PENDAHULUAN “Why do we talk about hernia ?

”
Approximately 75% of abdominal wall hernias occur in
the groin.

inguinal hernias are five times more common than

femoral hernias.

The most common subtype of groin hernia in

men and women is the indirect inguinal hernia

The incidence of inguinal hernias

in males peaks before the first
year of age and after age 40.
It is estimated that 5% of the population will develop
an abdominal wall hernia
More than 1 million abdominal hernia repairs are performed each year, with inguinal hernia
repairs constituting nearly 770,000 of these cases.
DEFINISI

Components of a hernia
Hernias are composed of a sac, the parts of which are
described as the neck, body and fundus (Fig. 40.1), and
the hernial contents. The sac consists of peritoneum
which protrudes through the abdominal wall defect
or ‘hernial orifice’, and envelopes the hernial contents.
The neck of the sac is situated at the defect. Hernias
with a narrow or rigid neck are more likely to obstruct
and strangulate (see below). The body is the widest part
of the hernial sac, and the fundus is the apex or furthest
extremity. Viscera most likely to enter a hernial sac are
those normally situated in the region of the defect and
those which are mobile, namely the omentum, small
intestine and colon. Some hernial contents have been
ascribed generic names.

ETIOLOGI

There is good evidence that hernia is a ‘collagen disease’ and

due to an inherited imbalance in the types of collagen.
Predisposing factors
A hernia occurs because of (a) weakness or defect in
the abdominal wall, and (b) positive intra-abdominal
pressure (IAP) (which is often raised) forces the viscus
into the defect.
Sites of weakness in the abdominal wall
Weaknesses in the abdominal wall may be:
_ Congenital (i.e. present at birth) – e.g. patent processus
vaginalis or canal of Nuck, posterolateral
or anterior parasternal diaphragmatic defect, patent
umbilical ring in children.
_ Where a normal anatomical structure passes through
the abdominal wall – e.g. oesophageal hiatus, umbilical
ligament in adults, obturator foramen, sciatic
foramen.
_ Acquired – e.g. surgical scar, site of an intestinal
stoma, muscle wasting with increasing age, fatty infiltration
of tissues because of obesity.

The etiology of indirect hernias is largely explainable in terms of the embryology of the groin
and of testicular descent. An indirect inguinal hernia is a congenital hernia, regardless of the
patient’s age. It occurs because of protrusion of an abdominal viscus into an open processus
vaginalis. The following terms are employed:
 If the processus contains viscera, the patient has an indirect inguinal hernia
 If peritoneal fluid fluxes between the space and the peritoneum, the patient has a
communicating hydrocele
 If fluid accumulates in the scrotum or spermatic cord without exchange of fluid with
the peritoneum, the patient has a noncommunicating scrotal hydrocele or a hydrocele
of the cord; in a girl, fluid accumulation in the processus results in a hydrocele of the
canal of Nuck

KLASIFIKASI
Indirect inguinal and femoral hernias occur more commonly
on the right side. This is attributed to a delay in atrophy of the
processus vaginalis after the normal slower descent of the right
testis to the scrotum during fetal development.
PATOFISIOLOGI

Pathophysiology
• Defect in the abdominal wall may be congenital (e.g.
umbilical hernia, femoral canal) or acquired (e.g. art incision)
and is lined with peritoneum (the sac)
• Raised intra-abdominal pressure further weakens the
defect, allowing some of the intra-abdominal contents
(e.g. omentum, small-bowel loop) to migrate through the
opening
• Entrapment of the contents in the sac leads to
incarceration (unable to reduce contents) and possibly
strangulation (blood supply to incarcerated contents is
compromised)
Inguinal hernias may be congenital or acquired. Most adult
inguinal hernias are considered acquired defects in the abdominal
wall although collagen studies have demonstrated a heritable
predisposition. A number of studies have attempted to delineate
the precise causes of inguinal hernia formation; however,
the best-characterized risk factor is weakness in the abdominal
wall musculature (Table 37-3). Congenital hernias, which
make up the majority of pediatric hernias, can be considered
an impedance of normal development, rather than an acquired
weakness.

During the normal course of development, the testes

descend from the intra-abdominal space into the scrotum in the
third trimester. Their descent is preceded by the gubernaculum
and a diverticulum of peritoneum, which protrudes through the
inguinal canal and becomes the processus vaginalis. Between
36 and 40 weeks of gestation, the processus vaginalis closes
and eliminates the peritoneal opening at the internal inguinal
ring. Failure of the peritoneum to close results in a patent processus
vaginalis (PPV), hence the high incidence of indirect
inguinal hernias in preterm babies.

The presence of a PPV likely predisposes a patient to the

development of an inguinal hernia. This likelihood depends on
the presence of other risk factors such as inherent tissue weakness,
family history, and strenuous activity.
Repeated physical exertion may increase intra-abdominal pressure; however, whether this
process occurs in combination with a PPV or through age-related weakness of abdominal
wall musculature is unknown.

The pinchcock action of the internal ring musculature during abdominal muscular straining
prohibits protrusion of the intestine into a patent processus. Muscle paralysis or injury can
disable the shutter effect. In addition, the transversus abdominis aponeurosis flattens
during tensing, thus reinforcing the inguinal floor.

A direct inguinal hernia usually occurs as a consequence of a defect or weakness in the

transversalis fascia area of the Hesselbach triangle. The triangle is defined inferiorly by the
inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined
tendon. [5]
An indirect inguinal hernia follows the tract through the inguinal canal. It results from a
persistent processus vaginalis. The inguinal canal begins in the intra-abdominal cavity at the
internal ring, approximately midway between the pubic symphysis and the anterior superior
iliac spine, and courses down along the inguinal ligament to the external ring, located
medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic
tubercle. The hernia contents then follow the tract of the testicle down into the scrotal sac.
MANIFESTASI KLINIS
Signs and symptoms
Hernias may be detected on routine physical examination, or patients with hernias may
present because of a complication associated with the hernia.
Characteristics of asymptomatic hernias are as follows:
 Swelling or fullness at the hernia site
 Aching sensation (radiates into the area of the hernia)
 No true pain or tenderness upon examination
 Enlarges with increasing intra-abdominal pressure and/or standing
Characteristics of incarcerated hernias are as follows:
 Painful enlargement of a previous hernia or defect
 Cannot be manipulated (either spontaneously or manually) through the fascial defect
 Nausea, vomiting, and symptoms of bowel obstruction (possible)
Characteristics of strangulated hernias are as follows:
 Patients have symptoms of an incarcerated hernia
 Systemic toxicity secondary to ischemic bowel is possible
 Strangulation is probable if pain and tenderness of an incarcerated hernia persist after
reduction
 Suspect an alternative diagnosis in patients who have a substantial amount of pain
without evidence of incarceration or strangulation
When attempting to identify a hernia, look for a swelling or mass in the area of the fascial
defect, as follows:
 For inguinal hernias, place a fingertip into the scrotal sac and advance up into the
inguinal canal
 If the hernia is elsewhere on the abdomen, attempt to define the borders of the fascial
defect
 If the hernia comes from superolateral to inferomedial and strikes the distal tip of the
finger, it most likely is an indirect hernia
 If the hernia strikes the pad of the finger from deep to superficial, it is more consistent
with a direct hernia
 A bulge felt below the inguinal ligament is consistent with a femoral hernia

DIAGNOSIS

History and physical examination remain the best means of diagnosing hernias. The review
of systems should carefully seek out associated conditions, such as ascites, constipation,
obstructive uropathy, chronic obstructive pulmonary disease, and cough. `

Important considerations of the patient’s history include

the duration and timing of symptoms. Hernias will often increase
in size and content over a protracted time. Much less commonly,
a patient will present with a history of acute inguinal herniation
following a strenuous activity. It is more likely that an asymptomatic
inguinal hernia became evident once the patient experienced
symptoms after an acute event. Questions should also be
directed to characterize whether the hernia is reducible. Patients
will often reduce the hernia by pushing the contents back into
the abdomen, thereby providing temporary relief. As the defect
size increases and more intra-abdominal contents fill the hernia
sac, the hernia may become harder to reduce.

History
In an emergency setting, a patient with a hernia may present because of a complication
associated with the hernia, or the hernia may be detected on routine physical examination.
In most instances, the diagnosis of hernia is made because a patient, parent, or provider has
observed a bulge in the inguinal region or scrotum (see the images below). This bulge is not
necessarily constant but may be intermittent; depending on the intra-abdominal pressure,
the herniating viscus may enter the space or remain outside it.

An asymptomatic hernia commonly has the following characteristics [27] :

 Swelling or fullness at the hernia site
 Aching sensation (radiating into the area of the hernia)
 No true pain or tenderness upon examination
 Enlargement with increasing intra-abdominal pressure or standing
An incarcerated hernia may be associated with the following:
 Painful enlargement of a previous hernia or defect
 Inability to manipulate the hernia (either spontaneously or manually) through the
fascial defect
 Nausea, vomiting, and symptoms of bowel obstruction (possible)
A strangulated hernia may be associated with the following:
 Symptoms of an incarcerated hernia, combined with a toxic appearance
 Possibility of systemic toxicity secondary to ischemic bowel
 Probability of strangulation if pain and tenderness of an incarcerated hernia persist
after reduction

Physical Examination
Physical examination is essential to the diagnosis of inguinal
hernia. Asymptomatic hernias are frequently diagnosed incidentally
on physical examination or may be brought to the patient’s
attention as an abnormal bulge. Ideally, the patient should be
examined in a standing position to increase intra-abdominal
pressure, with the groin and scrotum fully exposed. Inspection is
performed first, with the goal of identifying an abnormal bulge
along the groin or within the scrotum. If an obvious bulge is not
detected, palpation is performed to confirm the presence of the
hernia.
Palpation is performed by advancing the index finger
through the scrotum toward the external inguinal ring
(Fig. 37-11). This allows the inguinal canal to be explored.
The patient is then asked to perform Valsalva’s maneuver to
protrude the hernia contents. These maneuvers will reveal an
abnormal bulge and allow the clinician to determine whether the
hernia is reducible or not. Examination of the contralateral side
affords the clinician the opportunity to compare the presence
and extent of herniation between sides. This is especially useful
in the case of a small hernia. In addition to inguinal hernia, a
number of other diagnoses may be considered in the differential
of a groin bulge (Table 37-5).

Physical Examination
In general, the physical examination should be performed with the patient in both the
supine and standing positions, with and without the Valsalva maneuver. The examiner
should attempt to identify the hernia sac, as well as the fascial defect through which it is
protruding. This allows proper direction of pressure for reduction of hernia contents. The
examiner should also identify evidence of obstruction and strangulation.
The first step in attempting to identify a hernia is to look for a swelling or mass in the area of
the fascial defect. A fingertip is placed into the scrotal sac and advanced upward into the
inguinal canal. If the hernia is elsewhere on the abdomen, an attempt should be made to
define the borders of the fascial defect.
If the hernia comes from superolateral to inferomedial and strikes the distal tip of the
finger, it most likely is an indirect hernia. If the hernia strikes the pad of the finger from
deep to superficial, it is more likely to be a direct hernia. A bulge felt below the inguinal
ligament is consistent with a femoral hernia.

PEMERIKSAAN PENUNJANG

Laboratory studies are not specific for hernia but may be useful for general medical
evaluation. Imaging studies are not required in the normal workup of a hernia

Laboratory studies include the following:

 Stain or culture of nodal tissue
 Complete blood count (CBC)
 Electrolytes, blood urea nitrogen (BUN), and creatinine
 Urinalysis
 Lactate

Laboratory Studies
Laboratory studies that may be helpful include the following:
 Stain or culture of nodal tissue - This can help diagnose atypical tuberculous adenitis
 Complete blood count (CBC) - Results are nonspecific, but leukocytosis with left shift
may occur with strangulation
 Electrolyte, blood urea nitrogen (BUN), and creatinine levels - It is advisable to assess
the hydration status of the patient with nausea and vomiting; these tests are rarely
needed for patients with hernia except as part of a preoperative workup
 Urinalysis - This can help narrow the differential diagnosis of genitourinary causes of
groin pain in the setting of associated hernias
 Lactate levels - Elevation may reflect hypoperfusion; a normal level does not
necessarily rule out strangulation
Imaging studies are not required in the normal workup of a hernia. However, they may be
useful in certain scenarios, as follows:
 Ultrasonography can be used in differentiating masses in the groin or abdominal wall
or in differentiating testicular sources of swelling
 If an incarcerated or strangulated hernia is suspected, upright chest films or flat and
upright abdominal films may be obtained
 Computed tomography (CT) or ultrasonography may be necessary if a good
examination cannot be obtained, because of the patient’s body habitus, or in order to
diagnose a spigelian or obturator hernia

TATALAKSANA

Reducing raised intra-abdominal pressure

Causes of increased IAP should be corrected. Stopping
smoking, investigation and treatment of prostatism and
constipation, weight reduction, and effective management
of ascites should be attempted where indicated.
Changes in occupation and physical exercise also may
have to be considered.
Operation
Operation is indicated for all other patients because of
symptoms and the risk of complications. Surgery aims
to (i) reduce the hernial contents, (ii) excise the sac
(herniotomy) in most cases, and (iii) repair and close
the defect, either by approximation of adjacent tissues
to restore the normal anatomy (herniorrhaphy), or by
insertion of additional material (hernioplasty).
the rates of incarceration
and strangulation are low in the asymptomatic population.
As a result, nonoperative management is an appropriate
consideration in minimally symptomatic patients.

A 2012 systematic review

found that 72% of asymptomatic inguinal hernia patients
developed symptoms (mostly pain) and had surgical repair
within 7.5 years of diagnosis.26
Nonoperative inguinal hernia treatment targets pain, pressure,
and protrusion of abdominal contents in the symptomatic
patient population.
The indication for emergent inguinal hernia repair is
impending compromise of intestinal contents. As such, strangulation
of hernia contents is a surgical emergency. Clinical
signs that indicate strangulation include fever, leukocytosis, and
hemodynamic instability. Preoperatively,
the patient should receive fluid resuscitation, nasogastric
decompression, and prophylactic intravenous antibiotics.
Inguinal hernia repairs are of the following three general types:
 Herniotomy (removal of the hernial sac only)
 Herniorrhaphy (herniotomy plus repair of the posterior wall of the inguinal canal)
 Hernioplasty (herniotomy plus reinforcement of the posterior wall of the inguinal
canal with a synthetic mesh)

Management
Ideally, all inguinal herniae should be repaired by elective
surgical operation. Surgery is usually performed under
general anaesthesia but local or regional anaesthesia is also
used. Surgical repair classically consists of two elements:
excision of the hernial sac (herniotomy) and repair or buttressing
of the weakness in the posterior inguinal canal
(herniorrhaphy).

In infants (always indirect herniae), the

internal and external rings are superimposed and only
a herniotomy is required for effective treatment.
Management
Nonoperative therapeutic measures include the following:
 Trusses
 Binders or corsets
 Hernia reduction
 Topical therapy
 Compression dressings
Surgical options depend on type and location of hernia. Basic types of inguinal hernia repair
include the following:
 Bassini repair
 Shouldice repair
 Cooper repair
 Simple inguinal hernia repair in children

Based on a comprehensive understanding of inguinal anatomy,

Bassini (1844–1924) transformed inguinal hernia repair
into a successful venture with minimal morbidity.
Modifications of the Bassini repair were manifest in the McVay and Shouldice repairs. All
three of these techniques, as well as modern variations such as the Desarda operation, are
currently practiced

In the early 1980s, Lichtenstein popularized the tensionfree

repair, supplanting tissue-based repairs with the widespread
acceptance of prosthetic materials for inguinal floor reconstruction.
This technique was superior to previous tissue-based repair
in that mesh could restore the strength of the transversalis fascia,
thereby avoiding tension in the defect closure.

Tissue-based herniorrhaphy is a suitable alternative

when prosthetic materials cannot be used safely.

Indications
for tissue repairs include operative field contamination,
emergency surgery, and when the viability of hernia contents is uncertain.
The mesh is a 7 × 15 cm rectangle with a rounded medial
edge, and it must be large enough to extend 2 to 3 cm superior
to Hesselbach’s triangle. The lateral portion of the mesh is split
such that the superior tail comprises two thirds of its width, and
the inferior tail comprises the remaining one third. The medial
edge of the mesh is affixed to the anterior rectus sheath such
that it overlaps the pubic tubercle by 1.5 to 2 cm. This refinement
to the original Lichtenstein technique minimizes medial
recurrence
Most surgeons would agree that
the laparoscopic approach to bilateral or recurrent inguinal
hernias is superior to the open approach
International Endohernia Society
(IEHS) guidelines offer a Grade A recommendation that TEP
and TAPP are preferred alternatives to Lichtenstein repair for
recurrent hernias after open anterior repair
Synthetic Mesh Material. Polypropylene and polyester are
the most common synthetic prosthetic materials used in hernia
repair. These materials are permanent and hydrophobic,
and they promote a local inflammatory response that results in
cellular infiltration and scarring with slight contraction in size.
Fixation Technique. Independent of prosthesis material, the
method of its fixation remains disputed. Suturing, stapling, and
tacking prostheses entail tissue perforation, which may cause
inflammation, neurovascular injury, and chronic pain development.
Conversely, improper prosthesis fixation may result
in mesh migration, repair failure, meshoma pain, and hernia
recurrence. Mesh may be fixed with fibrin-derived glue, and
self-gripping mesh has been developed to minimize trauma
to surrounding tissues and to reduce the risk for entrapment
neuropathy. For hernias repaired via a strictly preperitoneal
approach, prosthesis fixation may not be necessary at all.

Management after inguinal hernia repair

Patients require analgesia for the first few days. They
should avoid straining and lifting for about 4 weeks
after surgery, and avoid very heavy physical work for
about 6–8 weeks. The average length of stay off work
is approximately 2–4 weeks after open repair and 1–2
weeks after laparoscopic repair.
KOMPLIKASI
COMPLICATIONS
As with other clean operations, the most common complications
of inguinal hernia repair include bleeding, seroma, wound infection,
urinary retention, ileus, and injury to adjacent structures
(Table 37-6). Complications specific to herniorrhaphy and hernioplasty
include hernia recurrence, chronic inguinal and pubic
pain, and injury to the spermatic cord or testis. The incidence,
prevention, and treatment of these complications are discussed
in the ensuing section.

Complications of surgery
Haematoma (wound or scrotal)
Acute urinary retention
Wound infection
Chronic pain
Testicular pain and swelling leading to testicular atrophy
Hernia recurrence (about 5%)

Complications of hernia repair include the following.

• Haematoma: may be in the wound or scrotum.
• Acute urinary retention: this frequently follows bilateral
repair.
• Wound infection: this should be rare as hernia repair
is a clean operation, but in practice infection occurs in
5-8%.
• Chronic pain: trapping of the ilioinguinal nerve.
• Testicular pain and swelling followed by atrophy usually
means that the repair is too tight and the testicular
artery is compromised. Testicular atrophy will occur
when the swelling subsides.
• Recurrence of hernia occurs in about 5% of patients
but the rate is higher when surgical technique is poor.
PROGNOSIS
Prognosis
The prognosis depends on the type and size of hernia, as well as on the ability to reduce risk
factors associated with the development of hernias. As a rule, the prognosis is good with
timely diagnosis and repair. Morbidity typically is secondary either to missing the diagnosis
of the hernia or to complications associated with management of the disease.
A hernia can lead to an incarcerated and often obstructed bowel, or even to a strangulated
bowel with a compromised blood supply, which, if missed, can result in bowel perforation
and peritonitis. Reduction of the strangulated bowel leads to persistent ischemia or necrosis
with no clinical improvement. Surgical intervention is required to prevent further
complications (eg, perforation and sepsis.
In general, patients with uncomplicated inguinal and abdominal wall hernias do well.
However, mortality is 10% for those who have hernias with associated strangulation. It
should be kept in mind that surgery to repair the hernia or manage its complications may
leave the patient at risk for infection or intra-abdominal adhesions. In addition, hernias can
reappear in the same location, even after surgical repair.

Rekurensi
Recurrence
rates should be less than 2%. About 50% of
recurrences appear within 5 years after the initial
repair, and approximately 50% of recurrences are
indirect hernias.

Most recurrences develop within 5 years after the operation. They are often associated with
incarcerated hernias, concurrent orchiopexy, sliding hernias (in girls), or emergency
operations. The recurrence rate is higher in children younger than 1 year and in the elderly.
It is also higher in patients with ongoing increased intra-abdominal pressure, growth failure
and malnutrition, prematurity, seizure disorder, or chronic respiratory problems.
Technical factors that increase the likelihood of recurrence include the following:
 Unrecognized tear in the sac
 Failure to repair a large internal inguinal ring
 Damage to the floor of the inguinal canal
 Infection or other postoperative complications
In some cases, a direct hernia may result from vigorous dissection; in others, it may be a
simultaneous hernia that was initially unrecognized.