What's Hernia

“CLINICAL INFORMATION OF INGUINAL HERNIA”

· Complaints

o dull dragging pain referred to the testis - increases on work

o If obstructed may have constipation, vomiting, pain

o If strangulated may have severe pain, shock, collapse.

· Clinical Findings

o piriform swelling - in the inguinal canal

o bubonocele does not come into scrotum

o Cough impulse + Reducibility +

o Neck of the hernia is supero-medial to pubic tubercle

· Special tests

o Deep ring occlusion - hernia does not appear

o Finger Invagination - impulse at tip of finger

o Dr.Desarda's test - Sliding of contents from ring finger to index finger indicates indirect and from middle to index finger indicates direct hernia

· Types :

1. Reducible

2. Irreducible (complication of (1))

3. Obstructed -------"---------

4. Strangulated ------"----------

5. Inflamed (the viscus in the hernia is inflamed - e.g. appendicitis, salpingitis)

· Differential Diagnosis:

· Males

1. Femoral hernia

2. Direct inguinal

3. Vaginal hydrocele

4. encysted hydrocele of cord

5. Undescended testis

6. Spermatocele

7. Varicocele

8. Diffuse lipoma of cord.

· Females

1. Femoral hernia

2. Hydrocele of canal of Nuck

· Treatment

[1] Principles of treatment :

1. Restore the disrupted anatomy

2. Repair using fascia / aponeurosis NOT muscle

3. NO tension

4. Suture material used should hold until natural support is formed over it. ( i.e. monofilament nylon or polyethylene)

[2] Management

*** Described by DEVLIN

1. Resuscitation - in case of strangulated hernia with gangrene with shock or with intestinal obstruction.

2. Reduction of hernia - includes taxis, & reduction under anesthesia.

3. Repair - of the defect - may be herniorrhaphy or hernioplasty.

· Strangulated hernia -

o treat as emergency

o treat shock if any. Start IV antibiotics

o Incision over the most prominent part of swelling - sac carefully identified & dissected out. Sac opened.

o Aspirate all fluid ( highly infectious)

o Resect any unviable intestine or omentum

o EO aponeurosis & external ring divided. Sac opened throughout the length upto deep ring & a little inside.

o Viable contents reduced. Definite repair carried out - any prosthetic repair is contra-indicated.

- Non - Operative approach - in elderly, unfit / unwilling for surgery.

- Use of truss is advised in such cases- Truss must be applied with hernia reduced. Must prevent reappearance of the hernia on straining.

- Surgery - treatment modality of choice.

1 - Herniotomy - may be sufficient in young, muscular individuals and in children.

2 - Herniorrhaphy - in adults with good muscular tone.

3 - Hernioplasty - in elderly with poor muscular tone.

C/I in strangulated hernia - may get infected leading to wound sinuus.

· Herniorrhaphy -

o Dr. Desarda's repair: Giving physiologically dynamic and strong posterior wall should be the principle of any type of inguinal hernia repair to give 100% success rate. Undetached strip of the external oblique aponeurosis is sutured between the muscle arch and the inguinal ligament to give a strong posterior wall which is kept physiologically dynamic by the additional muscle strength provided by the external oblique muscle to the weakened muscle arch.

o Lytle's repair (syn : Marcie's repair)- narrowing of the deep ring by suturing medial wall - Tight enough so that cord & little finger just fit in.

o Bassini's repair - Suturing of conjoint tendon to the incurved part of inguinal ligament - medial most stitch through the pubic periosteum - sutures taken with non-absorbable sutures - originally done by Bassini using black silk - now monofilament nylon used. - Chances of femoral hernia increased.

o Shouldice repair - Double breasting of transversalis fascia - best tissue repair - at the Shouldice clinic in Toronto, stainless steel wire used for darning.

o Ogilvie's repair - plication of transversalis fascia

o McVay's repair / Cooper's repair - Conjoint tendon sutured to the Cooper's ligament - also prevents Femoral hernia formation - closes off the Fruchaud's orifice.

o Condon's repair - Conjoint tendon sutured to the ilio-pubic tract.

o Halsted's repair - repaired at 3 levels (6 layer repair) - Bassini's + Shouldice + double breasting of external oblique - cord becomes subcutaneous

o NYHUS / Cheatle - Henry repair - pre-peritoneal repair - may be combined with prostatectomy. Used for large double hernias (direct + indirect), bilateral hernias, & Recurrent hernias.

o Inguinoclysis - only in elderly men with recurrent / very large hernias - obliteration of the inguinal canal with bilateral orchidectomy.

o Pantaloon hernia - Treated by 1^st converting the hernia into one giant indirect hernia & then treating it as indirect hernia

· Complications :

1] Of the hernia -

· Irreducibility

· Obstruction

· Strangulation

· Toxic shock

· Peritonitis

2] Of the surgery -

· Sepsis ( most common ) - may lead to formation of incisional hernia.

· Hematoma