HERNIAHERNIACHINCHU MDefnitionDefnitionA hernia is a protrusion of an organ or part of an organ through an abnormal opening in the walls of its containing cavit !repeate" INCREA#E in repeate" INCREA#E in ab"ominal pressure is ab"ominal pressure is usuall "ue to usuall "ue to Chronic cough#training $la""er nec% or urethral obstruction&regnanc 'omiting #ever muscular e(ortAscetic )ui"*pes *pes Inguinal +emoralEpigastric &ara umbilicalUmbilicalIncisionalCongenital "iaphragmatic herniaInguinal hernia Inguinal hernia E,amination-.!Inspection for site/ si0e/ shape an" color!1!&alpation for surface/ temp/ ten"erness/ composition an" re"ucibilit!2!E,pansible cough impulse!3!4eneral e,am- for common causes of increase intra ab"ominal pressure In"irect 'ersus Direct In"irect 'ersus Direct inguinal hernias inguinal hernias In"irect is the most common form of hernia an" its usuall congenital! Direct usuall ac5uire" occur in ol" men with wea% ab"ominal muscles!In"irect 'ersus Direct inguinal hernias Indirect Inguinal Hernia Direct Inguinal Hernia&ass through inguinal canal! $ulge from the posterior wall of the inguinal canalCan "escen" into the scrotum! Cannot "escent into the scrotum!6ateral to inferior epigastric vessels! Me"ial to inferior epigastric vessels!Re"uce"- upwar"/ then laterall an" bac%war"!Re"uce"- upwar"/ then straight bac%war"!Controlle"- after re"uction b pressure over the internal 7"eep8 inguinal ring!Not controlle"- after re"uction b pressure over the internal 7"eep8 inguinal ring!*he "efect is not palpable 7it is behin" the fbers of the e,ternal obli5ue muscle8!*he "efect ma be felt in the ab"ominal wall above the pubic tubercle!After re"uction- the bulge appears in the mi""le of inguinal region an" then )ows me"iall before turning "own to the scrotum!After re"uction- the bulge reappears e,actl where it was before!Common in chil"ren an" oung a"ults!Common in ol" age!+emoral hernia +emoral hernia #mall femoral hernia ma be unnotice" b the patient or "isregar"e" for ears perhaps until the "a it strangulates! A"herence of the greater omentum sometimes causes a "ragging pain! Rarel a large sac is present ! +emoral hernia versus +emoral hernia versus inguinal herniainguinal herniaInguinal hernia Femoral hernia1 -more common in male 1 -more common in females2 -pass through the inguinal canal2 -pass through the femoral canal3 -nec% of the sac is above an" me"ial the pubic tubercle3 -nec% of the sac is below an" lateral the pubic tubercle4 -less common to be strangulate"4 -more common to be strangulate"5 -can be treate" without surger 5 -must be treate" surgicall6 -the two "iagnostic signs of hernia +6 -the two "iagnostic signs of hernia -7 -the sac mainl contain 9 bowel 7 -the sac mainl contains 9 omentumUmbilical herniaUmbilical hernia#igns an" smptomsAge 9 "oesn:t appear until the umbilical cor" has separate" an" heale" !No specifc smptomsHave wi"e nec% an" re"uce easil / rarel give intestinal obstruction!Nature histor 9 ;< = "isappear spontaneousl "uring the frst ear! E,amination Inspection #ite 9 in the center of the umbilicus#i0e an" shape 9 si0e can var from var small to ver large ! #hape is usuall hemispherical!&alpation Composition 9 contain bowel / which ma%es it resonant to percussion ! *he re"uce spontaneousl when the chil" lies "own !Re"ucibilit 9 easCough impulse9 invariabl present !Ac5uire" umbilical herniaAc5uire" umbilical herniaHernia through the umbilical scar / so it is a true umbilical hernia! Not common an" is usuall secon"ar to increase intra ab"ominal pressure! *he most common causes.> pregnanc1> ascitis2> ovarian cst3> fbro"is?> bowel "istentionIncision herniaIncision hernia#igns an" smptoms&revious operation or acci"ental traumaAge 9 all ages / but more common in ol" age!#mptom 9 lump /pain /intestinal obstruction 7 "istention /colic/ vomiting /constipation / sever pain in the lump 8 &athophsiolog&athophsiologDuring fetal "evelopment/ out pouching of peritoneum originates at the inguinal ringE,ten"s me"iall "own into the scrotum or labia ma@ora+ailure to close process vaginalis results in potential sac/ an" ab"ominal contents herniates into the sacClinical featuresClinical features#welling&ain*en"ernessIrritabilitAb"ominal "istensionDiagnosisDiagnosisHistor &hsical e,amination$loo" e,aminationUrine e,aminationImaging stu"iesManagemeManagement and nt and repair repair &reoperative assessment &reoperative assessment proper histor an" e,aminationi"entif high ris% patientsprepare the preoperative notes -consent!!pre op D,proce"ure planne"Anasthesia anticipate" 7general / local/ spinal8&reoperative assessment &reoperative assessment Investigation "ata 7 pre operative tests 8 -.! 6ab -A C$C - to chec% hemoglobin level anemiaan" B$Cs infectionsA 6+*s - in"icate" in @aun"ice" patients an" suspecte" hepatitis or an clotting problemsA &* C &**A A$4A grouping an" cross matching 1! Imaging -A Chest D ra - for all patients 2! EC4 - for an patient who is more than 3< ears of agePre op Pre op preparationpreparationMost pt are treate" surgicall Increase IA& abnormalities 7Chronic cough/ Constipation/ $la""er outlet obstruction8 shoul" be evaluate" an" reme"ie" to e,tent possible before elective herniorrhaph!In case of intestinal obstruction an" possible strangulation/ $roa" spectrum A$/N4 suction ma be in"icate"/ correction of volume statusC elctroles!Re"uctionRe"uctionUncomplicate"-Manual 4entle pressure over hernia 4entle traction over the mass!Complicate" 7strangulate"8- no attempt shoul" be ma"e to re"uce the hernia*REA*MEN* E+ HERNIA6 #AC*REA*MEN* E+ HERNIA6 #ACINDIREC*- sac is "issecte" free from the cor" structures an" creamsteric fbers! #ac shoul" be open awa from an herniate" contents! Contents are then re"uce"/ an" the sac is ligate" "eep to inguinal ring with an absorbable sutureDIREC*-*oo broa"l base" for ligation an" shoul" not be opene"/ simple free" from transversalis fbers an" inverte"!&rimar tissue repair&rimar tissue repair$assini repair- inferior arch of transversalis fascia 7*+8 or con@oint ten"on is appro,imate" to shelving portion of inguinal ligament!Mc'a- *+ is suture" to cooper ligament!#houl"ice- *+ is incise" an" reappro,imate"!Epen tension free Epen tension free repairrepair6ichtenstein repair C&atch an" &lug techni5ue- Mesh is use" to reconstruct inguinal )oorMesh plug techni5ue - place mesh in the hernial "efectComplicationsComplications#crotal hematomaRetention of urineBoun" infectionRecurrence*han% *han% Fou Fou