Cpd Hernia

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CASE PRESENTATION CASE PRESENTATION & DISCUSSION ON & DISCUSSION ON INGUINOSCROTAL INGUINOSCROTAL

MASSMASS

martinjosephscabahugmdmartinjosephscabahugmd

General DataGeneral Data

C.P.C.P.5959--yearyear--oldold

malemaleSampalocSampaloc, Manila, Manila

Chief complaintChief complaint

InguinoscrotalInguinoscrotal mass on the rightmass on the right

History of Present IllnessHistory of Present Illness2 yrs 2 yrs bulging inguinal massbulging inguinal mass

5x8cm5x8cmstraining, prolonged standingstraining, prolonged standingreducible reducible ((--) pain, fever) pain, fever((--) changes in bowel movement) changes in bowel movement((--) urinary symptoms) urinary symptoms((--) respiratory symptoms) respiratory symptoms

10 months PTA10 months PTA increase size of increase size of mass, mass, reaches the scrotal areareaches the scrotal area

Persistence of symptomsPersistence of symptoms

ConsultConsult

AdmissionAdmission

Past Medical Past Medical HxHx::

((--) ) HypertentionHypertention((--) Diabetes Mellitus) Diabetes Mellitus((--) Bronchial Asthma ) Bronchial Asthma ((--) Heart ) Heart DisaeseDisaese

Physical ExaminationPhysical Examination

General Survey: General Survey: Conscious, coherent, ambulatoryConscious, coherent, ambulatorynot in not in cardiorespiratorycardiorespiratory distressdistress

BP130/90BP130/90 HR 81HR 81 RR 19RR 19 T 37.1T 37.1C&LC&L symmetrical chest expansionsymmetrical chest expansion

no retractions, clear breath soundsno retractions, clear breath sounds

Heart:Heart:normal rate regular rhythm, (normal rate regular rhythm, (--) thrills, ) thrills, murmurmurmur

Abdomen:Abdomen:flat, NABS, soft, non tender, flat, NABS, soft, non tender, no no organomegalyorganomegaly

InguinoInguino scrotal mass rightscrotal mass rightInguinal ring 4.5 cmInguinal ring 4.5 cmReducibleReducibleSoft Soft ((--) bowel sounds) bowel sounds((--) ) transilluminationtransillumination((--) ) erythemaerythema((--) tenderness) tenderness

Salient featuresSalient features

--5959--yearyear--old Maleold Male--inguinoscrotalinguinoscrotal massmass--ReducibleReducible--Noted when patient strains &Noted when patient strains &

prolonged standingprolonged standing--Soft, nonSoft, non--tendertender-- ((--) bowel sounds) bowel sounds-- ((--) ) transilluminationtransillumination

4.5 cm external inguinal ring

INGUINOSCROTAL MASS, RIGHT

INFLAMMATORY NON INFLAMMATORY


INFLAMMATORY

Epididymoorchitis Inguinoscrotalabscess

Lymphadenopathy

Swelling and rapid Swelling and rapid progression of painprogression of painfever, chillsfever, chillsredness, edematousredness, edematous

Multiple, Multiple, tendertender


NON INFLAMMATORY

Malignant Non-malignant


NON INFLAMMATORY

Malignant Non-malignant


NON INFLAMMATORY

Malignant

Soft tissue Soft tissue SarcomaSarcomaLarge size, Large size, superficial or deepsuperficial or deep

FibrosarcomaFibrosarcomaSubcutaneous Subcutaneous fat fat Disorganized Disorganized growthgrowth

LyposarcomaLyposarcomaDeep muscleDeep muscle

Testicular Testicular TumorTumorNodule, firm, Nodule, firm, nonnon--tendertender


NON INFLAMMATORY

Non-malignant

Soft tissueSebaceous cystsLipomaLipoma of the cordSpermatocoeleTorsion of the testis

Inguinoscrotal mass right

inflammatory Non-inflammatory

Epididymoorchitis

Inguinoscrotal abscess

Lymphadenopathy

malignant Non-malignant

Soft tissue

•Lipoma of the cord

•Sebaceous cysts

hernia

Swelling and rapid Swelling and rapid progression of painprogression of painfever, chillsfever, chills

red, edematousred, edematous



Epididymoorchitis


Lymphadenopathy


Soft tissue


•Sebaceous cysts

hernia



Epididymoorchitis


Lymphadenopathy


Soft tissue


•Sebaceous cysts

hernia

Multiple, tender Multiple, tender Obvious are of Obvious are of inflammationinflammation



Epididymoorchitis


Lymphadenopathy


Soft tissue


•Sebaceous cysts

hernia



Epididymoorchitis


Lymphadenopathy


Soft tissue


•Sebaceous cysts

hernia

Soft tissue Soft tissue SercomaSercomaLarge size, superficial Large size, superficial or deepor deep



Epididymoorchitis


Lymphadenopathy


Soft tissue


•Sebaceous cysts

hernia

FibrosercomaFibrosercomaSubcutaneous fat Subcutaneous fat Disorganized growthDisorganized growth



Epididymoorchitis


Lymphadenopathy


Soft tissue


•Sebaceous cysts

hernia

LyposercomaLyposercomaDeep muscleDeep muscle



Epididymoorchitis


Lymphadenopathy


Soft tissue


•Sebaceous cysts

hernia

Testicular TumorTesticular TumorNodule, firm, nonNodule, firm, non--tendertender



Epididymoorchitis


Lymphadenopathy


Soft tissue

•Sebaceous cysts

•Lipoma


•Spermatocoele

•Torsion of the testis

hernia

No cough impulseNo cough impulse



Epididymoorchitis


Lymphadenopathy


Soft tissue

•Sebaceous cysts

•Lipoma


•Spermatocoele


hernia

Cyst of Cyst of reterete testestestesCystic massCystic mass+ transillumination+ transilluminationbilateralbilateral



Epididymoorchitis


Lymphadenopathy


Soft tissue

•Sebaceous cysts

•Lipoma


•Spermatocoele


hernia

Sudden onset of painSudden onset of painScrotal enlargement Scrotal enlargement with edemawith edema

Hernia

direct indirectHistory:

•55M, Recurrent bulging mass, inguinosrotal area, R

•Aggravated by straining, relieved by lying down

PE:

•inguinoscrotal mass, R•Soft, non-tender, reducible

•No transillumination

•+ cough impulse

•No bowel sound

Prevalence

•Indirect, more common

•Rutledge report, 1,437 patients

•60% indirect

•36% direct

•4% femoral•Lichtenstein report

• 44.4% Indirect•43.1% direct•12.5% others

SurgicalSurgical5%5%

Secondary Secondary

Direct InguinalDirect Inguinal

HerniaHernia

SurgicalSurgical95%95%

PrimaryPrimary

Indirect Indirect Inguinal Inguinal

HerniaHernia

TreatmentTreatmentCertaintyCertaintyImpressionImpression

ParaclinicalParaclinical Diagnostic ProcedureDiagnostic Procedure

Do I need Do I need paraclinicalparaclinical procedure?procedure?

Certain of my primary diagnosis Certain of my primary diagnosis pattern recognitionpattern recognitionprevalenceprevalence

NO.NO.

Goal of TreatmentGoal of Treatment

Reduce herniated organ/bowelReduce herniated organ/bowel

repair defect repair defect ≥≥4cm4cmLigation of the sacLigation of the sac

Treatment OptionsTreatment Options

There are at present three general options for There are at present three general options for the surgical repair of indirect inguinal hernia, the surgical repair of indirect inguinal hernia, namely: namely:

open repair with mesh grafting, open repair with mesh grafting, open repair without mesh grafting, open repair without mesh grafting, laparoscopic repair with mesh grafting laparoscopic repair with mesh grafting

Not availableNot availableP 8000P 8000--P10000P10000

Intra Intra abdominal abdominal complicationcomplication

samesameLAPAROLAPARO--SCOPICSCOPIC

Available most of Available most of the timethe timeP 5000P 5000Graft rejectionGraft rejection

RR 0.2%RR 0.2%Low Low

recurrence raterecurrence rateLess postLess post--op op

painpainEasy to Easy to

performperformEarly back to Early back to

workwork

OPEN WITH OPEN WITH MESHMESH

AvailableAvailableP 2000P 2000InfectionInfectionrecurrencerecurrence

Repair floor Repair floor anatomicalanatomical

OPEN OPEN WITHOUT WITHOUT MESHMESH

AVAILABILITYAVAILABILITYCOSTCOSTRISKRISKBENEFITBENEFIT4 cm internal 4 cm internal ringring

At present, although open repair with mesh At present, although open repair with mesh and laparoscopic repair are now commonly and laparoscopic repair are now commonly done especially in developed countries, the done especially in developed countries, the controversy is far from being settled because controversy is far from being settled because of the tendency for blanket recommendations of the tendency for blanket recommendations and randomized controlled trials and metaand randomized controlled trials and meta--analyses showing conflicting results, some analyses showing conflicting results, some favoring open repair without mesh (1,5,7).favoring open repair without mesh (1,5,7).

others favoring open repair with mesh (9others favoring open repair with mesh (9--10) 10) and still others, laparoscopic approach (11and still others, laparoscopic approach (11--13). 13).

Protocol on HerniaProtocol on Hernia

A departmental consensus was made using A departmental consensus was made using the diameter of the external inguinal ring (>4 the diameter of the external inguinal ring (>4 centimeters) as predictor for preoperative centimeters) as predictor for preoperative preparation of mesh in patients for indirect preparation of mesh in patients for indirect inguinal hernia repair. inguinal hernia repair.

Protocol on HerniaProtocol on Hernia

The protocol was then prospectively validated The protocol was then prospectively validated on adult patients with unilateral indirect inguinal on adult patients with unilateral indirect inguinal hernia from January to August, 2003 using intrahernia from January to August, 2003 using intra--operative measurement of the external and operative measurement of the external and internal inguinal ring as the indicator for mesh internal inguinal ring as the indicator for mesh grafting. grafting.

The department believes that there are The department believes that there are indications for the use of mesh in the indications for the use of mesh in the treatment of indirect inguinal hernia. treatment of indirect inguinal hernia. Recurrence and large size of hernia defect are Recurrence and large size of hernia defect are the basic indications the basic indications favoring open repair without mesh (1,5,7) favoring open repair without mesh (1,5,7) open repair with mesh (4, 13) and still others, open repair with mesh (4, 13) and still others, laparoscopic approach (3, 6, 11). laparoscopic approach (3, 6, 11).

PrePre--op preparationop preparation

Psychological supportPsychological supportScreen for previous medical problemScreen for previous medical problem

HypertensionHypertensionMetoprololMetoprolol 50mg BID x 2 weeks50mg BID x 2 weeks

Optimize patientOptimize patient’’s conditions conditionConsentConsentPreparation of materialsPreparation of materials

Operative TechniqueOperative Technique

Oblique incision over LangerOblique incision over Langer’’s lines lineExternal oblique aponeurosis openedExternal oblique aponeurosis opened

IntraIntra--op findingsop findings

HernialHernial sac located sac located anteromediallyanteromedially to the to the cord containing cord containing omentumomentumInternal ring measures 4 Internal ring measures 4 cm in widest diametercm in widest diameter

Operative Technique Operative Technique

•Spermatic cord identified

•Hernial sac identified and opened

•Hernial contents reduced

•Ligation of the hernialsac


•Mesh approximated over the defect

•Medial corner of the mesh overlaps the pubic bone

•And sutured with interrupted prolene 3-0


Spermatic cord placed between the two tails of the mesh


Two tails crossed –over and sutured together


•Hemostasis

•Instrument and sponge checked

•Fascial closure with vicryl 0

•Subcuticular skin closure with vicryl 4-0

•Dry sterile dressing

Final DiagnosisFinal Diagnosis

Indirect Inguinal Hernia, RightIndirect Inguinal Hernia, RightGrade IIIGrade III--BB

PostPost--op supportop support

AnalgesiaAnalgesiaKetoprofenKetoprofen 100mg TIV q6 x 3 doses100mg TIV q6 x 3 dosesshifted to oral Paracetamol 500mg q4shifted to oral Paracetamol 500mg q4

Early ambulationEarly ambulationDiet as toleratedDiet as toleratedDaily wound careDaily wound careDischarged on the 2nd PODDischarged on the 2nd POD

Prevention and HealthPrevention and Health

Anticipate complicationsAnticipate complicationsAdequate Adequate hemostasishemostasisAvoid vascular compromiseAvoid vascular compromiseAvoid infectionAvoid infectionAvoid dehiscenceAvoid dehiscence

Prevention and HealthPrevention and Health

Alive patientAlive patientPatientPatient’’s health problem resolveds health problem resolvedNo complaintNo complaintNo disabilityNo disabilityNo medical suitNo medical suitSatisfied patientSatisfied patient

PathophysiologyPathophysiology

Inguinal Hernia

genetic

Physical exertion

metabolic

Muscle deficiency

Fascial factor

Processus vaginalis

Inguinal Hernia

genetic

•Autosomal dominant

•Preferential paternal factor

•Multiple, familial or part of connective tissue disorder

Inguinal Hernia

genetic

Physical exertion

metabolic

Muscle deficiency

Fascial factor

Processus vaginalis

Inguinal Hernia

metabolic

•Decrease hydroxyprolene

•Altered collagen precipitability and impaired hydroxylation

•Increase elastase, decrease anti-proteolyticinhibitor capacity (emphysema)

Inguinal Hernia

genetic

Physical exertion

metabolic

Muscle deficiency

Fascial factor

Processus vaginalis

Inguinal Hernia

Muscle Deficiency

•Congenital or acquired insufficiency of internal oblique expose the deep ring and inguinal floor

t Inguinal Hernia

genetic

Physical exertion

metabolic

Muscle deficiency

Fascial factor

Processus vaginalis

Inguinal Hernia

Physical exertion

•Increase in intraabdominal pressure

Inguinal Hernia

genetic

Physical exertion

metabolic

Muscle deficiency

Fascial factor

Processus vaginalis

Inguinal Hernia

Physical exertion

•Increase in intraabdominal pressure

Inguinal Hernia

genetic

Physical exertion

metabolic

Muscle deficiency

Fascial factor

Processus vaginalis

Inguinal Hernia

Patent Processus Vaginalis

•Evagination of the peritoneum

•60% at two months, 40% at two years, 30% adult

Inguinal Hernia

genetic

Physical exertion

metabolic

Muscle deficiency

Fascial factor

Processus vaginalis

Inguinal Hernia

Fascial factor

•Myopectineal Orifice Fruchaud

•Boundaries: superior, internal oblique + transverse abd muscle; lateral, iliopsoas; medial, rectus; inferior, pecten

•Transversalis fascia

Inguinal Hernia

genetic

Physical exertion

metabolic

Muscle deficiency

Fascial factor

Processus vaginalis

Myopectineal orifice of Fruchaud

Internal oblique and transverse abdominis

Ileopsoas m.

Pecten pubis

NyhusNyhus ClassificationClassification

Type IType I Indirect, smallIndirect, smallType IIType II Indirect, mediumIndirect, mediumType IIIType III A. DirectA. Direct

B. Indirect, largeB. Indirect, largeC. FemoralC. Femoral

Type IVType IV RecurrentRecurrent

Type 1Type 1 Indirect, smallIndirect, small

Type IIType II Indirect, mediumIndirect, medium

Type IIIType III A. DirectA. Direct

B. Indirect, largeB. Indirect, large

Type III CType III C

Unified ClassificationUnified Classification

Unified ClassificationUnified Classification

Recurrent herniaRecurrent herniaType 4Type 4Femoral herniaFemoral herniaCC

Indirect inguinal hernia. Internal ring dilated. Posterior Indirect inguinal hernia. Internal ring dilated. Posterior wall defectivewall defectiveBB

Direct inguinal herniaDirect inguinal herniaAAPosterior wall defectPosterior wall defectType 3Type 3

Indirect hernia with dilated internal ring. Posterior wall Indirect hernia with dilated internal ring. Posterior wall intactintactType 2Type 2

Indirect hernia with normal internal ringIndirect hernia with normal internal ringType 1Type 1

NyhusNyhus Classification of Inguinal Classification of Inguinal Hernias.Hernias.

GilbertGilbert’’s Classification of Inguinal s Classification of Inguinal Hernias. Hernias.

Femoral herniaFemoral herniaType VIIType VIIPantaloon herniaPantaloon herniaType VIType VI

Direct Direct diverticulardiverticular defect 1defect 1--2 cm 2 cm suprapubicsuprapubic, but anywhere , but anywhere along flooralong floor

Type VType VDefective canal floor, ring is soundDefective canal floor, ring is soundType IVType IV

Ring > 4 cm, sliding component, displaces inferior Ring > 4 cm, sliding component, displaces inferior epigastricepigastric vesselsvessels

Type IIIType IIIIndirect, ring < 4 cmIndirect, ring < 4 cmType IIType IIIndirect, tight ring, sac any size, reducibleIndirect, tight ring, sac any size, reducibleType IType I

DescriptionDescriptionTypeType

ReferencesReferences

1.1. BarthBarth R J, R J, BurchardBurchard K W, K W, TostesonTosteson A et al. ShortA et al. Short--term outcome after mesh or term outcome after mesh or ShouldiceShouldiceherniorrhaphyherniorrhaphy: A : A randomisedrandomised, prospective study. , prospective study. Surgery. 1998; 123: 121Surgery. 1998; 123: 121--126. 126.

2.2. Cameron J. Current Surgical Therapy. VII Ed. 2001; Cameron J. Current Surgical Therapy. VII Ed. 2001; 600600--616.616.

3.3. Chung RS, Rowland Chung RS, Rowland DY.MetaDY.Meta--analyses of analyses of randomized controlled trials of laparoscopic randomized controlled trials of laparoscopic vsvsconventional inguinal hernia repairs. conventional inguinal hernia repairs. SurgSurg EndoscEndosc. . 1999; 13(7):6891999; 13(7):689--94.94.

4.4. Fitzgibbons R. et al. Fitzgibbons R. et al. HyhusHyhus and Condonand Condon’’s Hernia. V s Hernia. V Ed. 2002;, 3Ed. 2002;, 3--7; 717; 71--79; 14979; 149--156.156.

5. 5. FriisFriis E, E, LindahlLindahl F. The tensionF. The tension--free free hernioplastyhernioplastyin a randomized trial. Am L in a randomized trial. Am L SurgSurg. 1996; 172 (4): . 1996; 172 (4): 315315--99

6. 6. Go PM. Overview of randomized trials in Go PM. Overview of randomized trials in laparoscopic inguinal hernia repair. laparoscopic inguinal hernia repair. SeminSeminLaparoscLaparosc SurgSurg. 1998; 5(4): 238. 1998; 5(4): 238--41.41.

7.7. PavlidisPavlidis TE, TE, AtmatzidisAtmatzidis KS, KS, LazardisLazardis CN, CN, PapaziogasPapaziogas BT, BT, MakrisMakris JG. Comparison between JG. Comparison between modern mesh and conventional nonmodern mesh and conventional non--mesh mesh methods of inguinal hernia repair. Minerva methods of inguinal hernia repair. Minerva ChirChir. . 2002; 57(1): 72002; 57(1): 7--1212

8.8. PingulPingul J. et al. Health Process Evidence based J. et al. Health Process Evidence based Clinical Practice Guidelines in Patient with Clinical Practice Guidelines in Patient with Inguinal HerniaInguinal Hernia

9.9. ScottScott--ConnConn, C. , C. ChassinChassin’’ss Operative Strategy in Operative Strategy in General Surgery. III Ed. 747General Surgery. III Ed. 747

10. 10. Schwartz, S. et al. Principles of Surgery. VII Ed. Schwartz, S. et al. Principles of Surgery. VII Ed. 1999; 15851999; 1585-- 1609.1609.

11. 11. The EU Hernia The EU Hernia TrialistsTrialists Collaboration. Repair of Collaboration. Repair of groin hernia with synthetic mesh: metagroin hernia with synthetic mesh: meta--analysis of analysis of randomized controlled trials. Ann randomized controlled trials. Ann SurgSurg. 2002; . 2002; 235(3):322235(3):322--32.32.

12.12. VrijlandVrijland W W, van den W W, van den TolTol M P, M P, LuijendijkLuijendijk R W R W et al. et al. RandomisedRandomised clinical trial of nonclinical trial of non--mesh versus mesh versus mesh repair of primary inguinal hernia. Br J mesh repair of primary inguinal hernia. Br J SurgSurg. . 2002; 89: 2932002; 89: 293--297.297.

13.13. WantzWantz GE. Experience with the tensionGE. Experience with the tension--free free hernioplastyhernioplasty for primary inguinal hernias in men. J for primary inguinal hernias in men. J Am Am CollColl SurgSurg. 1996; 183(4): 351. 1996; 183(4): 351--6.6.

BassiniBassini RepairRepair

Uses interupted sutures

ShouldiceShouldice RepairRepair

Uses continuous, imbricated sutures

McVayMcVay’’ss RepairRepair

Approximates the transversusabdominis and the tranversalis fascia

ParaclinicalParaclinical Diagnostic ProcessDiagnostic Process

AvailabilityAvailabilityCostCostRiskRiskBenefitBenefitDiagnostic Diagnostic ProcedureProcedure

Not availableNot availableP500.00P500.00PeritonitisPeritonitisHypersensitiviHypersensitivityty

Will Will differentiate a differentiate a direct from an direct from an indirect hernia indirect hernia

herniographyherniography

Not readily Not readily availableavailable

P3000.00P3000.00Exposure to Exposure to radiationradiation

Will Will r/or/o other other causes of causes of groin massesgroin masses

CTCT--scanscan

AvailableAvailableP150.00P150.00Exposure to Exposure to radiationradiation

Will Will r/or/ointestinal intestinal obstructionobstruction

xx--ray ray

Not readily Not readily availableavailable

P300.00P300.00AcceptableAcceptableWill Will r/or/o other other causes of causes of groin massesgroin masses

ultrasoundultrasound

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Health & Medicine

Cpd Hernia