Clinical Science Session

Inguinal Hernia
DI S USUN OL E H : PRESEPTOR :
SA L SA HA N I SA A N WA R DR. LIZA NURSANTY, SP.B, M.KES., FINACS
SMF ILMU BEDAH
RS AL-ISLAM BANDUNG
2018
ABDOMINAL WALL
Skin
Subcutaneous fat
Scarpa’s fascia
External oblique muscle
Internal oblique muscle
Transversus abdominis
Transveralis fascia
Preperitoneal fat
Peritoneum
ANATOMI INGUINAL REGION
•Inguinal region disebut juga groin.
•The inguinal canal starts at the internal
inguinal ring and ends at the superficial ring,
containing the spermatic cord in men and
the round ligament in women.
•The integrity of the abdominal wall depends
on the orientation of the inguinal canal, the
transversalis fascia, and the sphincter-like
function of the internal ring
Boundaries
Anterior
◦ external oblique aponeurosis

Lateral
◦ Internal oblique muscle

Posterior
◦ fusion of the transversalis fascia and transversus abdominus muscle,

Superior
◦ arch formed by the fibers of the internal oblique muscle.

Inferior
◦ inguinal ligament
INGUINAL CANAL
4-6 cm long
Anteroinferior of pelvic basin
Cone-shaped
Base
◦ superolateral margin
HESSELBACH’S TRIANGLE
Medial aspect of Rectus abdominis muscle
Lateral: Inferior epigastric vessels
Base: Inguinal ligament
Definition
Inguinal hernia is a condition in which intra-abdominal fat or part of the small intestine, also
called the small bowel, bulges through a weak area in the lower abdominal muscles jolan isi
perut/organ perut melalui inguinal kanal.
Hernia’s Structures
•Consist of sac, ring, covering, dan content.
Epidemiologi:
Hernia inguinal
Approximately 75% of abdominal wall hernias occur in the groin.
The lifetime risk of inguinal hernia is 27% in men and 3% in women.
Etiologi:
Hernia inguinal
Penyebab tidak secara penuh dimengerti, namun dipercaya terjadi akibat multifaktorial.
Studi prefalensi  diakibatkan karena adanya kelainan jaringan ikat kongenital pada anak-anak
dengan kongenital dislokasi panggul.
Aktifitas fisik yang berlebih
Etiologi:
•Coughing. •Ascites.
•Chronic obstructive pulmonary disease. •Upright position.
•Obesity. •Congenital connective tissue disorders.
•Straining (constipasi, prostatism). •Defective collagen synthesis.
•Pregnancy. •Previous right lower quadrant incision.
•Birthweight < 1500g •Arterial aneurysms.
•Family history of a hernia. •Cigarette smoking.
•Valsava maneuvers. •Heavy listing.
•Ascites. •Physical excertion.
•Upright position.
Clinical manifestation
•a small bulge in one or both sides of the groin that may increase in size and disappear when
lying down; in males, it can present as a swollen or enlarged scrotum
•discomfort or sharp pain—especially when straining, lifting, or exercising— that improves when
resting
•a feeling of weakness or pressure in the groin
•a burning, gurgling, or aching feeling at the bulge
Classification
Hernia Types
Direct
•Direct inguinal hernias are caused by connective tissue degeneration of the abdominal muscles,
which causes weakening of the muscles during the adult years.

•Dua faktor utama dalam perkembangan direct inguinal hernia:

1. Peningkatan tekanan intraabdominal yang ditandai dengan induksi-induksi yang meningkatkan
hernia.
2. Kelemahan dari dinding inguinal posterior.
Indirect
•Indirect inguinal hernias are congenital hernias and are much more common in males than
females
•In a male fetus, the spermatic cord and both testicles—starting from an intra-abdominal
location—normally descend through the inguinal canal into the scrotum, the sac that holds the
testicles  Sometimes the entrance of the inguinal canal at the inguinal ring does not close as it
should just after birth  leaving a weakness in the abdominal wall  Fat or part of the small
intestine slides through the weakness into the inguinal canal  causing a hernia
Hernia Direct and Indirect
Indirect Direct
Patient’s age Any age but ussualy Older
young
Cause Maybe congenital Acquired
Bilateral 20% 50%
Protusion on coughing Oblique Straight
Appearance on standing Does not reach full size Reach full size
immediately immediately
Reduction on lying down May not reduce Reduce immediately
immediately
Descent into scrotum Common Rare
Occlution of internal ring Controls Does not control
Neck of sac Narrow Wide
Strangulation Not uncommon Unusual
Relation to inferior epigastric vessels Lateral Medial
Nyhus Classification
Classification by severity:
◦ Hernia Reponible
◦ The protruding mass can be placed back into the abdominal cavity
◦ Hernia Irreponible
◦ The protruding mass cannot be placed back into the abdominal cavity
◦ Hernia Incarcerated
◦ An irreducible hernia in which he intestinal flow is completely obctructed
◦ Hernia Strangulated
◦ An irreducible hernia in which the blood an intestinal flow are completely obstructed; develops when
the loop of intestine in the sac become twisted or swollen and a constriction is produced at the neck
of the sac
Diagnosis - Anamnesis
Groin pain
Extrainguinal symptoms
◦ Change in bowel habits
◦ Urinary symptoms

Pressure on nerves
◦ Generalized pressure
◦ Local sharp pains
◦ Referred pain
◦ Scrotum, testicle or inner thigh

Duration
Progressiveness
Diagnosis – Physical Examination
Diagnosis - Imaging
•USG
•CT scan
•MRI
Management
•Non Operative
•Nonoperative inguinal hernia treatment targets pain, pressure, and protrusion of abdominal
contents in the symptomatic patient population

•Operative
•Surgical repair is the definitive treatment of inguinal hernias
Hernioraphy Technique
Basini
•The Bassini repair was an historic
advancement in operative technique. Its
current use is limited, as modern techniques
reduce recurrence.
•The original repair includes dissection of the
spermatic cord, dissection of the hernia sac
with high ligation, and extensive
reconstruction of the floor of the inguinal
canal
 Shouldice
•The Shouldice repair recapitulates
principles of the Bassini repair, and its
distribution of tension over several
tissue layers results in lower recurrence
rates
 McVay repair
•The McVay repair addresses both inguinal and femoral ring defects. Once the spermatic cord has
been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space.
 Prosthetic repair (Lichtenstein Tension-
free repair)
•The Lichtenstein technique expands the
domain of the inguinal canal by reinforcing
the inguinal floor with a prosthetic mesh,
thereby minimizing tension in the repair
Recurrence
•Around 1% for Shouldice repair
•Most recurrences are of the same type as the original hernia

•Recurrence Factors
• Patient
• Technical
• Tissue
Recurrence Factors
Patient factors
◦ malnutrition, immunosuppression, diabetes, steroid use, and smoking.

Technical factors
◦ mesh size, prosthesis fixation, and technical proficiency of the surgeon.

Tissue factors
◦ wound infection, tissue ischemia, and increased tension within the surgical repair