Surgery 4th stage Lecture (4) Inguinal Hernia Kufa-university D.H.Zaini Surgery 4th stage Lecture (4)

Inguinal Hernia Surgical Anatomy :- Superficial inguinal ring is a triangular opening in the aponeurosis of ext. oblique, 1.25 cm(half inch )from pubic tubercle (above) normally not admit the tip of little finger. Deep inguinal ring is an oval shape in transversalis fascia (fascial envelop of the abdomen, below which are peritoneal fat then peritoneum), u. shape. 1.25cm above the mid point of inguinal ligament the competency depends on integrity of fascia . The inguinal canal in infant where the deep & superficial rings are almost superimposed. But in adult the canal is oblique, 3.75cm in length, directed downward & medially from deep to superficial ring. Inguinal Hernia

*spermatic cord In .male the canal transmit *ilioinguinal N. *genital branch of genit0femoral N. In female the canal transmit *round ligament replaced the spermatic cord

1- Ant. ( External oblique aponeurosis & conjoined m 1- Ant. .( External oblique aponeurosis & conjoined m. laterally ) 2- post. .inf. epigastric A. (branch of ext. iliac A.) . Fascia transversalis . Conjoined tendon (end of 2 muscles int. oblique & transversis abdominis) 3- sup .conjoined muscle 4- inf. .inguinal ligament Boundaries

Difference between Inguinal hernia (direct & indirect)& Femoral hernia... Indirect inguinal H. Oblique inguinal H. * travels down the canal out side the spermatic card * the neck lat. to inf. epigastric A. * above & medial to pubic tubercle direct inguinal H. Forward inguinal H. *comes ant. directly forward through post. wall of canal *the neck med. to inf. epigastirc A. *except saddle bag H. in which the hernia consists of two sacs that straddle the inf. Epigastric A. , one sac being medial & the other lat. to the A. Femoral H. *the neck of the sac is below & lat. to the pubic tubercle

Indirect Inguinal H. oblique hernia It is the most common H. commonly in the young while direct is most commonly in middle age or after. In first decade of life is more common on R. side in male associated with undescending R. testes In second decade of life the L & R. is equal , 30% of indirect inguinal H. is bilateral & if not diagnosed clinically, it diagnosed by U\S so must send for sonar even it is unilat. clinically. Indirect Inguinal H.

Types of indirect inguinal H... 1-Bubonocele (Greek = grain) The H. is just within the canal. 2-Funicular (Latin = short cord) The H. is just above the epididymis ( the processes vaginalis is closed just above epi. The content of sac can be felt separately from testis. 3-Complete or scrotal . There is mass within scrotum It is rarely present at birth but commonly encountered in infants The testis appear to lie within the lower part of the hernia Also can occur in adolescence or adulthood.

.Occur at any age , M:F 20:1 1- pain in groin or referred to testis when performing heavy works or strenuous exercise or any condition lead to increase intra abdominal pressure. 2- in cough the bulging may be seen & felt (visible & palpable cough impulse) which may remain persist until reduced...& may appear once the pt. stand. 3- sensation of weight & dragging on mesentery which produce epigastric pain . 4- in infant the hernia appear on crying & it is translucent (gossamer) even in early adulthood but never in adults. 5- in young female the ovary may prolapsed to the sac. Clinical Features

DDx of indirect inguinal H. in female: 1- hydrocele of canal of nuck most common DDx problem 2- femoral hernia * Indication of operation in infant:- 1- After 3 ms. of age as elective surgery. 2- Before that in emergency. Specially if it is irreducible, obstructed or strangulated. DDx of indirect inguinal H. in female: Treatment

ddx. Of indirect inguinal H. in male 1) Vaginal hydrocele but hydrocele can get above it (no content , just fluid) hernia cannot get above it (we feel content) 2) Encysted hydrocele of the cord 3) Spermatocele obstruction of epidydimis lead to accumulation of spermatic fluid. 4) Femoral hernia 5) Incomplete descending of testes 6) Lipoma of the cord But lipoma not change with position & cough. ddx. Of indirect inguinal H. in male

1-Herniotomy . . In infant & early childhood in whom the canal is not well developed. . Herniotomy excision of sac and transfixion of the neck. 2-Herniorrhaphy .in older children & adult .Herniorrhaphy Herniotomy + strengthening of the post . wall of canal to prevent recurrence. Types of operation

methods of strengthening 1-Bassini:- interrupted silk suture between conjoined tendon & inguinal ligament. 2- Darning. continuous suturing by nylon 3- mesh which is either Nylon prolene 4- obliteration of canal . In elderly & complicated cases specially obstructed type . Excision of all the content of canal ( cord & testes ) . 5- overlapping . Exteralization of cord , making it lie subcutaneously. . Overlapping the external oblique behind the cord & bind it with the post .wall methods of strengthening

*in case when the operation is contraindicated because there is complication of anesthesia or the operation it self or if the patient refuse the operation . the pt. should be wear a truss. Types of Anesthesia used:- 1- general 2- spinal 3- epidural 4- local infiltiration

in case of strangulated hernia present as emergency Before operation we should :- . Replace fluid & electrolytes depletion by i.v. fluid . Give brod spectrum antibiotics & metronidazole for anaerobic microorganisms. . NG. tube for decompression to avoid vomiting & inhalation pneumonitis. Note

strangulated H. is more liable for infection so mesh is not used strangulated H. is more liable for infection so mesh is not used. because it lead to increase the infection so the repair will failed & there is high rate of recurrence. note