Groin Main[

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BISMILLAH AL REHMAN AL RAHIM.

GROIN HERNIAS INGUINAL HERNIA FEMORAL HERNIA By ; Abrar Hussain Zaidi

CONTENTS                     

Anatomy     Examination Surgical problems

Groin: The area where the upper thigh meets the trunk. More precisely, the fold or depression marking the junction of the lower abdomen and the inner part of the thigh.

INGUINAL CANAL

Definition 

The oblique passage in the anterior abdominal wall, through which passes the spermatic cord in the male and the round ligament of the uterus in the female

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A conduit in the abdominal wall through which a testis descends into the scrotum.

INGUINAL CANAL ANATOMY Site The inguinal canal is situated just above the medial half of the inguinal ligament. Length Approximately 4cm (1.57 inches). Direction It is oblique, directed inferiorly, anteriorly and medially.

INGUINAL CANAL-ANATOMY

INGUINAL CANAL-ANATOMY

Boundaries- Anterior wall External oblique aponeurosis  Reinforced in lateral 1/3 by internal oblique muscle

Boundaries- Lateral Deep inguinal ring  Opening in fascia transversalis  1 cm above the inguinal ligament  Midway between anterior superior iliac spine and symphysis pubis  Medial to it lie the Inferior Epigastric vessels

Boundaries-Medial 

Superficial inguinal ring Triangular defect in external oblique aponeurosis Overlies the pubic crest which forms the base of the opening

Boundaries-Posterior wall  

Fascia transversalis Reinforced in medial 1/3 by conjoint tendon

Boundaries- Floor Inguinal ligament  Lower border of external oblique aponeurosis  Medially is continuous with lacunar ligament Gives attachment to fascia lata on the inferior border

Boundaries- Roof 

Arched fibers of conjoint tendon

Contents of inguinal canal Spermatic cord and ilioinguinal nerve in males Round ligament of uterus and ilioinguinal nerve in females

Spermatic cord   

VAS DEFERENCE VESSELS COVERINGS

The abdominal wall in the groin area is made up of different structures

From deep to superficial layers; 

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Peritoneum - the lining of the abdominal cavity (becomes the hernia sac) Subperitoneal fat - fat beneath the peritoneum Transversalis fascia - sheet of fibrous tissue that envelops the peritoneum Transversus abdominis muscle Internal oblique muscle External oblique muscle Subcutaneous fat Skin

Spermatic cord-Coverings Each anterior abdominal wall layer gives it a covering to sheath From within outwards the coverings are derived as follows o Internal Spermatic fascia from fascia transversalis o Cremasteric fascia from internal oblique o External spermatic fascia from external oblique

Spermatic cord - Contents         

Vas deferens Artery to vas deferens (branch of inferior vesical artery) Testicular artery (branch of abdominal aorta) Testicular vein Testicular lymphatics Testicular nerve fibers Processus vaginalis Cremasteric artery (branch of inferior Epigastric artery) Nerve to cremaster (genital branch of genitofemoral nerve)

INGUINAL HERNIA

INGUINAL HERNIA DEFINITION Protrusions of abdominal cavity contents through the inguinal canal.  

They are very common - 7% of the population Hernia repair is one of the most frequently performed surgical

INGUINAL HERNIAPathology    

A defect in the wall A sac Coverings Contents inside the sac

Defect in the wall 

Congenital –Inguinal Canals -umbilicus

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Acquired Traumatic/operative Weakness of wall Combination

A hernia consists of:   

A sac Its coverings Its contents

TYPES OF INGUINAL HERNIAS  

DIRECT INDIRECT

Hernias can be:    

Reducible Irreducible Obstructed or incarcerated Strangulated

CAUSATIVE FACTORS  

CONGENITAL AQUIRED WEAK ANT ABDOMINAL WALL COUGH CONSTIPATION WIEGHT LIFTING PREVIOUS SURGERY

Raised intra-abdominal pressure

CLINICAL PRESENTATION 

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Bulge in the groin area that can become more prominent when coughing, straining, or standing up. Often painful, and the bulge commonly disappears on lying down.

CLINICAL PRESENTATION The hernia often increases in size on coughing or straining -cough impulse +VE It reduces in size or disappears when relaxed or supine

CLINICAL PRESENTATION The inability to "reduce", or place the bulge back into the abdomen usually means the hernia is "incarcerated," /obstructed /strangulated -necessitating emergency surgery.

CLINICAL PRESENTATION 

Irreducible hernias have either a narrow neck or the contents adhere to the sac wall

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Obstructed hernias contain obstructed but viable intestine

CLINICAL PRESENTATION 

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Irreducible but non-obstructed hernias may cause little pain, Content are usually -omentum If the hernia causes obstruction: colicky abdominal pain, distension and vomiting may occur The hernia will be tense tender and irreducible

CLINICAL PRESENTATION If strangulation occurs  

Blood circulation is compromised The lump will become red and tender Patient is ill ,toxic and has clinical signs of intestinal obstruction

Diagnosis Diagnosis is based on clinical features

Herniography Ultrasound or CT Rarely required In occult hernia

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History Define any causative factor General assessment

INGUINAL HERNIA EXAMINATION  

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Standing position Lying position Inspection Palpation Percussion Auscultation

INGUINAL HERNIA EXAMINATION    

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Describe the swelling Cough impulse Reducibility Contents Abdominal examination/+PR. Systemic examination

INGUINAL HERNIA EXAMINATION

INGUINAL HERNIA EXAMINATION

INGUINAL HERNIA EXAMINATION

INGUINAL HERNIA TREATMENT 

CORRECTION OF CAUSATIVE /AGGRAVATING FACTORS

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PREPARATION

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SURGERY

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POST OPERATIVE CARE

open / Laparoscopic

SURGICAL TREATMENT PRINCIPLES   

Mange the contents Excise the sac Strengthen the posterior wall

SURGICAL TREATMENT Surgical Procedures   

HERNIOTOMY HERNIORRHAPHY HERNIOPLASTY

ELCTIVE VS EMERGENCY SURGERY

Surgical repair - techniques

 Bassini

+/- Tanner Slide  Darnning  Shouldice

Surgical repair - techniques 

Lichtenstein / mesh reair Shouldice or Liechtenstein now regarded as 'gold standard' as judged by low risk of recurrence

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Laparoscopic repair

HERNIORRHAPHY

1) Reflected medial leaf after a strip has been separated; 2) Internal oblique muscle seen through the splitting incision made in the medial leaf; 3) Interrupted sutures between the upper border of the strip and conjoined muscle and internal oblique muscle; 4) Interrupted sutures between the lower border of the strip and the inguinal ligament; 5) Pubic tubercle; 6) Abdominal ring; 7) Spermatic cord; and 8) Lateral leaf.

COMPLICATIONS OF INGUINAL HERNIA

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OBSTRUCTION STRANGULATION INFLAMATION

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OPERATIVE COMPLICATIONS

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EARLY POSTOPERATIVE COMPLICATIONS LATE POSTOPERATIVE COMPLICATIONS

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POST OPERATIVE CARE   

Pain management Prophylaxis against infection Preventive measures against recurrence

INGUINAL HERNIA

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FEMORAL HERNIA

FEMORAL HERNIA 

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Femoral hernias occur just below the inguinal ligament Abdominal contents pass through a naturally occurring weakness called the ‘femoral

canal’.

Femoral Canal 

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located below the inguinal ligament on the lateral aspect of the pubic tubercle. Passageway by which many lymphatics from lower limb pass to abdomen.

Boundaries - Femoral Canal    

Anterior --Inguinal ligament, Posterior--Pectineal ligament Medial ---Lacunar ligament laterally --Femoral vein.

Femoral Canal - CONTENTS 

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It normally contains a few lymphatics, loose areolar tissue and occasionally a lymph node called Cloquet's node. The function of this canal appears to be to allow the femoral vein to expand when necessary to accommodate increased venous return from the leg during periods of

Femoral Hernia-Definition 

Protrusion of Abdominal contents through the ‘femoral

canal’.

Femoral Hernia-Clinical Features Symptoms  More common in women, usually elderly and frail (although they can happen in children).  Typically present as a groin lump.  May or may not be associated with pain.  Often, they present with a complication; irreducibility , intestinal obstruction

Femoral Hernia-Clinical Features Signs  

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The obvious finding -- a lump in the groin. Cough impulse is often absent and should not be relied on The lump is more globular than the pear shaped lump of the inguinal hernia. The bulk of a femoral hernia lies below the inguinal

The incidence of strangulation in femoral hernias is high. A femoral hernia has often been found to be the cause of unexplained small bowel obstruction.

Femoral Hernia-Differential Diagnoses 2. 3. 4. 5. 6. 7.

Inguinal hernia Enlarged inguinal lymph node Aneurysm of the femoral artery Saphena varix Psoas abscess Undescended testis/Ectopic testis

Femoral hernia Management 

Uncomplicated femoral hernias - repaired as an EARLY elective procedure

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Often require emergency surgery

Femoral hernia - Management Three classical approaches to the femoral canal 

Low (Lockwood)

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Transinguinal (Lotheissen)

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High (McEvedy)

Femoral hernia - Management Irrespective of approach the operative aims are; 

Dissection of the sac

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Reduction / manage the contents

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Ligation of the sac

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Approximation of the inguinal and pectineal ligaments

FEMORAL HERNIA REPAIR

POST OPERATIVE CARE    

Pain management Prophylaxis against infection Preventive measures Manage associated problems

FEMORA L HE RNI A -

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Special types of hernia Richter's hernia  

Partial enterocele presents with strangulation and obstruction

Maydl's hernia  

W loop strangulation Strangulated bowel within abdominal cavity

Littre's hernia  

Strangulated Meckel's diverticulum Can cause small bowel fistula

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Mortality of elective hernia repair

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The mortality of elective hernia repair increases with age < 60 yrs

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