine the contralateral side and compare the two sides to each
other.
The extent of bulging on the two sides can be a criteria for the diagnosis
of hernia on one or both sides.
Physical Exam
The differentiation between a direct and an indirect inguinal hernia
in the physical exam:
- If the finger is inside the inguinal canal and the patient exerts
pressure or coughs and the hernia comes in contact with the tip of the
finger it is a direct hernia.
- If with closure of the internal ring with the finger while the
patient strains (coughs) the hernial sac does not bulge out the hernia
is an indirect one, and if the hernial sac bulges the hernia is a direct
one.
Physical Exam
Important Point: the examination of the femoral hernia is difficult.
This hernia presents under the inguinal ligament and the presence
of too much or too little fat in the inguinal region can cause an error in
the diagnosis. (Femoral Psuedohernia)
Imaging in hernia:
1- Overwieght individuals
2- Recurrent hernia
3- Hernias that are not found in the physical exam
Because of the very good results of mesh the initial tissue repair is not used any
more.
Important Point: The laparascopic procedure is not different from the open
surgery method in the recurrency rate. It has less post-op complications and a
sooner return to work. Intestinal obstruction and ileus is seen more often after
a laparascopic procedure.
Treatment
Contraindications of laparascopy:
1- A previous surgery in the area (a surgery that the surgeon entered the
abdomen such as prostatectomy)
2-Primary medical condition
Important Point: Indication for urgent surgery is when the intestines are under pressure
and the patient has symptoms of bowel obstruction either in incarceration or in a sliding
hernia.
Emergency Surgery
Treatment:
1-Simple Reduction
2-Taxis
3-Surgery
1-Fever
2-Leukocytosis
3- Hemodynamic instability
4- Tender and warm hernia contents
5- Erythema in hernial sac
1-Cord lipoma
2-Seroma
3-Weakness of external oblique muscle
4-Cough
Complications of Hernia Surgery
1-Pain
4-Wound infection
5-Seroma
6-Urinary Retention
Sportsman’s Hernia
Occult hernia, pubic pain in sportsmen, sportsmen’s
hernia
Due to repetitive movement in lower extremity such as skiing, hockey, or
American football, usually hernia is not found in physical exam other than the time
of surgery.
Symptoms: Acute or chronic pain that gets worse with movement, coughing or
sneezing and can reduce the sportsman’s function. In the physical exam no
bulging or evidence of hernia is seen and pain and tenderness in the inguinal canal
and the external ring is present.
Prevalence of hernia is higher in, premature and LBW and on the right side.
Important Point: Method of exploring the opposite side is somewhat controversial. Now
laparascopy is mostly used. But sonography has also been used.