HERNIA

CC: bulging inguinal mass, right.

Salient features:
- 40 yo, laborer, male.
- Smoker
- Known hx of inguinal hernia
- Tender bulging inguinal mass
- No NV, abdo pain nor abdo tenderness
- Stable VS (no signs of strangulation)

*Hernia- abnormal protrusion of organ.

75%- abdominal wall
90% males
Inguina hernia
Indirect hernia: peak- 40-60 yrs old
Most common type of hernia 70% femoral hernia in women.

Classification:
 Acquired or congenital.
Congenital- devt defect. Male, patent processes vaginalis- common in preterm babies.
In female- canal of nuch oblirate 8 week of life.
Acquired- weakness abdo. Wall musculature amd inc. intra abdo pressure and risk factors.

Pathology:
 Indirect hernia- lateral to inf. Epigastric vessels.
 Direct inguinal hernias- medial to inf. Epigastric vessel (Hasselbach triangle)
 Femoral hernias- loc: inferior to inguinal ligment and protrude to femoral ring.

Why inguinal and femoral common in the right side?- presence of the sigmoid colon right side.
 Boundaries of inguinal hernia❤️
The boundaries of the inguinal canal are comprised of the external oblique aponeurosis anteriorly, the
internal oblique muscle laterally, the transversalis fascia and transversus abdominis muscle posteriorly,
the internal oblique muscle superiorly, and the inguinal (Poupart’s) ligament inferiorly.

How to diagnose inguinal hernia?- base on hx and P.E

- groin mass, protrudes while standing, coughing or straining, inguinal pain. Reducible vs
nonreducible. 1/3 no symptomps (imaging na)

PE: digital examination and inguinal occlusion test:

- digital examination: insert index finger to external ring (scrutom), if walang mass na nakapa..
do valsalva maneuver (ere or cough)
Imaging:
- if pt. is obese
- you can do UTZ, MRI(best, but costly) LAPAROSCOPY AND CT SCAN
- UTZ- 60% sensitivity and 80% specificity
- CT scan- sensitivity of 80% and specificity of 65%.
- MRI was an effective diagnostic test, with a sensitivity of 95% and specificity of 96%

DIOGNOSIS: right indirect non rudicible, incarcerated type 3b

How will you manage?

- Asymptomatic vs symptomatic
- Symptomatic- elective repair operative.
- Minimally symptomatic or asymptomatic- watchful waiting.

Symptomatic- pain with exertion, inability to perform daily activities due to pain or discomfort, inability
to manually reduce the hernia (chronic incarceration)

Indication for surgical repair:

 complicated hernia-urgent slx repair
 Femoral hernia- early elective sxl repair
 Symptomatic inguinal hernia- early elective sxl repair.
Open inguinal hernia repair
- Tissue repair (operative field contamination, high recurence rate)
Bassini repair- triple layer repair (internal oblique, abdominis and transvarsalis fascia are
fixed to shelving edge of inguinal ligament and pubic periosteum with interrupted
sutures)
Shouldice repair- continuous running suture
McVay repair- femoral hernias and inguinal, lesser recurrence, 2-4 cm relaxing
incision(sup. Transversalis flab copper ligament)
Desarda repair- strip of external oblique
- tension free mesh repair (gold standard type in both open and laparoscopic, very low recurrence
rate)
lichtenstein tension free repair-
plug and patch repair—Lapoaroscopic hernia repair
TAP- bilat. Hernias large hernias, scarring
TEP- preperitoneal space without intrafperitoneal infiltration. Nasa extraperitoneal lng sya.
 ITOM- posterior approach without preperitoneal repair.
- Robotics- assisted herniorapy