Pembimbing: dr.H.

Asep Hermana,SpB FINACS

Leny Anjani

Hernia is a protrusion of a viscus through an abnormal opening in the wall of a cavity in which it is a contained

External hernia : The sac protrudes completely through the abdominal wall. Examples: Inguinal (indirect and direct), Femoral umbilical, and epigestric. Intraparietal hernia: The sac is contained with in the abdominal wall. Example: Spigelian hernia. Internal hernia: The sac is within the visceral cavity. Example: Diaphragmatic hernia (congenital or acquired) and the small intestine hemiahrg in the paraduodenal pouch.

Reducible hernia: The protruding viscus can be returned to the abdomen. Incarcerated (irreducible) hernia: The protruding viscus cannot be returned to the abdomen. Strangulated hernia: The vascularity of the viscus is compromised surgical emergency

Incidence of inguinal hernias in males has a bimodal distribution with peaks before 1 year of age and then again after age 40. When subdivided into age groups, those aged 25 to 34 years had a lifetime prevalence rate of 15% whereas those aged 75 years and over had a rate of 47%

Table 37-2 Presumed Causes of Groin Herniation

Coughing Chronic obstructive pulmonary disease Obesity Straining Constipation Prostatism Pregnancy Birthweight <1500 g Family history of a hernia Valsalva's maneuvers Ascites Upright position Congenital connective tissue disorders Defective collagen synthesis Previous right lower quadrant incision Arterial aneurysms Cigarette smoking Heavy lifting

Table 37-3 Connective Tissue Disorders Associated with Groin Herniation

Osteogenesis imperfecta Cutis laxa (congenital elastolysis) Ehlers-Danlos syndrome Hurler-Hunter syndrome Marfan syndrome Congenital hip dislocation in children Polycystic kidney disease Alpha1-antitrypsin deficiency Williams syndrome Androgen insensitivity syndrome Robinow's syndrome Serpentine fibula syndrome Alport's syndrome Tel Hashomer camptodactyly syndrome Leriche's syndrome Testicular feminization syndrome Rokitansky-Mayer-Kster syndrome Goldenhar's syndrome Morris syndrome Gerhardt's syndrome Menkes' syndrome Kawasaki disease Pfannenstiel syndrome Beckwith-Wiedemann syndrome Rubinstein-Taybi syndrome Alopecia-photophobia syndrome

Table 37-4 Gilbert Classification System

Type 1 Type 2 Type 3 Type 4

Small, indirect Medium, indirect Large, indirect Entire floor, direct

Type 5 Type 6

Diverticular, direct Combined (pantaloon)

Type 7

Femoral

Table 37-5 Nyhus Classification System

Type I

Indirect hernia; internal abdominal ring normal; typically in infants, children, small adults Indirect hernia; internal ring enlarged without impingement on the floor of the inguinal canal; does not extend to the scrotum

Type II

Type IIIA Type IIIB

Direct hernia; size is not taken into account Indirect hernia that has enlarged enough to encroach upon the posterior inguinal wall; indirect sliding or scrotal hernias are usually placed in this category because they are commonly associated with extension to the direct space; also includes pantaloon hernias Femoral hernia Recurrent hernia; modifiers AD are sometimes added, which correspond to indirect, direct, femoral, and mixed, respectively

Type IIIC Type IV

Anamnesa Patients who present with a symptomatic groin hernia will frequently present with groin pain. Regardless of size, an inguinal hernia may impart pressure onto nerves in the proximity, leading to a range of symptoms. These include generalized pressure, local sharp pains, and referred pain. Pressure or heaviness in the groin is a common complaint, especially at the conclusion of the day, following prolonged activity. Sharp pains tend to indicate an impinged nerve and may not be related to the extent of physical activity performed by the patient. Lastly, neurogenic pains may be referred to the scrotum, testicle, or inner thigh. A change in bowel habits or urinary symptoms may indicate a sliding hernia consisting of intestinal contents or involvement of the bladder within the hernia sac.

Palpation is performed by placing the index finger into the scrotum, aiming it toward the external inguinal ring. Certain techniques of the physical examination have classically been used to differentiate between direct and indirect hernias. The inguinal occlusion test involves placement of a finger over the internal inguinal ring and the patient is instructed to cough. If the cough impulse is controlled, then the hernia is indirect. If the cough impulse is still manifest, the hernia is direct. As well, with a finger in the inguinal canal, the cough impulse can be used to determine the type of hernia. If the cough impulse is felt on the fingertip, the hernia is indirect

The most common radiologic modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI)

Table 37-6 Differential Diagnosis of Groin Hernia

Malignancy Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumor Primary testicular Varicocele Epididymitis Testicular torsion Hydrocele Ectopic testicle Undescended testicle Femoral artery aneurysm or pseudoaneurysm Lymph node Sebaceous cyst Hidradenitis Cyst of the canal of Nuck (female) Saphenous varix Psoas abscess Hematoma Ascites

The treatment of inguinal hernias can be subdivided according to approach (open vs. laparoscopic).

Table 37-8 Complications of Groin Hernia Repairs

Recurrence Chronic groin pain Nociceptive Somatic Visceral Neuropathic Iliohypogastric Ilioinguinal Genitofemoral Lateral cutaneous Femoral Cord and testicular Hematoma Ischemic orchitis Testicular atrophy Dysejaculation Division of vas deferens Hydrocele Testicular descent Bladder injury Wound infection Seroma Hematoma Wound Scrotal Retroperitoneal Osteitis pubis Prosthetic complications Contraction Erosion Infection

Femoral hernias constitute up to 2% to 4% of all groin hernias; 70% occur in women. Approximately 25% of femoral hernias become incarcerated or strangulated, and a similar number are missed or diagnosed late.

Symptoms Patients may complain of an intermittent groin bulge or a groin mass that may be tender. Because femoral hernias have a high incidence of incarceration, small-bowel obstruction may be the presenting feature in some patients. Elderly patients, in whom femoral hernias occur most commonly, may not complain of groin pain, even in the setting of incarceration.

Physical examination. The characteristic finding is a small, rounded bulge that appears in the upper thigh just below the inguinal ligament. An incarcerated femoral hernia usually presents as a firm, tender mass. The differential diagnosis is the same as for inguinal hernia.

Radiographic evaluation. Radiographic studies are rarely indicated. Occasionally, a femoral hernia is found on a CT scan or gastrointestinal contrast study performed to evaluate a small-bowel obstruction

The surgical approach can be inguinal, preperitoneal, or femoral.

Of patients who present with acute intestinal obstruction, fewer than 5% have an internal hernia. When internal hernias are complicated by intestinal volvulus, there is an 80% incidence of strangulation or gangrene.

Internal hernias occur within the abdominal cavity owing to congenital or acquired causes. Congenital causes include abnormal intestinal rotation (paraduodenal hernias) and openings in the ileocecal mesentery (transmesenteric hernias). Other, less frequent types are pericecal hernias, hernias through the sigmoid mesocolon, and hernias through defects in the transverse mesocolon, gastrocolic ligament, gastrohepatic ligament, or greater omentum.

usually are of intestinal obstruction without evidence of an external hernia. When there is intestinal obstruction or intestinal strangulation, the diagnosis is based on clinical rather than on laboratory findings.

Plain abdominal films may show small-bowel obstruction. An abdominal CT scan can sometimes establish the diagnosis of an internal hernia preoperatively. Contrast studies may also sometimes be useful.