Groin Hernia

GROIN HERNIAS

Learning objectives What are the groin hernias? What causes the groin hernias? How are the groin hernias diagnosed? What are the complications? How are they treated?

Groin Hernias Introduction Groin hernias are common and may affect people of all ages They are an external bulge (swelling) in the groin area that contains: * fat * connective tissues and or * portion of intestine They are most common type of surgery performed on kids and teens

Groin Hernias • Introduction • There are two main types of groin hernia ► Inguinal Hernia ► Femoral Hernia

Groin Hernias Incidence Femoral hernia is less common than inguinal hernia More than 70% of all hernia that occurs are hernias

inguinal

Sex Hernia are more likely to occur in men than in women

Groin Hernias Introduction Morbidity/Mortality The pre and post operative morbidity/mortality increase significantly owing to the high incidence of complication Surgical intervention should be performed as soon as possible once hernia is diagnosed

Inguinal Hernia What is Hernia? A hernia is the protrusion of an organ through the wall that normally contains it The wall can be: the abdominal wall, muscle fascia, and diaphragm An inguinal hernia occurs in the groin area, usually a part of intestine protrudes through the abdominal wall into the inguinal canal

Anatomy recall Inguinal Canal Cylindrical shaped space (4 cm long) That passes obliquely and inferomedially (through the inferior part of the abdominal wall)

Inguinal Canal Anatomy recall • Inguinal Canal • The canal is parallel and 2-4 cm superior to the medial half of the inguinal ligament

Inguinal Hernia • Anatomy recall • Inguinal Canal • The inguinal canal has opening at either end Deep (internal) inguinal ring Superficial (external) inguinal ring

Inguinal Hernia • Deep (internal) inguinal ring • It the entrance to the inguinal canal • It is the site of an out pouching of the transversalis fascia

• Superficial (external) inguinal ring • It is the exit from the canal • It is formed by the splitting of the diagonal fibers of the external oblique muscle aponeurosis

Inguinal Hernia

• The Inguinal canal is defined by 4 walls Anterior wall Posterior wall Superior wall (also called roof) Inferior wall (also called floor)

Inguinal hernia • Anterior wall: • Is formed mainly by the aponeurosis of the external oblique muscle

Inguinal hernia • Posterior wall of the inguinal canal • Mainly formed by transversalis fascia

Superior wall (or roof): conjoin tendon or falx inguinal Is formed by the inferior border (tendon) of two muscles:

* Internal oblique muscle * Transversus abdominalis muscle

Inguinal hernia

• Inferior wall ( or floor) • Is formed mainly by the superior surface of the incurving inguinal ligament

Inguinal hernia • Inguinal canal contents: Women: Round ligament of the uterus Men: Spermatic cord Blood vessels Lymphatic vessels Ilioinguinal nerve Ductus deferens (men)

Inguinal hernia

A hernia consists of: A sac Its coverings

* fascia transversalis and * cremaster layers) Contents

Inguinal Hernia

Hernia Sac Is the peritoneal envelope of hernia The sac can be: Incomplete Completed Inguino-scrotal or majora labial

Inguinal hernia Hernia sac Has tree parts The neck (connected with the abdominal cavity) The body The fundus

Inguinal Hernia • Contents of the hernia sac • All the abdominal organs may be except the pancreas

• Causes • Weakness of abdominal muscles may from: ► Birth

(congenital defects)

► Premature infant (low birth weight) ► Elderly ► Failure by degeneration of the transversalis fascia ► Malnutrition and vitamin deficiency ► Abdominal injury and disease

Inguinal hernia • Causes • Some types of strain that may include hernia Obesity • Suddenly weight gain • lifting heavy objects • Constipation • Diarrhea • Persistent coughing or sneezing • Pregnancy • Having ascites • Having tumor (abdominal cavity) • Having enlarged prostate (dysuria) • Cigarette smoking •

Inguinal hernia • Physiopathology • To get a hernia two factors are required: ► Weakness of the abdominal muscles ► Increase abdominal cavity pressure (strain)

Inguinal hernia ► CLINICAL DIAGNOSIS Reviewing the patient’s symptoms and medical history are the first steps in diagnosing a hernia

HISTORY: Duration: It might be long or sudden Most hernia produce no symptoms until the patient notices a lump or swelling in the groin area

Inguinal hernia CLINICAL DIAGNOSIS HISTORY: Frequently, hernias are detected in the course of routine physical examination: such as preemployment examinations Some patients with the complain of bulge in the inguinal region while lifting or straining Patients may describe minor pain into the scrotum Sense of discomfort (enlarge hernia)

Inguinal hernia • • • •

CLINICAL DIAGNOSIS HISTORY: Remember In general, direct hernias produce fewer symptoms than indirect inguinal hernia

• Indirect hernias are less likely to become:

* irreducible and * incarcerated or * strangulated

Inguinal hernia ► CLINICAL DIAGNOSIS

HISTORY: Occasionally, patients may present with paresthesia (by irritation or compression of inguinal nerves by the hernia)

• Extreme pain should raise the surgeon’s suspicion of complications

► CLINICAL DIAGNOSIS HISTORY: Ask about patients personal past history for risk factors: Cystic fibrosis Developmental dysplasia of the hip Undescended testes Abnormalities of urethra Cigarette Smoking Excess weight

Ask about patients family history for: A parent or siblings who had have a hernia

Ask about patients occupation (job) : require certain physical abilities or strengths

some jobs may

Inguinal hernia PHYSICAL EXAMINATION First examined inguinal area with the patient standing and then in the supine position

► General Appearance ► LOCAL INSPECTION Frequently reveals a loss of symmetry in the inguinal area or discrete bulge

Inguinal hernia PHYSICAL EXAMINATION • Palpation • Hernias must be examined with the patient standing and in supine • Start with any position • Always examine both groins • Hernia can be: Reducible, Irreducible, Obstructed (or incarcerated), and Strangulated

Inguinal hernia

PHYSICAL EXAMINATION • Palpation • I f there is a bulge: easily reducible or not • Perform Vasaval’s maneuver, or cough may accentuate the bulge, making it clear visible

Inguinal hernia CLINICAL DIAGNOSIS PHYSICAL EXAMINATION

► Palpation: Assess the following: Temperature Tenderness Shape Size Tension Composition

Inguinal hernia • PHYSICAL EXAMINATION • ► Palpation:

• Usually the bulge is • •

Painless disappears when the patient affected lies down (reducible hernia)

• PHYSICAL EXAMINATION

• ► Palpation: • Bilateral Hernia • Simultaneous Right and Left Inguinal Hernia • Common in children and elderly men • • If a left inguinal hernia is present, there is a 25% risk of an occult right inguinal hernia • Both hernias may be repaired with one surgical procedure

Inguinal hernia PHYSICAL EXAMINATION ► Palpation: The bulge can not be back into place by manipulation, because of either: * narrow neck or * adhesions Contain viable (Irreducible hernia)

Inguinal hernia • PHYSICAL EXAMINATION • ► Palpation: • The bulge can not be back into place, because the hernia is large or so occluded, the contain may be or may not be viable This hernia is termed obstructed or incarcerated hernia

Inguinal hernia • PHYSICAL EXAMINATION • ► Palpation: • Any attempt to reduce incarcerated hernia should be abandoned (to avoid traumatizing incarcerate viscera)

Inguinal hernia PHYSICAL EXAMINATION ► Palpation: ► The opening through which the hernia protrudes becomes tight and constricts the blood circulation to the bowel ► necrosis ► ► peritonitis ► This is Strangulated hernia)

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