HERNIAS. Prof. Dr. M. Süphan ERTÜRK

Transcription

1 HERNIAS Prof. Dr. M. Süphan ERTÜRK

2 Definition A hernia is an abnormal protrusion of any viscus from its proper anatomical cavity through: congenital defect weakened region in it s wall

3 Frequency Groin % Indirect inguinal % Direct inguinal 15 % Femoral 5 % Incisional 10 % Ventral 10 % Epigastric Umbilical Spigelian Others 5 % Hiatal Lumbar Obturator Perineal Sciatic Peristomal

4 Etiology Congenital defects Enlarged foramen Loss of tissue strength and elasticity Trauma Increased intra-abdominal pressure

5 Descriptive terms Reducible Irreducible Incarcerated Strangulated Complete Incomplete Sliding Richter s hernia Maydl s hernia Littre s hernia

6 Inguinal Anatomy. Surgical Anatomy, Skandalakis

7 Inguinal Anatomy.. Surg Clin North America

8 Indirect inguinal hernia. Indirect inguinal hernia passes through the internal ring and traverses the inguinal canal. It may extend into the scrotum (complete hernia). Current Diagn Treatm, Lange

9 Indirect inguinal hernia.. It occurs as a result of congenitally patent processus vaginalis. First clinical evidence may appear at Childhood Middle or old age When incompletely obliterated Indirect inguinal hernia Communicating hydrocele Spermatic cord hydrocele Hydrocele of testis

10 Indirect inguinal hernia... Most common type of hernia in both men and women 5 to 10 times more common in men than in women More common on the right 60% right 30% left 10% bilateral A pediatric inguinal hernia is almost always indirect Potential indirect hernias Undescended testis Testis in the inguinal canal Testicular or spermatic cord hydrocele.

11 Direct inguinal hernia. It occurs in the floor of the inguinal canal because of an acquired weakness in fascia transversalis. The incidence therefore increases with age, and it is often bilateral. The abdominal structures protrude through the Hesselbach s triangle into the posterior wall of the inguinal canal.

12 Direct inguinal hernia.. The hernia rarely descends into the scrotum. The neck of the direct hernia is wide, so it is less often associated with strangulation. Direct hernias are seen almost exclusively in male patients.

13 Current Diagn Treatm, Lange

14 Femoral hernia. The hernia content passes beneath the inguinal ligament traverses the femoral canal seen as a mass at the level of foramen ovale Textbook of Surg, Oxford

15 Femoral herni.. Incarceration* and strangulation* are frequent (30-40%). More common in women (1/3 of all groin hernias) than in men (2% of all groin hernias). However, inguinal hernia is more frequent both in men and in women than femoral hernia. Femoral hernias are related to physical exertion and to pregnancy

16 Diagnosis. History Some patients may describe a sudden pain and bulge while lifting, coughing or straining (physical activity). The mass may be continiously intermittantly present In general, direct hernias produce fewer symptoms than indirect inguinal hernias less likely to become incarcerated or strangulated.

17 Diagnosis.. Physical examination A mass may be Visible Tender Reducible Bowel sounds may be audible. A mass may be Small or nonpalpabl Palpabl with coughing and straining.

18

19 Diagnosis... Radiology Plain films Upper GI series Contrast medium enema Herniography US CT MRI

20 Treatment. Ideally, all hernias should be treated surgically. Because the risk of incarceration, strangulation and obstruction are greater than the risk of elective operation

21 Treatment.. The principles of repair Preparation of hernial sac Opening the sac (herniotomy) Return of hernia contents into the peritoneal cavity Excision or reduction (invagination) of the hernial sac Repair of the hernial defect Tissue approximation (Bassini, Halsted, McWay, Shouldice) Prosthetic reinforcement Open (Lichtenstein, Stoppa, Rives, Kugel) Laparoscopic

22 İng Herni, D Uğur

23 İng Herni, D Uğur

24

25 Umbilical hernia Umbilical hernias occur at the umbilicus. 10 times more often in women than in men. The defect is common in children, but is usually (95%) obliterated spontaneously. In adults, umbilical hernias are often associated with increased intra-abdominal pressure (ascite, pregnancy, obesity, large intra-abdominal tumor). Treatment Simple transverse repair of the fascial defect (<3 cm). Prosthetic material (tension-free repair) (>3 cm / recurrent hernia).

26 Epigastric hernia It develops through a defect in the linea alba above the umbilicus. About 20% of epigastric hernias are multiple Treatment Simple repair 10% recurrence rate Prosthetic repair For larger hernias Current Diagn Treatm, Lange

27 Incisional hernia Results from poor wound healing in a previous surgical incision 90% are seen during first 3 years Common etiologic factors: Poor surgical technique wound infection wound hematoma advanced age Obesity Malnutrition increased postoperative abdominal pressure (ileus, ascites, pulmonary complication) Treatment Primary repair (Recurrence rate is 25%) Prosthetic repair (Open / laparoscopic)

28

29

30 Diaphragmatic hernias Potential defects Single Esophageal hiatus Paired Posterolateral (Bochdalek) Anterior (Morgagni, Larrey) Treatment Nissen, Toupet, Belsey Mark IV Primary/prosthetic repair İnsan Anat Atlası, Sobotta