HERNIA

INGUINALIS
Oleh : dr. Kalvin Raveli
Pembimbing : dr. Jimmy Vareta, Sp.B
 Why do we talk
about hernia?
5% of the population will develop an abdominal wall
hernia

75% of abdominal wall hernias occur in the groin.

Inguinal hernias are five times more common than

femoral hernias.

>1 million abdominal hernia repairs are performed

each year, 770,000 cases → Inguinal Hernia

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.
ANATOMI
ANATOMI
 Definisi
Hernia merupakan protrusi atau
penonjolan isi suatu rongga melalui
defek atau bagian lemah dari dinding
rongga yang bersangkutan.

Hernia terdiri atas cincin, kantong, dan

isi dari hernia tersebut
ETIOLOGI
 KLASIFIKASI
Hernia inguinalis dapat dibedakan
menjadi direk dan indirek
Hernia Inguinalis Direk, disebut juga
hernia inguinalis medialis, isi hernia
menonjol langsung melalui Trigonum Types of hernia by complexity
Hesselbach .
Hernia Inguinalis Indirek atau hernia
inguinalis lateralis, isi hernia keluar
dari rongga peritoneum melalui anulus
inguinalis internus. Dari anulus
inguinalis internus, hernia masuk ke
kanalis inguinalis, dan jika berlanjut
dapat keluar ke anulus inguinalis
eksternus.
What are the
“
borders of
Hesselbach’s
triangle?
“
 PATOFISIOLOGI
Defect in the abdominal wall may be congenital
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.
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.
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.
 PATOFISIOLOGI
A direct inguinal hernia usually occurs as a consequence of a defect or
weakness in the transversalis fascia area of the Hesselbach triangle.

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.

Entrapment of the contents in the sac leads to incarceration (unable to

reduce contents) and possibly strangulation (blood supply to
incarcerated contents is compromised)
 ANAMNESIS

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.
Patient will present with a history of acute inguinal herniation following
a strenuous activity.
Questions should also be directed to characterize whether the hernia is
reducible.
 ANAMNESIS
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.
In general, the physical examination should be performed with the
patient in both the supine and standing positions, with and without the
Valsalva maneuver.
 PEMERIKSAAN FISIK
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
 PEMERIKSAAN FISIK
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)
 PEMERIKSAAN FISIK

Characteristics of strangulated Laboratory studies include

hernias are as follows: the following:
• Patients have symptoms of an
incarcerated hernia Stain or culture of nodal tissue
• Systemic toxicity secondary to
ischemic bowel is possible Complete blood count (CBC)
• Strangulation is probable if pain
and tenderness of an incarcerated Electrolytes, blood urea nitrogen
hernia persist after reduction (BUN), and creatinine
• Suspect an alternative diagnosis in
Urinalysis
patients who have a substantial
amount of pain without evidence of
incarceration or strangulation. Lactate
PEMERIKSAAN
PENUNJANG
DIAGNOSIS
BANDING

Reducing raised intra-abdominal
pressure
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.
TATA LAKSANA
Surgery aims to:
• reduce the hernial contents
• excise the sac (herniotomy) in most cases
• repair and close the defect, either by approximation of
adjacent tissues to restore the normal anatomy
(herniorrhaphy), or by insertion of additional material
(hernioplasty).
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)
TATA LAKSANA
 TATA
LAKSANA
Polypropylene mesh in totally
extraperitonal (TEP)inguinal hernia Polytetrafluoroethylene (PTFE) mesh in
repair. paraumbilical hernia repair.
 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.
Complications of surgery Prognosis
• Haematoma (wound or • Prognosis is good with timely
scrotal) diagnosis and repair.
• Acute urinary retention • Morbidity typically is
secondary either to missing
• Wound infection the diagnosis of the hernia
• Chronic pain or to complications
• Testicular pain and associated with
swelling leading to management of the disease.
testicular atrophy • Mortality is 10% for those
• Hernia recurrence (about who have hernias with
5%) associated strangulation.
 Identitas Pasien

• Nama : Tn. Suparto

• Umur : 75 tahun
• Jenis Kelamin : Pria
• Pekerjaan: Buruh Bangunan
Spesialis Angkat Batu
• Nomor MR : 00.13.11.55
• Tanggal Masuk : 17 April 2018
• Alamat : Palembang
 Anamnesis

• Keluhan Utama : Benjolan terasa nyeri di lipat paha kanan

• Telaah : Hal ini dialami os sejak 1 tahun lalu, benjolan semakin
lama semakin membesar, awalnya bersifat hilang timbul, biasanya
timbul pada pagi hari dan hilang saat malam hendak tidur. Namun,
sejak 2 hari yang lalu benjolan tidak dapat dimasukkan kembali.
Nyeri (+), Demam (-), Riw. Pekerjaan angkat berat (+), os adalah
buruh bangunan yang sering angkat batu sehari 30 karung seberat
20 kg sudah puluhan tahun, mual dan muntah (-), tidak bisa BAB
sejak 2 hari yang lalu, BAK lancar.
 ANAMNESIS

• Riwayat Penyakit Terdahulu : (-)

• Riwayat Alergi : (-)
• Riwayat Penggunaan Obat : (-)
• Riwayat Operasi : (-)
 Status Presens

• Kesadaran : CM
• Tekanan Darah : 120/70 mmHg
• Denyut Nadi : 80 X/menit
• Laju Nafas : 20 X/menit
• Temperatur : 36,8 ºC
• VAS :4
 Pemeriksaan Fisik

• Kepala : Mata: Conj. Palpebra Inferior: Anemis (-/-),

Refleks cahaya (+/+), Pupil isokor (+/+), Ø pupil
(3cm/3cm)
• T/H/T : Dalam batas normal
• Leher : TVJ: R-2cmH20
• Thorax: Inspeksi : Simetris Fusiformis
Palpasi : SF kiri = kanan
Perkusi : Sonor pada kedua lapangan paru
Auskultasi : SP : vesikuler (+/+) ST : Rh (-/-) Wh (-/-)
 Pemeriksaan Fisik

• Abdomen:
Inspeksi : Tampak benjolan pada lipat paha kanan (+)
Palpasi : Teraba massa pada lipat paha kanan (+) dengan
konsistensi lunak, permukaan licin, immobile, batas
tegas, nyeri (+), ukuran 10x5 cm, massa irreponible.
Perkusi : Timpani (+)
Auskultasi : Peristaltik (+)
• Genitalia : Dalam Batas Normal
• Ekstremitas : Superior: edema (-/-), dalam batas normal
Inferior : edema (-/-), dalam batas normal
Pemeriksaan Fisik
 Pemeriksaan Penunjang

Pemeriksaan Hasil Rujukan

Darah Lengkap
Hb 14 13-18
Ht 40.9 40-54
Leukosit 6.3 4-11
Trombosit 203 150 – 400
Koagulasi
BT 2 1-5
CT 10 5-15
Kimia Darah
Glukosa Sewaktu 222 65-140
Imunoserologi
HbsAg Non Reaktif
Pemeriksaan Penunjang
 DIAGNOSIS • Hernia Inguinalis Dextra Inkarserata

• Pemasangan NGT
• Pemasangan Kateter
TATALAKSANA • IVFD Ringer Lactate 20 tpm
• Inj. Ketorolac 1 amp
• Inj. Ranitidine 1 amp

• Cek DR, CT, BT, GDS, HbSAg, ECG, CXR,Ko Sp.An, Sp.PD
RENCANA
TINDAKAN • Pro Laparotomi Eksplorasi + Hernioraphy tgl 17/4 pk
21.00
 Follow Up

17/04/2018
S Nyeri pada benjolan di lipat paha kanan sejak 2 hari yll tidak hilang
O KU: Baik, CM, Nyeri (+) TD: 120/80 mmHg HR: 80x/i RR: 20x/i, T:36.8 C
Massa Hernia (+) Irreponible
A Hernia Inguinalis Dextra Inkarserata
P - Pro Laparotomi Eksplorasi + Hernioraphy
- Puasa
- Konsul Sp.An dan Sp.PD untuk toleransi operasi
- Inj. Cefotaxim 1 g Pre OP
 Jawaban Konsul Sp.An

17/04/2018
S Nyeri pada benjolan di lipat paha kanan sejak 2 hari yll tidak hilang
O KU: Baik, CM, Nyeri (+) TD: 120/80 mmHg HR: 80x/i RR: 20x/i, T:36.8 C
Alergi (-) Asma (-), Riw. Operasi (-), Cor/Pulmo: dbn
A Hernia Inguinalis Dextra Inkarserata
P - Pro Laparotomi Eksplorasi + Hernioraphy
- NPO
 Jawaban Konsul Sp.PD

17/04/2018
S Nyeri pada benjolan di lipat paha kanan sejak 2 hari yll tidak hilang
O KU: Baik, CM, Nyeri (+) TD: 120/80 mmHg HR: 80x/i RR: 20x/i, T:36.8 C
Massa Hernia (+) Irreponible, Riw. DM (+)
A Hernia Inguinalis Dextra Inkarserata + DM tipe 2
P - Rawat Bersama
- Diet DM 1700 kkal rendah lemak dan rendah purin
- Inj. Apidra SC 4 Unit
- Periksa GDS Post Op
- Periksa GDS pagi dan HbA1C tgl 18/4
 Follow Up

17/04/2018
S Keluhan nyeri luka operasi (+)
O Selesai dilakukan Laparotomi Eksplorasi + Adhesiolysis + Hernioraphy-Mesh +
Omentektomi dalam spinal anestesia
A Post laparotomi ai Ileus Obstruktif ec Hernia Inguinalis Dextra Inkarserata
P - Diet MB
- IVFD (Tramadol 1 Amp + Ketorolac 1 Amp + RL 1 kolf ) 20 tpm
- Inj. Cefotaxim 2 x 1 g
- Inj. Ranitidin 3 x 1 Amp
- Inj. As. Traneksamat 2 x 500 mg
 Follow Up

18/04/2018
S Keluhan nyeri luka operasi (+)

O KU: Baik, CM, Nyeri (+) TD: 120/80 mmHg HR: 80x/i RR: 20x/i, T:36.8 C

A Post laparotomi ai Ileus Obstruktif ec Hernia Inguinalis Dextra Inkarserata + DM

P - Metformin PO 2 x 500 mg p.c.
TERIMA KASIH