1.HERNIAS MOHD HANAFI RAMLEE

2. WE START WITH Q&A SESSION FIRST? 3. ARE YOU REMEMBER???? 4. INGUINAL Anteriorly Skin, superficial fascia and external oblique aponeurosis; internal oblique covers its lateral 1/3. Posteriorly: The conjoint tendon (representing the fused common aponeurotic insertion of internal oblique and transverse abdominis muscle into the pubic crest), forms the posterior wall of the canal medially ; the transversalis fascia lies laterally. Above: Lowest fibers of internal oblique and transverse abdominis. Below: Lies the inguinal ligament FEMORAL CANAL Superioranteriorly [rigid openig] inguinal ligament Inferoposteriorly pubic ramus and the pectineus muscle Medially Gimbernats ligament(pubic part of inguinal ligament) and pubic bone Laterally femoral vein HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? 5. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? INGUINAL CANAL 6. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? INGUINAL CANAL 7. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? FEMORAL CANAL 8. FEMORAL CANALINGUINAL CANAL 9. Inguinal ligament Attached to pubic tubercle and anterior superior iliac spine. Mid-inguinal point half way between ASIS and pubis - landmark for femoral artery in groin. (see lower limb pulses and cardiovascular examination). Midpoint of inguinal ligament Half way between ASIS and pubic tubercle - landmark for deep inguinal ring and indirect inguinal hernia. Medial to this for direct inguinal hernia. TERMS: INGUINALOGY? 10. MID-PT INGUINAL LIGMID-INGUINAL POINT 11. INGUINAL Sex: males more than females. Age: all ages. Peak time of presentation: 1st few months of life, late teens and early twenties, 40 60. Occupation: heavy work (lifting) FEMORAL Age: uncommon in children, majority found in 60-80 y/o women Sex: more common in women HOW DO YOU DIFFERENTIATE IT EPIDEMOLOGICALLY? [age & sex] 12. INGUINAL Local symptoms: discomfort, pain, swelling in the groin. Systemic symptoms (if hernia is obstructing the lumen of loop of bowel): colicky abdominal pain, vomiting, abdominal distension, absolute constipation. FEMORAL local: lump in groin, pain and discomfort Systemic (if obstructed): colic, distension, vomiting and constipation HOW DO YOU DIFFERENTIATE IT BY HISTORY? 13. INGUINAL SITE: just above the pubic crest and the pubic tubercle and is widest medial to the pubic tubercle SIZE:1-2cm in diameter/extend down to the knee joint SHAPE: pear-shaped or hour- glass appearance SKIN:normal as the surrounding skin. But if strangulated, the skin ,may be a little reddened SURFACE:usually smooth SURROUNDING: Normal TEMPERATURE: normal but if strangulated or infected, it become hot TENDERNESS: discomfort. If strangulated, it can be very tender COMPOSITION: gut (soft, resonant, fluctuant, bowel sounds), omentum (firm, dull, non-fluctuant) COUGH IMPULSE: positive REDUCIBILITY: positive FEMORAL CANAL SITE: below and lateral to the pubic tubercle SIZE: small SHAPE: flattened SKIN: normal as the surrounding skin. But if strangulated, the skin ,may be a little reddened SURFACE: smooth SURROUNDING: Normal TEMPERATURE: normal but if strangulated or infected, it become hot TENDERNESS: discomfort. If strangulated, it can be very tender COMPOSITION: depend on content COUGH IMPULSE: many femoral hernia do not have a positive cough impulse REDUCIBILITY: reduced incompletely PHYSICAL EXAMINATION? 6S 2T C F 2C R 14. Incarcerated irreducible hernia where the irreducibility is due to adhesions within the sac in the absence of obstruction or strangulation. OR hypotheses - because of faeces within the large bowel. SIMPLY: a hernia as being irreducible but not obstructed or strangulated. Obstructed The bowel within the hernia is obstructed. The patient may have the four cardinal signs of obstruction (pain, vomiting, distention and constipation). Strangulated occluded blood supply by pressure at the neck of the hernia. Viability of bowell will impaired [except if contain omentum only] 1st veins are occluded P 2nd arterial occlusion gangrene developing. TERMS: INGUINALOGY? 15. DIRECT INGUINAL HERNIA Hernia pushes its way directly forward through posterior wall of inguinal canal. Does not go down into the scrotum INDIRECT INGUINAL HERNIA Pass through internal ring, along the canal in front of spermatic cord, within layers of spermatic fascia and cremasteric fascia, If large enough, descend into the scrotumHOW DO YOU DIFFERENTIATE IT ANATOMYCALLY? 16. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? DIRECT INGUINAL HERNIA 17. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? INDIRECT INGUINAL HERNA 18. DIRECT INGUINAL HERNIA Reduces upwards and then straight backwards. Not controlled, after reduction, by pressure over the internal inguinal ring. The defect may be felt in the abdominal wall above the pubic tubercle. After reduction the bulge reappears exactly where it was before. Uncommon in children and young adults. Always acquired Large orifice appears immediately on standing, disappearing at once when lies down. INDIRECT INGUINAL HERNIA Reduces upwards, then laterally and backwards Controlled, after reduction, by pressure over the internal inguinal ring The defect is not palpable as it is behind the fibers of the external oblique muscle After reduction the bulge reappears in the middle of the inguinal region and then flows medially before turning down to the neck of the scrotum. Narrow opening of internal ring: hernia does not reach its full size until the patient has been up for some time. tendency to strangulate WHAT OTHER FEATURES COULD DIFFERENTIATE BETWEEN 19. LEFT INGUINAL HERNIA WHAT IS THIS HERNIA? 20. STRANGULATED HERNIA Patient presented with acute, painful, non-reducible inguinal hernia. It's worth mentioning that in spite of rapid diagnosis and prompt surgical exploration, gangrenous bowel was identified. This highlights the potential seriousness of this condition WHAT IS THIS HERNIA? 21. FEMORAL HERNIA Femoral hernias occur just below the inguinal ligament, when abdominal contents pass into the weak area at the posterior wall of the femoral canal. They can be hard to distinguish from the inguinal type (especially when ascending cephalad): however, they generally appear more rounded, and, in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and inguinal hernia. WHAT IS THIS HERNIA? 22. UMBILICAL HERNIA They involve protrusion of intraabdominal contents through a weakness at the site of passage of the umbilical cord through the abdominal wall. These hernias often resolve spontaneously. Umbilical hernias in adults are largely acquired, and are more frequent in obese or pregnant women. Abnormal decussation of fibers at the linea alba may contribute. WHAT IS THIS HERNIA? 23. INCISIONAL HERNIA An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median laparotomy incisions in the linea alba, they are termed ventral hernias. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue. WHAT IS THIS HERNIA? 24. EPIGASTRIC HERNIA An epigastric hernia is a type of hernia which may develop in the epigastrium. Epigastric hernias are most common in infants but may occur in humans of any age. They typically result from a minor defect of the linea alba between the rectus abdominis muscles. This allows tissue from inside the abdomen to herniate anteriorly. On infants, this may manifest as an apparent 'bubble' under the skin of the belly between the umbilicus and xiphisternum. WHAT IS THIS HERNIA? 25. LITTRE HERNIA a hernia involving a Meckel's diverticulum. WHAT IS THIS HERNIA? 26. SPORT HERNIA It is a syndrome characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal. Football and ice hockey players are affected most frequently, and both recreational and professional athletes may be affected. A hernia cannot be found on physical examination or medical imaging, and is not revealed during surgery. The term hernia thus is a misnomer,[3] but has persisted, as surgical reconstructions similar to those performed for inguinal hernias are often effective for "sports hernias" as well. WHAT IS THIS HERNIA? 27. PERINEAL HERNIA a hernia involving the perineum (pelvic floor). The hernia may contain fluid, fat, any part of the intestine, the rectum, or the bladder. It is known to occur in humans, dogs, and other mammals, and often appears as a sudden swelling to one side (sometimes both sides) of the anus. WHAT IS THIS HERNIA? WHAT IS THIS HERNIA? 28. LECTURE: HERNIA abnormal weakness or hole in an anatomical structure which allows something inside to protrude through. 29. Groin Hernias 96% Inguinal 9:1 M:F 4% Femoral 4:1 F:M Lifetime risk approximately 25% in males and