Interactive

Case Discussion
Department of Surgery
Group 6
MEMBERS
PGI
SARMIENTO, Jenny Anne D.
TORMON, Immanuel N.
TRIGUERO, Stephanie R.

Clerks Clerks
LAMSAL, Manu Asjley R. LIBUIT, Iana Katrina B.
LANDAYAN, Andrea May Anne E. LINAN, Denisse Isabelle P.
LAROSA, Ariane Joy U. LINAN, Diego Vittorio Miguel IV P.
LAURENTE, Nneka Marie P. LIPSKI, Katherine M.
LAVILLA, Kendrick Malcolm A. LIZARONDO, John Patrick T.
LEE, Gleeve Asther B. MALLICK, Aniket
LEE, John Micheal E. PREM KUMAR, Sherlyn
LEGASPI, Jhon Dexter A. RAHAL, Roshni
LELINA, Jaerah Chamille B. SWAIN, Sunil Kumar
LIBANG, Clarenze J. SWAIN, Anil Kumar
OBJECTIVES

● To present the clinical case

● To assess its salient features and to come up with the
clinical impression accompanied by the basis
● To have a brief discussion of Inguinal hernia
● To come up with the proper diagnostic tests
● To determine the proper management
CASE PROPER
General Data :
● A.I.

● 40yrs old

● Male
 Chief complaint :

Inguino-scrotal mass , left

HPI :

10 yrs PTC 8 hrs PTC FHPTC

● Bulging inguinal ● Bulging mass in left ● Increase in severity

mass , left extending inguino-scrotal of tenderness
up to scrotal area region after lifting ● Still no associated
● Mass reducible heavy object symptoms
● More pronounced ● Mass irreducible ● Patient brought to
during exertion of ● Tender
effort institution
● (-) abd pain , nausea ,
● (-) abd pain , vomiting ● Admitted
vomiting , fever
, constipation , ● No consult done
dysuria , fever.
● Patient did not seek
consult
Past Medical History

(-) DM
(-) Allergy to food & drugs
(-) HPN
(-) Asthma
(-) Lung, liver and kidney disease
Family History

(-) TB
(-) HPN
(-) DM
(-) Malignancy
(-) Asthma
Personal and Social History

Smoker
Alcoholic Drinker
Review of Systems
General: (-) fever (-) weight loss (-) anorexia
Skin: (-) lesions, (-) pruritus
HEENT: (-) Headache (-) blurring of vision, (-)
sore throat
Respiratory: (-) cough, (-) hemoptysis
CVS: (-) chest pain, (-) palpitations, (-) DOB
GIT: (-) diarrhea, (-) constipation (-) melena
GUT: (-) dysuria, (-) anuria, (-) hematuria
Hematologic: (-) easy bruisability
Endocrine: (-) polyphagia, (-) polydipsia
Neurologic: (-) tingling sensation, (-)
numbness
Musculoskeletal: (-) muscle pains, (-) joint
pains
Physical Examination
General survey: Conscious, coherent, not
respiratory distress
Vital signs: BP: 120/70 mmHg
HR: 90 bpm
RR: 24 cpm
T: 37.2°C
HEENT: Anicteric sclerae, pink palpebral
conjunctiva, (-) naso aural discharge, (-)
tonsillopharyngeal congestion, (-) cervical
lymphadenopathy
Chest & Lungs: symmetric chest expansion, (-)
retractions, vesicular breath sounds
CVS: adynamic precordium, normal rate,
regular rhythm, (-) murmur
Physical Examination
Abdomen: flat, soft, normoactive bowel
sounds, non tender

Genitourinary: inguinal bulge left, extending

to the scrotum, skin non erythematous,
warm to touch, tender on palpation. External
inguinal ring is dilated.

DRE: No skin tag, intact sphincter, no mass

palpated, smooth wall, (+) fecal material on
tactating finger

Extremities: grossly normal, (-) edema, (-)

cyanosis, full & equal pulses
SALIENT FEATURES
● 40y.o., male
● Inguinoscrotal mass, Left
● Post heavy weight lifting
● Irreducible
● Tender to touch with increasing severity
● 10-year history of reducible inguinoscrotal mass (L),
○ More pronounced during exertion
● Smoker
● Physical Exam findings:
○ Inguinal bulge extending to the scrotum (L)
○ Warm to touch
○ Tender on palpation
○ Dilated External inguinal ring
Indirect Inguinal
Hernia, Incarcerated
CLINICAL IMPRESSION
DIFFERENTIAL
DIAGNOSIS
 DIFFERENTIAL DIAGNOSIS
Femoral hernia, incarcerated
RULE IN RULE OUT
Patient’s age 40-years-old Common among female (3:1 ratio)
Irreducible mass Intestinal obstruction
Pronounce during exertion Fever, nausea & vomiting
Tender and warm to touch
Increasing severity in the
tenderness
 DIFFERENTIAL DIAGNOSIS
Acute Reactive Hydrocele
RULE IN RULE OUT
History of 10-year painless scrotal Sudden bulging mass
swelling

Primary hydrocele could still be Most common in infants

predominant in middle and later life

Residence in warm climate (-) signs of inflammation

Intermittent Irreducible mass

 DIFFERENTIAL DIAGNOSIS
Testicular torsion
RULE IN RULE OUT

Can still occur at any age Most common in neonates and

prepubertal boys

Acute onset of pain (-) nausea and vomiting

Precipitated by exertion from heavy (-) lower abdominal pain

lifting

Pain is unilateral
DIAGNOSTIC
COMPLETE BLOOD COUNT
Result Reference Range Interpretation

WBC 12.7 4.5 to 11.0 × 109/L HIGH

Neutrophils 62.7 40-60 HIGH

Lymphocytes 32.7 20-40 NORMAL

Monocytes 4.6 2-10 NORMAL

Eosinophils 2.0 1-6 NORMAL

Basophils 0.3 0.5-1 NORMAL

Hemoglobin 151 125-160 NORMAL

Hematocrit 0.402 0.38-0.5 NORMAL

Platelets 514 150-450 x 103/ul HIGH

 URINALYSIS
4/9/14

Results Reference Interpretation

Color Yellow Color – Yellow (light/pale Normal

to dark/deep amber)

Clarity Slightly turbid Transparent / Clear Suggestive of Infection

PH 5.0 4.5-8 Normal

Specific Gravity 1.02 1.005-1.025 Normal

RBC 2 / hpf ≤3 Normal

Pus Cells 1 / hpf 1-2 / hpf Normal

Bacteria few None Suggestive of Infection

PLAN ● Prompt fluid resuscitation
● Cardiopulmonary workup prior to operation
● Hernia repair

OPERATION DONE ● Hernioplasty, Left

INTRAOPERATIVE ● Hernial sac filled with clear serous fluid, non

FINDINGS foul smelling
● Segments of omentum found incarcerated
in the hernial sac
Indirect Inguinal
hernia left,
Incarcerated
omentum
FINAL DIAGNOSIS
1ST POSTOPERATIVE DAY

● Stable vital signs

● IFC - 50cc/hr
● Abdomen: soft and non tender
2ND POSTOPERATIVE DAY

● Stable vital signs

● With bowel movement and flatus
● Discharged with oral Cefuroxime 500mg TID
● Mefenamic acid 500mg
DISCUSSION
HERNIA
Derived from latin word for rupture

Sabiston textbook of surgery, 20th edition

Schwartz principle of surgery, 10th edition
● Although a hernia can occur at various
sites of the body, these defects most
commonly involve the abdominal wall,
particularly the inguinal region.
● Abdominal wall hernias occur only at
sites at which the aponeurosis and fascia
are not covered by striated muscle
●
Sabiston textbook of surgery, 20th edition
Schwartz principle of surgery, 10th edition
ETIOLOGY OF ABDOMINAL HERNIA

● Rise in the intra-abdominal pressure

● Weakening of abdominal boundaries or
anatomical weak sites like linea alba, femoral
canal
● Obesity
● Smoking
● A congenital defect (indirect inguinal hernia ,
Umbilical hernia )

Sabiston textbook of surgery, 20th edition

Schwartz principle of surgery, 10th edition
Sabiston textbook of surgery, 20th edition
Sabiston textbook of surgery, 20th edition
Flashcard quizlet, hernia,
Flashcard quizlet, hernia,
The most common content of a
sac in an abdominal hernia is

Small Intestine

Flashcard quizlet, hernia,

● The neck or orifice of a hernia - located at the innermost
musculoaponeurotic layer
● Hernia sac - lined by peritoneum and protrudes from the
neck.
● There is no consistent relationship between the area of a
hernia defect and the size of a hernia sac.
● A hernia is reducible when its contents can be replaced
within the surrounding musculature.
● it is irreducible or incarcerated when it cannot be reduced.
● Hernias can be congenital (mainly prenatal or in infants -
omphalocele) or acquired Sabiston textbook of surgery, 20th edition
Schwartz principle of surgery, 10th edition
EXTERNAL HERNIA INTERNAL HERNIA
Sameh Shehata,
Sameh Shehata, slideshare
Sameh Shehata, slideshare
PARADUODENAL HERNIA

Sameh Shehata, slideshare

ANATOMY
 BOUNDARIES OF THE
INGUINAL CANAL:

● Anterior
- External oblique aponeurosis

● Lateral
-Internal Oblique Muscle

● Posterior
-Transversalis Fascia and
Transversus Abdominis Muscle

● Superior
-Transversus Abdominis and
Internal Oblique Muscle

● Inferior
-Inguinal Ligament
INGUINAL CANAL
● Boundaries of inguinal canal:

Superior Internal oblique and transversus abdominis muscle

Inferior Inguinal (Poupart’s) ligament

Lateral Internal oblique muscle

Posterior Transversalis fascia and transversus abdominis muscle

Anterior External oblique aponeurosis

OTHER IMPORTANT ANATOMIC SITES

● Hesselbach’s Triangle
○ Also known as the Inguinal Triangle
■ Area where direct hernias protrude

● Boundaries of the Hesselbach’s triangle:

Superolateral Inferior epigastric vessels

Medial Lateral edge of rectus sheath

Inferior Inguinal Ligament

OTHER IMPORTANT ANATOMIC SITES
● Femoral ring
○ Small inflexible abdominal opening in
the femoral canal
● Boundaries of the femoral ring:

Anterior Iliopubic tract, inguinal ligament

Posterior Cooper’s ligament

Medial Lacunar Ligament

Lateral Femoral Vein

INGUINAL HERNIA
INGUINAL HERNIA
● Most common abdominal wall hernia (75%)

INDIRECT IH DIRECT IH FEMORAL IH

Congenital Acquired Slender women,
young or old
Lateral to epigastric Medial to epigastric Below the inguinal
vessel vessel at the ligament, medial to
(close to the internal Hesselbach’s triangle femoral vein
or deep inguinal ring) (close to the external
or superficial inguinal
ring)
INGUINAL HERNIA
● Clinical Manifestation:
○ Most common symptom is a groin mass that protrudes while standing,
coughing, or straining
○ Sometime reducible while lying down
○ Extrainguinal symptoms includes:
■ Changes in bowel habit
■ And urinary symptoms
○ Usually painful
■ Secondary to the compression of the nerves by the hernial sac
■ Generalized pressure, localized sharp pain, or referred pain
● Scrotum
● Testes
● Inner thigh
INGUINAL HERNIA
● Difference between Direct and Indirect Inguinal Hernia:

Feature DIRECT IH INDIRECT IH

Age Aged people Children, young people

Pathway of protrusion Pass through the Coming down the inguinal

hesselbach’s triangle, rarely canal, may enter the
enters the scrotum scrotum

Contours of sac semi-spheric , wide base Elliptic, pear shaped

Relation of Spermatic cord Anterior and lateral to the Posterior to the sac
with sac sac

Relationship of sac neck Sac neck is medial to it Sac neck is lateral to it

with inferior Epigastric
artery

Incarcerated incidence Low High

INGUINAL CANAL
● The anatomical space beneath the external oblique aponeurosis, between
the internal and external inguinal ring.
○ The inguinal ring contains the inferior epigastric vessel
○ Where the operation is performed (where the hernial sac is isolated)
● In men, it contains the cremasteric muscle which covers the cord
structures (vas deferens, testicular vessels, and associated connective
tissues).
● In women, it contains the round ligament from the uterus, genital branch of
genitofemoral nerve, and ilioinguinal nerve.
Causes of Inguinal Hernia
● Any condition that increases pressure of the abdominal cavity may
contribute to the formation and worsening of a hernia
○ Obesity
■ Whose external groin anatomy is difficult to access
○ Heavy lifting
○ Coughing
○ Straining during bowel movement or urination
○ Chronic lung disease
○ Fluid in the abdominal cavity (ascites)
○ Hereditary
CLINICAL TYPES OF INGUINAL HERNIA
1. Reducible hernia
a. Contents of the hernial sac return to the abdomen
spontaneously or with manual pressure when the patient is
recumbent
2. Irreducible hernia
a. Contents or part of contents cannot be returned to the
abdomen, without serious symptoms
b. Hernias are trapped by the narrow neck
Physical Examination:
Patient should be examined in
standing position to increase the
intra-abdominal pressure with groin
and scrotum fully exposed
•Inspection
•Palpation-performed by
advancing the index finger
through the scrotum towards the
inguinal ring, patient is then asked
to perform Valsalva maneuver
INCARCERATED VS STRANGULATED
DIAGNOSTICS
IMAGING
● Ultrasound
● CT-scan
● MRI
Ultrasound
● readily available and cheaper, least invasive
● 86% sensitivity and 77% specificity
● Positive intra-abdominal pressure is used to elicit
herniation
○ False negative - no movement
○ False positive - in thin patients, movement of the
spermatic cord and posterior abdominal wall
Reference: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-39842018000300193#f2
 CT-scan
● Has a limited place in diagnosis of inguinal
hernia
● Sensitivity of 80% and specificity of 65%
● indicated if the hernia is suspected to be
incarcerated or strangulated

Reference: https://pubs.rsna.org/doi/full/10.1148/rg.312105129
 ● sensitivity of 95% and specificity of
96% in the detection of an inguinal
hernia.
● is costly and rarely used for
MRI diagnosis of an inguinal hernia due
to its limited access.
● can be used to assist in the
differentiation of sports-related
injuries versus inguinal hernias.

Reference: https://www.ncbi.nlm.nih.gov/books/NBK513332/
 NYHUS CLASSIFICATION SYSTEM
TYPE I Indirect hernia; Internal abdominal ring normal; typical in infants, children,
adults

TYPE II Indirect hernia; internal ring enlarged without impingement on the floor of the
inguinal canal; does not extend to the scrotum

TYPE IIIA Direct hernia; size not taken into account

Indirect hernia that has enlarged enough to encroach upon the posterior
TYPE IIIB inguinal canal; indirect sliding or scrotal hernia are usually placed this category
because they are commonly associated with extension to the direct space;
also includes pantaloon hernias

TYPE IIIC Femoral hernia

TYPE IV Recurrent hernia; modifies A-D are sometimes added, which corresponds to
indirect, direct, femoral, and mixed, respectively
© BRUNICARDI FC et al, Schwartz Principles of Surgery 11e
 INCARCERATED VS STRANGULATED
Incarcerated Strangulated
● Incarceration occurs ● compromise of intestinal contents:
when hernia contents fail strangulation of hernia contents is a
to reduce; surgical emergency.
● minimally symptomatic, ● Clinical signs : tenderness, fever,
chronically incarcerated leukocytosis, and hemodynamic
hernia may also be instability.bulge is usually warm,
treated nonoperatively. tender, and the overlying skin is often
● Taxis should be attempted erythematous or discolored.
for incarcerated hernias ● Taxis should not be performed when
without sequelae of strangulation is suspected, as
strangulation. reduction of potentially gangrenous
tissue into the abdomen may result
in an intra-abdominal catastrophe
 Herniorrhaphy & Hernioplasty
❏ Herniorrhaphy
● It involves a surgeon making a long incision directly over the
hernia then using surgical tools to open the cut enough to
access it.
● Tissues or a displaced organ are then returned to their
original location, and the hernia sac is removed.
● The surgeon stitches the sides of the muscle opening or
hole through which the hernia protruded. Once the wound
has been sterilized, it is stitched shut.
● Bassini repair, Shouldice repair and McVay repair
❏ Hernioplasty
● Instead of stitching the muscle opening shut, the surgeon covers it
with a flat, sterile mesh, usually made of flexible plastics, such as
polypropylene, or animal tissue.
● The surgeon makes small cuts around the hole in the shape of the
mesh and then stitches the patch into the healthy, intact
surrounding tissues.
● Damaged or weak tissues surrounding the hernia will use the mesh,
as a supportive, strengthening scaffold as they regrow.
● Hernioplasty is better-known as tension-free hernia repair.
● Lichtenstein repair and Plug and patch repair
MANAGEMENT
EMERGENT INGUINAL HERNIA REPAIR
SURGICAL TREATMENT OF INGUINAL HERNIA

Open Repair

Tissue Repair Prosthetic Repair

Lichtenstein
Bassini Repair
Tension-Free Repair

Shouldice Repair Plug and Patch

(Rutkow and Robbins)

McVay Repair
SURGICAL TREATMENT OF INGUINAL HERNIA
Tissue Repair

Bassini Repair McVay Repair

Conjoint tendon (Transversus Abdominis
and Internal Oblique) and the Inguinal
Ligament are tied together by interrupted
mattress sutures.
Conjoint tendon with Cooper’s and Lacunar
Ligament medially and with illiopubic tract and
inguinal ligament laterally are sutured
SURGICAL TREATMENT OF INGUINAL HERNIA
Tissue Repair
Shouldice Repair

1. Lower Flap to Deep Layer of Upper Flap (Medial to Lateral)

2. Upper Flap to Inguinal Ligament (Lateral to Medial)
3. Internal Oblique and Transversus Abdominis to Deep layer of Inguinal Ligament (Lateral to Medial)
4. Internal Oblique and Transversus Abdominis to Superficial layer Inguinal Ligament (Medial to Lateral)
SURGICAL TREATMENT OF INGUINAL HERNIA
Prosthetic Repair Plug and Patch
(Rutkow and Robbins)
Lichtenstein
Tension-Free Repair

A polypropylene cone is used

to seal the Deep ring and is
sutured to the Conjoint
Tendon.

Mesh is placed and sutured

over the posterior wall

Mesh is placed and sutured over the

posterior wall
LAPAROSCOPIC HERNIA REPAIR
● This procedure reinforce the abdominal via
posterior approach.
● It includes : transabdominal preperitoneal repair
Totally extraperitoneal repair
Intraperitoneal onlay mesh repair

● The indications are usually as same the open

approach repair .
● Operating room setup for laparoscopic Inguinal
hernia repair
TRANSABDOMINAL PREPERITONEAL
PROCEDURE (TAPP)
● This procedure is useful for bilateral hernia , large hernia defects , and scarring from
previous lower abdominal surgery .
● An incision made in the peritoneum at the medial umbilical ligament superior to the hernia
defect and it is carried to the anterior superior iliac spine .
● Direct hernia : the sac is inverted and fixed to cooper’s ligament to prevent development of
hematoma or seroma.
● Indirect hernia : the sac is grasped and elevated superiorly from the cord and the space
below is developed bluntly to allow for mesh placement .
TOTALLY EXTRAPERITONEAL
PROCEDURE (TEP)
● Access to preperitoneal space without intraperitoneal
infiltration which minimizes the risk of injury to intra-abdominal
organs and port site herniation .
● Also Indication for bilateral or for unilateral hernias .
INTRAPERITONEAL ONLAY MESH
PROCEDURE (IPOM)
● This procedure permits the posterior approach without preperitoneal
dissection .
● This procedure is done : where the anterior approach is unfeasible
Recurrent hernias that are refractory to other approaches
Where extensive preperitoneal scarring make TEP or TAPP challenging
● A mesh is directly placed over the defect and fixed in place with sutures or
spiral tracks .

● Disadvantages : lateral cutaneous nerve of the thigh and the

genitofemoral nerve are especially prone to injury
Intraperitoneal mesh migration which leads to postoperative morbidity ,
recurrence and reoperation .
Operation: Hernioplasty (L) Tension free hernia repair

● No signs of peritonitis or infected hernia

● Reinforcement with a synthetic mesh
● Incarcerated
THANK YOU!