CLINICAL INFORMATION OF (GROIN) INGUINAL HERNIA

 

Bubonocele / Inguinal Hernia

Bubon = groin

Bubonocele is a type of inguinal hernia which is limited in its extent to the inguinal canal.

Epidemiology :

v     Occurs at all ages; M > F

v     In 1st decade - right > left ( because of late descent of right testis)

v     After that R = L

v     Bilateral in 1/3 of cases

v     Etiology :

1) Increased Intra Abdominal Pressure due to straining :-

v     In children - Measles, whooping cough

v     In adults -   Smoking, chronic bronchitis, emphysema, hard physical labor, Intra Abdominal malignancy,

v                      Stricture urethra, chronic constipation

2) Increased Intra Abdominal Pressure due to stretching muscles :-

v     Ascites

v     Pregnancy

v     Complaints

Ø     dull dragging pain referred to the testis - increases on work

Ø     If obstructed may have constipation, vomiting, pain

Ø     If strangulated may have severe pain, shock, collapse.

v     Clinical Findings

Ø     piriform swelling - in the inguinal canal

Ø     bubonocele does not come into scrotum

Ø     Cough impulse + Reducibility +

Ø     Neck of the hernia is supero-medial to pubic tubercle

v     Special tests  

Ø     Deep ring occlusion - hernia does not appear

Ø     Finger Invagination - impulse at tip of finger

Ø     Dr.Desarda's test - Sliding of contents from ring finger to index finger indicates indirect and from middle to index finger indicates direct hernia

v     Types :

1.      Reducible

2.      Irreducible (complication of (1))

3.      Obstructed -------"---------

4.      Strangulated ------"----------

5.      Inflamed (the viscus in the hernia is inflamed - e.g. appendicitis, salpingitis) 

 

v     Differential Diagnosis:

v     Males

1.     Femoral hernia

2.     Direct inguinal

3.     Vaginal hydrocele

4.     encysted hydrocele of cord

5.     Undescended testis

6.     Spermatocele

7.     Varicocele

8.     Diffuse lipoma of cord.

v     Females

9.     Femoral hernia

10.  Hydrocele of canal of Nuck

v     Treatment

    [1] Principles of treatment :

1.     Restore the disrupted anatomy

2.     Repair using fascia / aponeurosis NOT muscle

3.     NO tension

4.     Suture material used should hold until natural support is formed over it. ( i.e. monofilament nylon or polyethylene)

[2] Management

1.     Resuscitation - in case of strangulated hernia with gangrene with shock or with intestinal obstruction.

2.     Reduction of hernia - includes taxis, & reduction under anesthesia.

3.     Repair - of the defect - may be herniorrhaphy or hernioplasty.  

v     Strangulated hernia -

Ø     treat as emergency

Ø     treat shock if any. Start IV antibiotics

Ø     Incision over the most prominent part of swelling - sac carefully identified & dissected out. Sac opened.

Ø     Aspirate all fluid ( highly infectious)

Ø     Resect any unviable intestine or omentum

Ø     EO aponeurosis & external ring divided. Sac opened throughout the length upto deep ring & a little inside.

Ø     Viable contents reduced. Definite repair carried out - any prosthetic repair is contra-indicated.

- Non - Operative approach - in elderly, unfit / unwilling for surgery.

- Use of truss is advised in such cases- Truss must be applied with hernia reduced. Must prevent                reappearance of the hernia on straining.

- Surgery - treatment modality of choice.

1 - Herniotomy - may be sufficient in young, muscular individuals and in children.

2 - Herniorrhaphy - in adults with good muscular tone.

3 - Hernioplasty - in elderly with poor muscular tone.

C/I in strangulated hernia - may get infected leading to wound sinuus.

v     Herniorrhaphy -

      o  Dr. Desarda's repair:  Giving physiologically dynamic and strong posterior wall should be the     principle of any type of inguinal hernia repair to give 100% success rate. Undetached strip of the external oblique aponeurosis is sutured between the muscle arch and the inguinal ligament to give a strong posterior wall which is kept physiologically dynamic by the additional muscle strength provided by the external oblique muscle to the weakened muscle arch.

Ø     Lytle's repair (syn : Marcie's repair)- narrowing of the deep ring by suturing medial wall - Tight enough so that cord & little finger just fit in.

Ø     Bassini's repair - Suturing of conjoint tendon to the incurved part of inguinal ligament - medial most stitch through the pubic periosteum - sutures taken with non-absorbable sutures - originally done by Bassini using black silk - now monofilament nylon used. - Chances of femoral hernia increased.

Ø     Shouldice repair - Double breasting of transversalis fascia - best tissue repair - at the Shouldice clinic in Toronto, stainless steel wire used for darning.

Ø     Ogilvie's repair - plication of transversalis fascia

Ø     McVay's repair / Cooper's repair - Conjoint tendon sutured to the Cooper's ligament - also prevents Femoral hernia formation - closes off the Fruchaud's orifice.

Ø     Condon's repair - Conjoint tendon sutured to the ilio-pubic tract.

Ø     Halsted's repair - repaired at 3 levels (6 layer repair) - Bassini's + Shouldice + double breasting of external oblique - cord becomes subcutaneous

Ø     NYHUS / Cheatle - Henry repair - pre-peritoneal repair - may be combined with prostatectomy. Used for large double hernias (direct + indirect), bilateral hernias, & Recurrent hernias.

Ø     Inguinoclysis - only in elderly men with recurrent / very large hernias - obliteration of the inguinal canal with bilateral orchidectomy.

Ø     Pantaloon hernia - Treated by 1^st converting the hernia into one giant indirect hernia & then treating it as indirect hernia

 Complications :

1] Of the hernia -

v     Irreducibility

v     Obstruction

v     Strangulation

v     Toxic shock

v     Peritonitis

2] Of the surgery -

v     Sepsis ( most common ) - may lead to formation of incisional hernia.

v     Hematoma

v     2ndary hydrocele - damage to lymphatics

v     Testicular ischemia & atrophy

v     Division of the vas deferens - especially in children

v     Sinus formation - use of non-absorbable sutures

v     Nerve entrapment - ilioinguinal N.

v     Lymphocele - common after operations for femoral hernia

v     Recurrence of hernia.

Hernia - General information

Hernia - General

v     Common Hernias : Inguinal, Incisional, Femoral, Umbilical

v     Acquired Hernia - Incisional

v     Hernias due to obesity - Direct inguinal, Para umbilical, Hiatus hernia.

Classification:-

Internal

v     Diaphragmatic hernia - congenital or acquired

v     Duodenum herniating in the Para duodenal pouch

v     Intestine herniating into the lesser sac or hole in mesentery or hole in transverse mesocolon or defect           in the broad ligament or Ileocaecal fossae - superior & inferior or retrocaecal fossa

External

v     Anterior

Ø     Inguinal - indirect, direct, pantaloon

Ø     Femoral

Ø     Umbilical - Exomphalos (major & minor), & child umbilical hernia.

Ø     Para umbilical

Ø     Epigastric

Ø     Divarication of Rectii

Ø     Spigelian-occurs at lateral border of rectus sheath at level of arcuate line.

Ø     Obturator

Ø     Interstitial / Interparietal - 4 types

§       Pro-peritoneal - diverticulum from inguinal or femoral hernia.

§       Intermuscular - common in obese patients - spreads between External Oblique & Internal Oblique - narrow neck - tendency to strangulation.

§       Inguinosuperficial - hernia into the superficial inguinal pouch - associated commonly with an ectopic testis in the pouch.

v     Posterior

Ø     Lumbar - superior & inferior. May be a phantom hernia - due to local muscular paralysis e.g. polio.

Ø     Gluteal - through greater sciatic foramen.

Ø     Sciatic - through lesser sciatic foramen.

v     Perineal hernia - 4 types

Ø     Post - operative - after AP resection of rectum.

Ø     Median sliding hernia - complete rectal prolapse.

Ø     Antero-lateral - in females - swelling of one side labium majus.

Ø     Postero-lateral - through levator ani muscle into the ischiorectal fossa.

v     Para-ileostomy hernia

v     Para-colostomy hernia

1. Types of indirect inguinal hernias :
   1. Complete / Scrotal / Vaginal
   2. Bubonocele
   3. Funicular indirect hernia
   4. Infantile - (2) + a diverticulum from the tunica which extends anteriorly upto the external ring.
   5. Encysted - (1) + the diverticulum
   6. Interstitial - The hernia traverses through muscle bundles and planes

1. Richter's hernia - only part of the intestine wall circumference is in the hernia. May strangulate without obstruction. Seen commonly in Femoral & obturator hernias.

1. Littre's hernia - hernial sac contains Meckel's diverticulum. Importance is that may form an inflamed hernia.
2. Garengoff's hernia - Hernial sac has the appendix. Importance is that may form an inflamed hernia.
3. Pantaloon hernia - direct + indirect inguinal hernia
4. Maydl's hernia - hernia - en - W --- W type of intestinal loop herniates - may strangulate with the gangrenous part being inside the abdomen - or may be reduced into the abdomen without noticing the gangrenous part.
5. Hydrocele - en - bisac : Abdominoscrotal hydrocele.

1. Retro-peritoneal approach for repair - used in Bilateral hernia, Double (inguinal + femoral) hernia and RECURRENT hernia.

 

Theories for Hernia formation

1. Russell's theory - pre-formed sac.
2. Reid's metastatic emphysema theory - d.t. smoking.
3. Cloquet's lipoma theory - pile driver action of fat.
4. Fruchaud's theory - big opening in the lower abdomen - between the pubic bone and conjoint tendon. Divided into two by inguinal ligament. Through the upper part passes the inguinal hernia, while through the lower part passes the femoral hernia.
5. Denervation theory - Ilioinguinal N. esp after appendectomy.
6. Oblique pelvis - high arch of the internal oblique - inefficient shutter mechanism - prone to inguinal hernia.
7. Wide female pelvis - Lower arch of internal oblique - more efficient shutter mechanism - indirect inguinal hernias are uncommon in females. Results in wider femoral ring - femoral hernias commonest in females.
8. Uglavasky theory - Chronic increased IAP
9. Peacock's theory - defective collagen synthesis.
10. Walk's theory - weakness of abdominal wall at exit of neurovascular bundle.
11. Keith's theory - stress related degeneration of connective tissue - especially in the fascia transversalis.
12. Deficient insertion of the conjoint tendon seen in males - especially white males - pre-disposes to direct inguinal hernia - less support to posterior inguinal canal wall. Attachment quite wide in females - direct hernia almost never occurs in females.
13. Dr. Desarda’s theory – Transversalis fascia can not give and  never gives protection from the herniation process as believed  today or stated in the text books or various research  articles. Transversalis fascia is papery thin  and is an extension of the endo-abdominal fascia. Posterior wall of the inguinal canal is not  only a single layer  wall composed of the transversalis fascia as believed today but is composed of two layers. Transversalis fascia is a posterior layer and in front  of it is another layer composed of the aponeurotic extensions from the Transversus Abdominis Aponeurotic Arch also called  as the "Dessidious part of the  Transversus Abdominis Aponeurotic Arch" These  aponeurotic extensions in the posterior wall of the inguinal canal gives  real protection from the herniation process. The inguinal hernia formation can take place only if these  aponeurotic extensions are  absent or deficient. Loss of strength and physiologically a-dynamic nature of the posterior wall of the inguinal canal due to  absent aponeurotic extensions in the posterior wall and loss of strength of cremasteric fascia and musculo-aponeurotic structures around the inguinal canal are the real factors or the  cause of hernia formation. Read our research article: Surgical physiology of inguinal hernia repair - a study of 200 cases Mohan P Desarda  BMC Surgery 2003, 3:2  doi:10.1186/1471-2482-3-2     http://www.biomedcentral.com/1471-2482/3/2/

1. HERNIA CALENDAR
   1. 0-2 years - indirect inguinal hernia
   2. 2-20 years - hernia is uncommon
   3. 20-50 years - indirect inguinal hernia
   4. >50 years -direct inguinal hernia

1. Aetiological factors in any hernia -
   1. Increased IAP -
      1. Children - common in pertussis, bronchiectasis, TB, cystic fibrosis, etc.
      2. Adults - Pregnancy, ascites, obesity, intra-abdominal tumour, chronic constipation, straining at micturition, chronic cough - TB, smoking, Ca lung etc.
   2. Obesity - acts as a 'pile driver' for the hernia.
   3. Smoking - pre-disposes to chronic cough, also causes defective collagen synthesis.
   4. Occupational - in occupations requiring long standing - bus conductors, heavy labourers - increased straining.
   5. Poor general condition - anemia, senility, hypoproteinemia, multiparas with lax abdominal walls, etc.
   6. Loss of strength and physiologically dynamic nature of the posterior wall of the inguinal canal.

EMAIL: desarda@gmail.com     or     desarda@hotmail.com