GIT

Forth stage

surgery
Lec-2
د.سمير الصفار

25/10/2015

Indirect Inguinal hernia

Epigastric hernia

Epigastric hernia

Umbilical hernia

Umbilical hernia
Spigelian Hernia
Spigelian Hernia
Inguinal hernia
Inguinal hernia

Diagnosis:

Groin swelling that disappear with supine position
Examine erect and supine
Does not transilluminate
Expensile cough impulse

How to differentiate IIH from DIH

When the swelling localized to groin
The differential diagnosis:
Femoral hernia
Lipoma of cord
Inguinal lymphadenopathy
Incompletely descended testis
Ectopic testis
Femoral artery aneurysm


Differential Diagnosis
When the swelling is inguino-scrotal
Vaginal hydrocele
Encysted hydrocele of cord
Spermatocele
Varicocele
Epididymoorchitis
Torsion of testis
Testicular tumor

In female
Femoral hernia
Hydrocele of canal of Nuck
Inguinal lymphadenopathy

Treatment:

Operation is treatment of choice:
Open surgery
The standard method
Laparoscopic hernia repair
should be reserved for bilateral or recurrent hernia


Open surgery
Herniotomy
Herniorrhaphy

Anaesthesia

Local
Spinal
General

Herniotomy

Indications:
In infants, children and adolescents
Steps of surgery:
Dissection of sac
Open of sac
Reduction of contents
Transfixation of neck
Cut of reminder

Herniorrhaphy

Repair of stretched DIR and transversalis fascia
Reinforcement of posterior wall by:
Shouldice repair
Mesh repair


Complications:
Bleeding
Skin bruises, SC hematoma
Scrotal hematoma
Retention of urine
Wound infection
Injury to vas deference
Ischemic orchitis
Neuralgia
-Ilioinguinal
-Iliohypogastric
-Genitofemoral
-Lateral cutaneous
Recurrence >1%

Direct Inguinal Hernia

Acquired
Adults
35% of inguinal hernia
12% bilateral
Not occur in females


Anatomy of Direct Hernia:
Hesselbach’s triangle
Inguinal ligament (base), rectus (medial), inferior epigastric vessels (lateral)

Hesselbach’s triangle

Pathogenesis:
Through weak posterior wall of inguinal canal
Medial to Inferior epigastric vv
Not attain large size or descent into scrotum
Lies behind spermatic cord
Wide neck

Varieties

Dual ( Pantoloon,saddle bag)
Funicular (Prevesical)


Clinical Features:
Swelling in the groin
On examination:
controlled on pressing on SIR
ECI
Treatment:
Surgical repair
Dissection of sac
Inverted
Repair of transversalis fascia
Mesh(Lichtenstein) or Shouldice repair

Strangulated Inguinal Hernia

Can occur at any time
More liable to occur in patients with irreducible hernia.
More commonly occur in IIH
Less often in DIH
Constricting agent
Neck of sac
External inguinal ring
Adhesions within the sac


Content of hernia
Small intestine
Omentum
Both

Clinical features:

Severe pain in the groin
Vomiting
General upset
Fever ?
Swelling with skin discoloration in the groin
Gangrenous bowel
Gangrenous bowel
Severely tender
Abdominal signs



Treatment:
Urgent surgery
Pinciples:
-Dissection of sac
-Open the sac
-Exploration of content
-Excision of gangrenous tissues


Femoral Hernia

Anatomy of the femoral canal

Boundaries of femoral ring

Anterior border is the inguinal ligament
Posterior border is the pectineal ligament
Medial border is the lacunar ligament
Lateral border is the femoral vein

Femoral Hernia

Women> men
20% of hernias in women
More in parous
Most liable for strangulation


Clinical features
Rare before puberty
May be un-noticed by the patient

Strangulated hernia

Sudden painful swelling in the groin
Abdominal symptoms

Examination

The swelling is inferior to inguinal ligament and lateral to pubic tubercule
Mostly irreducible

Differential Diagnosis:

Inguinal hernia
Lymphadenopathy
Saphena varix
Ectopic testis
Psoas abscess
Distended Psoas bursa
Lipoma
Rupture of adductor longus


Treatment:
Uncomplicated hernia:
Operation as early as possible
Strangulated hernia
Urgent surgery
Approaches for the surgery
Low approach – Lookwood
High approach - McEvedy
Inguinal approach - Lotheissen

Principle of surgery

Dissection of sac
Open sac
Reduction of contents if healthy otherwise gangrenous tissue must be excised.
Repair of femoral ring