LO 5 : HERNIA

DEFINITION

 protrusion or protrusion of the contents of a cavity consisting of rings, pockets, and

contents of the hernia, through defects or weak parts of the wall concerned

EPIDEMIOLOGY
 There are 6 times more hernias in men than women. In men, 97% of hernias occur in the
inguinal area, 2% as hernia membranes and 1% as umbilical hernias. In women the
variation is different, namely 50% occurs in the inguinal region, 34% in the femoral canal
and 16% in the umbilicus. Common hernias are groin, umbilicus, linea alba, semilunar line
of (piegel, diaphragm, and surgical incision. Other comparable but very rare herniation
sites are perineum, superior lumbar triangle, inferior lumbar triangle, and obturator
foramen.
 The incidence of inguinal hernia (medial / direct and lateral / indirect) 10 times more than
femoral hernias and both have a percentage of about 75-80% of all types of hernias, 10%
incisional hernia, 10% Ventralis hernia, 3% umbilical hernia, and hernias others around 3%
ETIOLOGY

 open processus vaginalis

 Intra-abdominal pressure that increases chronically, such as coughing, prostate
hypertrophy, constipation
 abdominal wall muscle weakness and connective tissue degeneration due to old age
 multiparous pregnancy and obesity
CLASSIFICATION

 Based on occurrence :
1. Congenital hernias: perfect and imperfect
2. Obtained Hernia / aquisita: not because of a congenital defect, but due to other factor
 Based on location :
1. Inguinal hernia

Limit of the inguinal canal: Trigonum Hasselbach

Craniolateral: internal inguinal ring
Kaudomedial: external inguinal
annulus
Roof: aponeurosis external
m.oblikus
Basically: the inguinal ligament
Inferior: inguinal ligament
Lateral: inferior efigastric vasa
Medial: lateral edge of rectus
abdominis
Basic: transverse fascia, transversus

Lateral Inguinal Hernia
Position lateral to the inferior epigastric vasa
Indirect iguinalis hernia : because it protrudes
through the annulus and inguinal canal
Medial Inguinal Hernia
Located medially from the inferior
epigastric vasa
Direct inguinal hernia : because it
protrudes directly
through the Hesselbach trigon

2. Umbilical Hernia
- Conginital hernias in the umbilicus which are only covered with peritonuem and skin due
to incomplete closure and absence of umbilical fascia.
- there are about 20% of babies and even higher rates in premature babies.
- protrusions containing the contents of the abdominal cavity that enter through the
umbilicus ring, most often containing omentum, can also contain the small intestine and
large intestine, due to elevated intra-abdominal pressure, usually when the baby cries.

3. Scrotal hernias Caused by disruption of diaphragm

4. Lumbar Hernia formation. The diaphragm is made up of 3
elements, namely membrane
5. Femoral Hernia
pleuroperitonei, transverse septum and
6. Diaphragmatic hernias growth from the edge originating from
the muscles of the chest wall
 By nature :
1. Reponible Hernias : Folded thigh lump that appears when standing, coughing, sneezing or
straining and disappears after lying down.
2. Irreponible hernia : If the contents of the hernia bag cannot be returned into the cavity.
Usually caused by adhesion of the contents of the bag to the peritoneum of the hernia
pouch. No complaints of pain or signs of intestinal obstruction.
3. Incarserata hernias : Arises because the intestine that enters the hernia sac is sandwiched
by the ring of the hernia resulting in symptoms of obstruction and strangulation of the intestine
4. Strangulata hernia : A condition where the contents of the hernia sac cannot re-enter the
abdominal cavity resulting in vascular disorders in the viscus / bag that is pinched
 Based on the direction of the hernia
1. External Hernia
2. Internal Hernia
 DIAGNOSIS
 History
 Physical examination :
1. Inspection
- Reponible hernias: There is a folded thigh lump that appears when standing, coughing, sneezing
or straining and disappears after lying down.
- Inguinal hernia: Lateralis: Lumps appear in the inguinal region that runs lateral to medial, oblong-
shaped protrusion.
Medial: Bulge usually occurs bilaterally, round in shape.
- Umbilical hernias: at umbilical lumps.
- Scrotal hernias: Lumps that are visible to the scrotum which are advanced protrusions of the
lateral inguinal hernia.
- Femoral Hernia: Lumps under the inguinal ligament
3. Palpation: palpable lump with an upper border is not firm.
4. Auscultation: Peristalsis (+)
DIFFERENTIAL DIAGNOSIS

 Hydrocele :Has a firm upper limit, positive illuminence and cannot be re-entered. Testicles
in hydrocele patients cannot be touched. In the hydrocele translumination / diposcopy
examination will give a positive result.
 Anguinal Limpadenopali :Notice if there is an infection in the leg side.
 Ectopic testism :Namely the testis is still in the inguinal canal.
 Lipoma / herniation :Praperitoneal fat through the inguinal ring.
 Inguinal granuloma
 Orchitis (1, 2, 3, 4, 6, 8)
MANAGEMENT

There are two types of hernia treatment:

1. Conservative
Conservative treatment is limited to the act of repositioning and using support or support to
maintain the contents of the hernia that has been repositioned. It is not a definitive action so that it
can recur. Consists of:
a. Reposition
Repositioning is an attempt to restore the contents of the hernia into the peritonyan cavity or
abdomen. Repositioning is done bimanually. Repositioning is carried out in patients with
republican hernias by using two hands. Repositioning is not carried out in strangular inguinal
hernias except in children. The left hand holds the contents of the hernia to form a funnel while
the right hand pushes it towards the ring of the hernia with slow pressure but settles until
repositioning occurs. Spontaneous repositioning more often and vice versa disorders of vitality
of hernia contents are rare compared to adults. This is caused by a more elastic hernia ring in
children. If there are no repairs or repositions within 6 hours, the operation will fail immediately.
 b. Injection
Sclerotic fluid is injected in the form of alcohol or kinin in the area around the hernia,
which causes the hernia door to experience sclerosis or constriction so that the hernia is
out of the cavity peritonyi.
c. Hernia Belt
Given to patients with small hernias and refusing surgery. Shape of a belt head like a
snake's head. The head of the belt is placed right at the door of the hernia so that it
prevents the discharge of the intra-abdominal organs.
2. Operative
The purpose of hernia surgery:
Surgery is the best and can be done - Reposition of hernia contents
at: - Close the hernia door
- Reponibilis hernia - Prevent residif by strengthening the
- Irreponibilis hernias abdominal wall
- Strangulated hernias
- Incarcerated hernias
The basic indications for surgery for a hernia are:
- Operation Timing
o Electively carried out on republican hernias
o 2 x 24 hours is performed on irreponibilis hernias
o Speed of operation is performed for incarcerated hernias with patients who have signs of ileus, but
ischemia and gangrene have not occurred in the contents of the hernia.
- If a life-threatening condition is carried out a conservative action is carried out if the hernia is still
reponitive. Palliative actions are performed on patients with poor general condition and incarcerated
hernias to treat ileus, then closing the hernia.

Hernia surgery is carried out in 3 stages:

1. Herniotomy :Open and cut the hernia bag and return the contents of the hernia to the
abdominal cavity.
2. Hernioraphy :Starting from binding to the neck of the hernia and hanging it on the conjoint
tendon (thickening between the free edge of the intraabdominal m.lilius and m.transversus
abdominis which inserts in the tuberculum pubicum).
3. Hernioplasty :Narrowing the conjoint tendon in the inguinal ligament so that the LMR is lost /
closed and the abdominal wall becomes stronger because it is covered with muscle.
Hernia surgery in children:
 Hernia surgery is performed without hernioplasty, divided into 2 namely:
 Children less than 1 year old
Using the Michele Benc technique. Performed without opening the external aaponeurosis
m.Abdominis (without opening the medial inguinal canal), which is to take the hernia
bag through the medial inguinal ring, then a herniotomy is continued followed by
herniorapy (without being hung) and without hernioplasty.
 Children over the age of 1 year
Using POTT techniques. Inguinal canal opened (opening external aponeurosis
m.abdominis), then performed herniotom
complications

 Vascular Injuries, Nerves and Ductus Deferens

 Hematoma,
 Infection,
 Residif,
 Fistel,
 Testicular atrophy.