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Hernia - Coggle Diagram
Hernia
Inguinal Hernia
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- Directly emerge through the triangle → direct inguinal hernia
- Lateral to the artery→ deep ring , inguinal canal, superficial ring → indirect inguinal hernia
- The sac of indirect inguinal hernia is attached to the spermatic cord
- Indirect inguinal hernia:
- Common in children (wide ring; same levels; Right side) , it goes to the scrotum
- O/E : - can’t feel the spermatic cord on the affected site -you can feel both testis
- Strangulation is more common than in direct hernia
- Common in adults - Usually bilateral - Donesn’t reach the scrotum
- The best way to differentiate is intra-operatively: Landmark is inf. epigastric a.: Medial = direct/ lateral = indirect
- Bantalon hernia: direct & indirect inguinal hernia at the same time on the same side
- Inflammatory hernia: contain inflammatory components, similar but less severe than Strangulated hernia
- deep inguinal ring is lateral to the inf epigastric a.
- inguinal (Hesselbach ) triangle: Medially: rectus abdominis; Speriolaterally: Inf epiagstric a.; Inferiorly: inguinal ligament
Components
1- Sac : A peritoneal pouch with neck, body and tail
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➢ Special contents:
- Richter’s hernia : Part of bowel circumference, common in the femoral hernia *
- Littre's hernia: Meckel’s diverticulum
- Maydl’s (W) hernia: 2 loops of intestine, the intermediate loop lie in the peritoneal cavity.
- Urinary bladder : in inguinal and femoral hernia
Natural History
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- Irreducible → Adhesions between the sac and the contents or overcrowding ( Urgent surgery within 2 wks)
- Obstructed hernia : Colicky pain (on off); distention, constipation, vomiting
Strangulated hernia :
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Continuous ischemic pain, O/E tender and tense.
Surgical treatment
- Herniotomy:
- Open the sac, Inspect the contents, Reduce the contents, Excise the sac, Close the defect
- Herniorrhaphy:
- Elderly, Same above steps
- Muscle repair using non-absorbable suture (nilon, protein) to stimulate fibrous tissue formation
- Hernioplasty:
- Herniotomy + mesh repair (synthetic material = polypropylene)
- Commonly used nowadays
- Truss : a belt used for patients unfit for surgery.
Femoral Hernia
- Femoral ring is very small opening, :arrow_up: strangulation, so it is urgent hernia
- :female_sign: with recurrent pregnancies
• Femoral hernia
• Femoral artery aneurysm
• Saphena varices “varicosity of saphenous vein”
• Lymph node
Lipoma, Psoas abscess, Hematoma, Ectopic testes
- Injury to ilio-inguinal n. during appendectomy can lead to direct inguinal hernia.
- inguinal hernia: sac is above & medial to pubic tubercle
- femoral hernia: sac is below & lateral to pubic tubercle
Epigastric Hernia
- Through linea alba, between xyhpoid process & umbilicus
- Obese :female_sign:, not obvious (deep palpation), pain (omentum), DD peptic ulcer
- Treated by anatomical repair
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Anatomy
Abnormal protrusion of an organ or viscous, usually within a peritoneal sac, through defect in the abdominal wall.
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Aetiology
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Acquired:
• :arrow_up: intra-abdominal pressure:
Chronic cough; chronic constipation ”straining”; Obesity; Heavy work; Pregnancy; Splenomegaly; Ascites or tumor
• Weak abdominal wall:
Obesity; Pregnancy; Surgical scar; Damaged nerve supply ; Smoking “ :arrow_down: collagen”
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Umbilical Hernia
- Common in children “congenital”.
- Defect in umbilical ring
- The main cause in adults is PHT (Ascites, splenomegaly)
- Role of 3: 3% of live birth; Incidence 3 out of 1000; Treated at age of 3 yrs
- Strangulation is not common - Treatment: anatomical repair
Para-umbilical Hernia
- Above the umbilical → :frowning_face: sad face
- Below umbilical → :smile: smile face
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Strangulated hernia
Management :
- Admission
- Resuscitation
- NPO
- Iv fluids and electrolytes
- Iv antibiotics
- Analgesia
- NG tube
- Urinary catheter
- Follow up and monitoring
On examination:
- Tense
- Tender
- irreducible
- no cough impulse
- :forbidden: Intestinal obstruction:
- omentum
- richter’s hernia
- littre’s hernia
- Sliding hernia: viscus (bladder; cecum; sigmoid) forms part of the wall of the heria sac.
- Common in : longstanding gernia / old males