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Hernia in Adult

Hernia is…
• A rupture ( Latin word)
• Penonjolan bagian organ atau jaringan melalui
lubang abnormal (kamus kedokteran Dorland)
• An abnormal protrusion of an organ or tissue
through a defect in its surrounding walls
(Sabiston)
• An area of weakness or complete disruption of
the fibromuscular tissues of the body wall
(Mangiot’s)
Tiga komponen:
1. Defek ~ Cincin
2. Kantong hernia
(peritoneum)
3. Isi
1. Intestine
2. Colon
3. Omentum
4. Buli
5. Ovarium
6. Uterus
7. Appendiks
Cause
• Faktor Etiologi: • Faktor Pencetus:
Kelemahan dinding Excessive straining
abdomen – LUTS
• BPH
• Urethral stricture
– Chronic cough
– Constipation
– Lift/push weight
Ventral Hernia

TYPES
Abdominal Wall Layers

INGUINO-SCROTAL REGION
Hesselbach’s Triangle
Hesselbach’s Triangle
Hesselbach’s Triangle
The Myopectineal Orifice of Fruchaud
Female Ingiunal Canal = Canal of Nuck
Inguinal Hernia >< Scrotal Hernia

DIRECT HERNIA >< INDIRECT HERNIA


Indirect Hernia VS Direct Hernia
Indirect Hernia Direct Hernia
• a.k.a. hernia lateral • a.k.a. hernia medial
• Defect: deep (internal) • Defect: Hesselbach’s
inguinal ring  spermatic triangle
cord (inguinal canal) 
superficial (external)
inguinal ring  scrotum
Indirect Hernia VS Direct Hernia
• Pantaloon Hernia: if indirect and direct hernia
occurs at the same time
Groin Hernia

INGUINAL HERNIA >< FEMORAL HERNIA


Inguinal Hernia VS Femoral Hernia
Inguinal Hernia VS Femoral Hernia
Inguinal Hernia Femoral Hernia
• Above inguinal • Below
ligament inguinal
• Mostly ♂ ligament
• Defect: • Mostly ♀
deep inguinal ring or • Defect:
Hesselbach’s triangle femoral ring
Differentiating Hernia Type

PHYSICAL EXAMINATION
Digital Examination
Digital Examination
• The examiner should place
the tip of the index finger at
the most dependent part of
the scrotum, direct it into the
external inguinal ring
• The patient is then asked to
strain

Indirect hernia will push


against the fingertip
Direct hernia will push
against the pulp of the finger
3 Fingers Examination
Hernia’s

TERMINOLOGY
Terminology
• Reducible/Reponible
Isi kantong dapat keluar-masuk
• Irreducible/Irreponible
Isi kantong tidak dapat masuk kembali, namun tidak ada
gejala dan tanda strangulata
• Incarcerate ???
• Strangulate
Isi kantong hernia terjepit sehingga menyebabkan gangguan
– Sirkulasi iskemiknyeri
– Pasase ususobstruksi usus mekanik
Irreducible
Inguino-scrotal Hernia

STRANGULATE!
What is the Diagnose?
Mechanical Bowel Obstruction
Trias obstruksi:
1. Perut semakin membuncit
2. Muntah setiap makan-minum
3. Tidak bisa flatus maupun BAB

PF regio abdomen:
I: distention, bowel contour, bowel movement
P: NT
P: hypertympanic
A: hyperperistaltic, metallic sound

RT: ampula recti kolaps


Mechanical Bowel Obstruction
• Abdominal radiograph
 is it NECESSARY?
Strangulated Scrotal Hernia
4T
1. Tense
2. Tender
3. Temperature
4. Tone
(Hyperemia)
Viability of the Intestine

4C
1. Consistency
2. Color
3. Capillary
4. Contractility
~ Peristaltic
Proses strangulasi

Vaskularisasi intestine/colon terganggu

Lapisan mukosa yang paling menderita
(o.k. letaknya paling profunda,
paling jauh dari pembuluh darah)

Mucosal slough

Klinis: hematoschezia
Spontaneously Reduce
Strangulated Scrotal Hernia En Masse
• Reduction en-masse of inguinal hernia, means
reduction/migration of a hernial sac along with
the incarcerated bowel into the properitoneal
space and is likely produced by forcible attempts
at reduction
• Occasionally, it can also be spontaneous
• There is usually a history of difficult reductions,
the last one being especially difficult, after which
the symptoms of intestinal obstruction occur
• The hernia appears to have been reduced but the
signs of bowel obstruction persist
Spontaneously Reduce
Strangulated Scrotal Hernia En Masse
• Reduction en-masse of inguinal/femoral
hernia can be defined as reduction of the
hernial sac together with its intestinal
contents so that the bowel still remains
incarcerated
• It has been quoted by Pearse to occur in
approximately 1 of 13,000 hernias
Spontaneously Reduce
Strangulated Scrotal Hernia En Masse
• Casten and Bodenheimer postulated that reduction en
masse can occur only if there is a relatively unyielding
neck of the sac and a lax internal ring
• Fibrosis is probably produced by recurrent trauma from
difficult reductions
• Pearse concluded that a preformed space between the
parietal peritoneum and anterior abdominal wall, the
properitoneal sac, or diverticulum was present in many
cases
• Millard suggested that such a sac was equally likely to
be produced by forcible attempts at reduction
Spontaneously Reduce
Strangulated Scrotal Hernia En Masse
• Reduction en-masse of hernia should be
considered as a cause of acute intestinal
obstruction in patients with persistent bowel
obstruction following reduction of
inguinal/femoral hernias!!!
A hernial sac is seen containing
incarcerated bowel loop between
the parietal peritoneum and anterior
abdominal wall, the properitoneal sac
(a) CT scan of the abdomen
demonstrating dilated small
bowel loops suggestive of bowel
obstruction
(b) The hernial sac [arrow] containing
thickened bowel loop and
mesenteric fat [arrowhead] is seen
in the properitoneal space,
superior to the left inguinal region
(c) A fibrous constriction band is seen
around the neck of the hernial sac
[arrow]. Note enhancement of
bowel wall [arrowhead]
(d) The inferior aspect of the hernial
sac containing bowel [arrow]
(e) Fluid in the hernial sac [arrow].
Wall enhancement of the bowel
loop and fluid in the hernial sac
suggest incarceration and
strangulation
Hernia Type
Sliding Hernia

Any hernia in which part of the sac is the wall of a viscus

Hernia dimana dinding viskus tersebut membentuk


Sebagian dari kantong hernia,
bagian lain kantong hernia dibentuk oleh peritoneum parietal
Littre’s Hernia
Richter’s Hernia
Amyand’s Hernia
Spigelian Hernia
Interstitial Hernia
Supravesical Hernia
Lumbar Hernia
Maydl’s Hernia
Differential Diagnosis
for
Scrotal Enlargement
DD/: Hidrocele
“Bottle Neck” Procedure
DD/: Testicular Tumor
DD/: Orchitis
DD/: Testicular Torsion
DD/: Pembesaran Skrotum
Anamnesis Pemeriksaan Fisik
Hernia Benjolan keluar masuk Batas atas tidak jelas
Testis teraba
(terletak inferior, o.k. terdorong massa hernia)
Hidrokel Benjolan yang menentap Batas atas jelas
dan semakin membesar Transiluminasi (+)
Testis tidak teraba
Tumor Testis Benjolan yang menentap Batas atas jelas
dan semakin membesar Transiluminasi (-)
Testis “tidak teraba”
(sudah menjadi tumor)
Orkhitis Gejala-gejala proses Ukuran testis membesar, NT (+)
inflamasi (nyeri, demam) Tanda-tanda inflamasi
(tumor,dolor,calor,rubor,functio laesa)
Torsio Testis Riwayat trauma Posisi testis horizontal
Prehn’s test
When to operate????
Operation Timing
• Elective
– Reducible
– Irreducible
• Emergency
– Strangulate
• Herniorrhaphy: hernia repair-operation
• Herniotomy: high ligation of the sac
or…
reduction of the sac into the
preperitoneal space without excision
• Hernioplasty: reconstruction of the posterior wall/
inguinal floor
Hernioplasty
• Tension:
– Bassini plasty
– Shouldice
– Nyhus
– Condon
– Stoppa
• Tension-free:
– Lichtenstein
– Perfix mesh plug (Rutkow-Robbins)
– Kugel
– Laparascopic
Bassini plasty
Lichtenstein
Mesh
Mesh
Complication after Herniorraphy
• Pain
• Wound infection
• Orchitis
• Seroma/hematoma in distal hernia sac
• Inguinodynia
• Recurrent
Inguinodyna
• Chronic groin pain or
neuropathic pain
• Debilitating pain with
prolonged suffering and
distress
• Characterized by
hyperesthesia along the
corresponding dermatome,
and exquisite pain at the site
of a neuroma or trapped
nerve; and contact
dysesthesia
• Patient describing as painful
exacerbations similar to an
electric shock, paroxysms of
“burning” and “shooting”
pains
“A surgeon can do more for the
community by operating on
hernia cases,
and seeing that is recurrence
rate is lower,
than he can by operating on
cases of malignant disease”
-Wakely-
Hernia Permagna
Hernia Permagna
Tipe hernia yang apabila isi kantung hernia
dikembalikan ke rongga peritoneum dapat
menimbulkan keadaan abdominal
compartment syndrome
Abdominal Compartment Syndrome
Peningkatan tekanan intraabdomen

Aliran darah ke organ-organ terganggu

Gangguan fungsi pulmonar, kardiovaskular,
renal, dan gastro-intestinal

Multiple organ dysfunction
Hernia Simtomatik Skrotalis Bilateral Ireponibilis
& Hernia Simtomatik Umbilikalis Ireponibilis
e.c. Asites Masif
Thank You….

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