Case Discussion - Hernia

Q. What is your diagnosis ?
A. Rt. oblique inguinal hernia, uncomplicated,
containing intestine (omentum), no other hernias,
no predisposing factors.
Q. Why this is a hernia ?
A. Because 1) It is a swelling, 2) At the anatomical
site of a hernia, 3) Gives an impulse on cough,
and 4) It is (or was) reducible on lying down and
by the patient fingers.
Q. Why inguinal and not a femoral hernia ?
A. Because 1) the hernia is above the inguinal
ligament and not below it, and 2) the neck of the
hernia is above and medial to the pubic tubercle
and because the hernia descends into the scrotum.
Q. Why oblique and not direct ?
A. Because 1) it descends into the scrotum, 2) On
doing the internal ring test, there was no swelling
to appear on coughing, and 3) the patient is a
young male.
Q. Describe how did you do the internal ring
test ?
A. After reduction of the hernia, the patient is
asked to stand while occluding the internal ring
(by pressing the finger 1/2 an inch above the mid
inguinal point), the patient is then asked to cough,
observing the appearance of any inguinal swelling.
Q. Why you did not do the external ring test ?
A. Because it is painful.
Q. Can a direct hernia descend into the
scrotum ?
A. A direct hernia can reach the scrotum very
rarely.
Q. Where is the defect in oblique inguinal
hernia ?
A. In the internal ring.
Q. Where is the defect in direct inguinal
hernia ?
A. The posterior wall of the inguinal canal
(Hasselbach's triangle).
Q. What are the boundaries of Hasselbach's
triangle ?
A. Lateral border of the rectus abdominis muscle
medially, the inferior epigastric artery laterally and
the inguinal ligament inferiorly.
Q. What are the subdivisions of the
Hasselbach's triangle ?
A. Hasselbach's triangle is subdivided into medial
and lateral parts by means of the medial umbilical
ligament.
Q. What are the common contents of a hernia
in general ?
A. Intestine, omentum and fluid.
Q. Mention the clinical types of oblique
inguinal hernias ?
A. 1) Bubonocoele, 2) Funicular type and 3)
Scrotal (complete) type
1. Bubonocoele = Hernia is only in the groin.
2. Funicular type = Hernia descends into the
scrotum but the testis is felt separate from
the hernial sac.
3. Scrotal (complete) type = Hernia descends
into the scrotum and the hernial sac
surrounds the testis which is not felt through
the contents of the hernia.
Q. What is hydrocoele of the hernial sac ?
and what is hernia of hydrocoele ?!
A. Hydrocoele of the hernial sac : Part of the sac
near its neck becomes encysted by a piece of
omentum and accumulates fluid.
A. Hernia of hydrocoele : In cases of vaginal
hydrocoele, a defect occurs in the dartos fascia of
the scrotum through which a part of the
hydrocoele herniates.
Q. What are the causes of residual swelling
after reducing the hernia ?
A. 1) Sliding hernia , 2) incomplete reducibility
due to adhesions between the contents and the
sac , 3) hydrocoele of the hernial sac and 4)
associated lipoma of the cord
Q. How would you clinically differentiate
between obstructed and strangulated
hernias ?
A.
• # This is difficult because both are very acute
conditions with the hernia being painful,
irreducible & tender.
• # Impulse on cough is preserved in
obstructed but is lost in strangulated hernias.
• # The hernia is tense in strangulation but not
in obstruction.
• # Symptoms and signs of intestinal
obstruction are present in obstructed hernias
and maybe present in strangulated hernis
• # The degree of shock and toxaemia are
more severe in strangulated hernias.
• # However, both conditions are considered
surgical emergencies and necessitate an
urgent interference to relieve the cause of
strangulation and to deal with the contents.
N.B. An enterocoele can be obstructed and can be
strangulated while an omentocoele can only be
strangulated as it has no lumen to be obstructed.
Q. What are the conditions that you may find
strangulation without obstruction ?
A. If the content of the hernia is one of the
following :
1. Omentum
2. Part of the circumference of the intestinal
lumen (Richter's hernia)
3. Michael's diverticulum (Littre's hernia)
4. Fallopian tube & ovary
5. Intestine, but there is an associated mesenteric
vascular occlusion
Q. What is the treatment of this case of
oblique inguinal hernia ?
A.
• O.I.H. in children and adolescents -----------
> Inguinal herniotomy
• O.I.H. in adults -------------------------->
Inguinal herniorrhaphy
• O.I.H. in elderly and recurrent cases --------
> Inguinal hernioplasty
Q. What is the principle of operation for
inguinal hernia in children & adolescents ?
A. Inguinal herniotomy, that is excision of the
hernial sac. They do not need repair as they have
very good muscles
Q. What is the principle of operation for O.I.H.
in adults?
A. Excision of the sac + repair of the defect
Q. What are the principles of such repair ?
A. Repair of the defect is done either by the local
tissues (herniorrhaphy) or by adding a graft of
tissue (hernioplasty).
The principles in both herniorrhaphy and
hernioplasty, in general, are the following ;
1. Narrowing the internal ring,
2. Repair of the fascia transversalis, and;
3. Reinforcement of the posterior wall of the
inguinal canal.
Q. What is the most popular type of repair ?
A. Bassini repair.
Q. What is its principle ?
A. Suturing the conjoined muscle to the inguinal
ligament.
Q. What are the causes of recurrence of a
hernia ?
A.
• 1. Untreated preoperative condition : Chronic
straining (asthmatic bronchitis, prostatic
enlargement ....etc.), debility, obesity
• 2. Intraoperative causes: Improper
haemostasis, tense repair, lax repair, repair
with absorbable suture material
• 3. Postoperative causes : Haematoma,
infection, early return to hard work
•
Case 2. PARAUMBILICAL HERNIA
Q. What is your diagnosis ?
A. Paraumilical hernia, uncomplicated.
Q. What are the types of umbilical hernias
you know ?
A.
1. True umbilical hernias :
i) Congenital umbilical hernia (exomphalos major
and minor)
ii) Infantile umbilical hernia (from weak umbilical
cicatrix)
iii) Adult umbilical hernia (from increased
intrabdominal pressure)
2. Paraumilical hernias : due to defect in linea alba
close to umbilicus:
1) Supraumbilical
2) Infraumbilical
Q. Is it common for patients with PUH to
complain of dyspepsia ?
A. Yes.
Q. Why ?
A. Due to traction on the greater omentum which
is commonly the content of such a hernia.
Q. What is the commonest complication of
paraumbilical hernia ?
A. Irreducibility, due to marked adhesions
between the contents.
Q. What is the danger of such irreducibility ?
A. It predisposes to obstruction and strangulation.
Q. What is the treatment of this case ?
A. Herniorrhaphy.
Q. What type of repair do you do ?
A. It varies according to the size of the defect as
follows :
• Very small defect ---------> Anatomical
repair
• Small to Moderate defect ---------> Mayo's
repair
• Moderate to Large defect --------->
Hernioplasty (prolene mesh graft)
Q. How do you clinically differentiate
between a paraumbilical and an epigastric
hernia ?
A. In paraumbilical hernia, the defect is close to
the umbilicus so that the umbilicus forms a
crescent at the edge of the sac, while in epigastric
hernia, there is a bridge of normal abdominal
muscles between the defect and the umbilicus.
Besides, epigastric hernia could be multiple
Q. What are the causes of incisional hernia
A. There are;
• 1. Untreated preoperative condition : Chronic
straining (asthmatic bronchitis, prostatic
enlargement ....etc.), debility, obesity
• 2. Intraoperative causes: Improper
haemostasis, tense repair, lax repair, repair
with absorbable suture material
• 3. Postoperative causes : Haematoma,
infection, early return to hard work.