د.توفيق جاسم
المرحلة الرابعة/الجراحة العامةكلية طب الكندي/جامعة بغداد
2014-2015
A truss
A truss may be used when operation is contraindicated or refused. If a truss to be worn, the hernia must be reducible. A properly fitted truss must control the hernia when the patient stand, with legs apart, stoops, and coughs violently. No place for trusses in infant herniatruss does not lower the risk of strangulation or allow the opening to close; therefore, these are not recommended treatments. Only umbilical hernias go away without treatment.
If an infant hernia becomes suddenly irreducible, urgent operative repair is indicated. Otherwise, it can be left until the child is over 3 months
Strangulated inguinal hernia
Strangulation occurs at any time during life and in both sexes. Indirect hernias strangulate more commonlyIn order of frequency, the constricting agent is;
The neck of the sac
The external inguinal ring in children
Adhesions within the sac(rarely)
Usually the small intestine is involved in the strangulation, some time omentum, or may be both. The incidence of strangulation in infancy is 4%.
Treatment of strangulation
Is by emergency operation. Vigorous resuscitation with intravenous fluids, nasogastric aspiration and antibiotic is essential, also advisable to catheterize the bladder for emptying and to monitor haemodynamic state
Inguinal herniotomy for strangulation
Incision over the most prominent part of the swelling, deliver the body and fundus of the sac on to the surface.. The external oblique and the superficial ring are divided to reliese any constriction in the canal. Once the constriction has been divided, the strangulated contents can be drawn down. Devitalized omentum is excised. Viable intestine is returned to the peritoneal cavity. Doubtfully viable and gangrenous intestine is excised. The sac is excised and closed by purse-string, a repair can be made if the condition of the patient permitsConservative measures
Indicated only in infants. In 75% of cases reduction is effected. Vigorous manipulation must never be attempted, the dangers are;Contusion or rupture of the intestinal wall
Reduction-en-masse; the sac with its contents is pushed back into the abdomen, as the bowel will still be strangulated by tne neck of the sac
The sac may rupture at its neck and the contents are reduced, but extraperitoneally
Direct inguinal hernia
In adult male, 35% of inguinal hernias are direct. 12% are bilateral. Its always acquired. The sac passes through a weakness or defect of the transversalis fascia.its rarely protruded into scrotum Often the patient has poor lower abdominal musculature.unlike the indirect hernia which can occur at any age, the direct I.H. tend to occur in the middle aged&elderly because their abdominal wall weaken as they age .Women never develop a direct ingujnal hernia. Predisposing factors are;Smoking
Occupations that involve straining and heavy lifting
Damage to the ilioinguinal nerve(previous appendicectomy), due to resulting weakness of the congoint tendon
Direct hernias do not often attain a large size or descend into the scrotum. As the neck of the sac is wide, direct hernias dont often strangulate(rarely strangulate)
Funicular(prevesical) direct inguinal hernia
This is a narrow-necked hernia with prevesical fat and a portion of the bladder that occurs through a small defect in the medial part of the conjoint tendon just above the pubic tubercle. It occurs principally in elderly males and occasionally becomes strangulated. Operation should always be advised.Dual(saddle-bag, pantaloon) hernia
Two sacs that straddle the inferior epigastric artery, one being medial and the other lateral
Operation for direct hernia
The principles of repair are the same as those of an indirect hernia, with the exception that the sac can usually be simply inverted after it has been dissected free and the transversalis fascia reconstructed in front of itSliding hernia(hernia-en-glissade)
The posterior wall of the sac is not formed of peritoneum alone, but by the sigmoid colon and its mesentry on the left, the caecum on the right and, sometimes, on either side by a portion of the bladder as a result of slipping of the posterior parietal peritoneum on the underlying retroperitoneal structures
Clinical features
Almost exclusively in men. 5 out of 6 sliding hernias are left sided, bilateral hernias are rare. The patient is nearly always over 40 years of age. No specific findings of a sliding hernia, but it should be suspected in a very large globular inguinal hernia descending scrotally. Occasionally large intestine is strangulated in a sliding hernia
Treatment
A sliding hernia is impossible to control with a truss, so the operation is indicated
Femoral hernia
The femoral hernia follows the tract just below the inguinal ligament through the femoral canal. The canal lies medial to the femoral vein and lateral to the lacunar (Gimbernat) ligament. Because femoral hernias protrude through such a small defined space,
Is the third most common type. It accounts for 20% of hernias in women and 5% in men. It cannot be controlled by a truss and it is the most liable to become strangulated because of the narrow neck and the rigidity of the femoral ring. Strangulatin is the initial presentation of 40% of femoral hernias
Surgical anatomy
The femoral canal is the medial component of the femoral sheath. It extends from the femoral ring above to the sapnenous opening below. Its 1.25 cm long and 1.25 cm wide at its base which is directed upwards. It contains fat, lymphatic vessels and lymph node of cloquet.The femoral ring is bounded;
Anteriorly by the inguinal ligament
Posteriorly by Astley Cooper,s(ileopectineal ligament, the pubic bone and the fascia over the pectineus muscle
Medially by the concave knife-like edge of gimbernat,s(lacunar)ligament
Laterally by a thin septum separating it from the femoral vein.
Pathology
A hernia passing down the femoral canal descending vertically to the saphenous opening.while its confined to the femoral canal, its necessarly small but, once it escapes through the saphenous opening, it expands. A fully distended hernia assumes the shape of a retort and its bulbous extremity may be above the inguinal ligament. By the time the contents have so tortuous path, they are usually irreducible and apt to strangulate
Clinical features
f/M is 2/1. Female patients are frequently elderly, while males usually between 30 and 40 years of age. The condition is more prevalent in multipara than nilliparae the right side is affected twice as often as the left and in 20% of cases the condition is bilateral. The symptoms are less pronounced than those of an inguinal hernia, a small hernia may be unnoticed or disregarded for years, perhaps until it strangulate. Adherence of the greater omentum may cause a dragging painDifferential diagnosis
Inguinal hernia. The neck of the sac lies above and medial to the pubic tubercle. The neck of the sac of a femoral hernia lies below thisSaphena varix. A saccular enlargement of the termination of the saphenous vein, usually accompanied by other signs of varicose veins. The swelling disappears completely when the patient lies flat. In both, there is cough impulse. A saphena varix impart a fluid thrill when the patient coughs or when the saphenous vein is tapped with the fingers of the other hand. Sometimes, a venous hum can be heard with a stethoscope
Enlarged femoral lymph nodes. May be other enlarged lymph nodes to aid the diagnosis. May be there is other clue such as an infected wound on the limb or on the perineum
Lipoma
Femoral aneurysm
Psoas abscess. There is often fluctuating swelling. Examination of the spine anr a radiograph will confirm the diagnosis
Distended psoas bursa. The swelling diminishes when the hip is flexed
Rupture of the adductor magnus with haematoma formatiom
Treatment of a femoral hernia
The constant risk of strangulation is sufficient reason to recommend operation soon after the diagnosis has been made. A truss is contraindicatedUmbilical hernia of infants &children
Umbilical hernias in children occur through a weak umbilicus in the first few months of life and are caused by incomplete closure of the umbilical ring which may result partially from failure of the round ligament (obliterated umbilical vein) to cross the umbilical ring and partially from the absence of Richet fascia. They occur more often in black girls The incidence in black infants is 8 times higher than in white infants.Its more common in premature infants, and children with Down syndrome or hypothyroidism. The hernia appears as a skin-covered conical shape swelling, which pushes the umbilicus outward, and becomes more prominent when the child cries or strains. In contrast to epigastric hernias, most childhood umbilical hernias close spontaneously by four or five years of age. However, spontaneous closure is less likely when the hernia is larger than 2 cm in diameter. Umbilical hernias in children rarely become incarcerated . Obstruction or strangulation below the age of 3 years is extremely uncommon..Some adults have an umbilical hernia because of obesity, pregnancy, or excess fluid in the abdomen (ascites).
Treatment
Asymptomatic umbilical hernias can be safely monitored(conservative treatment) until the child is aged 2-4 years to allow spontaneous closure, especially if the ring defect is small Reassurance of the patients is all that required. 95% will disappear spontaneously Surgical repair is needed in children older than two years, for very large hernias (greater than 2 cm in diameter), and for incarcerated hernias
A small curved incision is made below the umbilicus. The neck is isolated. After insuring that the sac is empty, it is either inverted into the abdomen or ligated by transfixion and excised. The defect in the linea alba is closed with interrupted absorbable sutures
Exomphalos(omphalocele)
its due to failure of all or part of the midgut to return to the coelum during early fetal life. The unruptured sac is semitranslucent, thin and consists of two layers; an outer amniotic membrane and inner peritoneumOmphalocele may be divided into those with a fascial defect less than or greater than 4 cm. in smaller defects, a single loop of intestine may not be obvious and ligation of what was thought to be a normal umbilical cord will result in transaction of the intestine, leaving an umblico-enteric fistula.
In large defects, the liver, spleen, stomach, pancreas, colon or bladder may be seen through the membrane
Small defects may be closed primarily soon after birth. Large defects present a substantial problem and four techniques have been described;
Non-operative therapy
For premature infants with a gigantic intact sac or those in whom associated anomalies make survival of a major operation unlikely desiccating. The sac is painted daily with a desiccating antiseptic solution, if successful, an eschar will forms. Eventually, granulation tissue grows in from the periphery and the subsequent ventral hernia can be repaired later