defination of hernia,epidemiology,etiology,parts of hernia,classification,clinical features,pathophysiology,predisposing factors and surgical management of strangulated hernia,

1. By DR BADAL KHAN PGR
SU425-8-2015 1

2. DEFINATION
IT IS AN ABNORMAL PROTRUSION OF A VISCOUS
OR A PART OF A VISCOUS THROUGH AN
OPENING ARTIFICIAL OR NATUERAL WITH A
SAC COVERING IT.
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3. 0
10
20
30
40
50
60
70
80
Series 3
Series 2
Series 1
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4. AETIOLOGY OF HERNIA
•STRAINING
•LIFTING OF HEAVY WEIGHT
•CHRONIC COUGH (TB,CH BRONCHITIS,ASTHMA)
•CHRONIC CONSTIPATION
•URINARY CAUSES
• OLD AGE; BPH CA PROSTATE
•YOUNG AGE;STRICTURE URETHRA
•VERY YOUNG AGE ;PHIMOSIS,METAL STENOSIS
• OBESITY
•PREGNENCY
•SMOKING
•ASCITES
•APPENDICECTOMY
•FAMILIAL COLLEGEN DISORDER
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5. PARTS OF HERNIA
1.COVERING
2. SAC
3.CONTENTS
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6. •COVERING OF THE SAC ARE THE
LAYERS OF THE ABDOMINAL WALL
THROUGH WHICH THE SAC PASESS
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7. IT IS A DIVERTICULAM OF PERITONEUM WITH
.MOUTH
.NECK
.BODY
.FUNDUS
•NECK IS NARROW IN INDIRECT
BUT WIDE IN DIREC HERNIA
•BODY IS THIN IN INFANTS, CHILDREN AND IN
INDIRECT BUT IS THICK IN DIRECT AND
LONG STADING HERNIA
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8. 1. OMENTUM-OMENTOCELE
2. INTESTINE-ENTEROCELE COMMONLY SMALL BOW
3. PORTTION OF CIRCUMFERENCE OF BOWEL
4. URINARY BLADDER-CYSTOCELE
5. MECKLE,S DIVERTICULAM-LITTRE,S HERNIA
6. OVARY
7. FALLOPIAN TUBE
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9. 1. CLASSIFICATION NO 1
CONGENITAL
ACQUIRED
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10. CLASSIFICATION NO 2
•ACCORDING TO CONTENTS
•OMENTUM-OMENTOCELE
•ENTEROCELE-INTESTINE
•CYSTOCELE-URINARRY BLADDER
•LITTRE,S HERNIA-MECKLE,S DIV..
•SLIDING HERNIA
•PART OF BOWEL-RICHTER,S HERNIA25-8-2015 10

11. CLASSIFICATION NO 3
•ACCORDING TO SITES
•INGUINAL
•FEMORAL
•OBTURATOR
•DIAPHRAGMATIC
•LUMBAR
•UMBLICAL
•EPIGASTRIC
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12. CLASSIFICATION NO 4
•CLINICAL CLASSIFICATION
•REDUCIBLE HERNIA
•IRREDUCIBLE HERNIA
•OBSTRUCTED HERNIA
•INFLAMED HERNIA
•STRANGULATED HERNIA
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14. A HERNIA IN WHICH BLOOD
SUPPLY OF THE HERNIATED
VISCUS IS SO CONSTRICTED
BY SWELLING AND CONG-
-STION AS TO ARREST ITS
CIRCULATION
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15. •STRANGULATION COMMONLY OCCURS
IN SMALL BOWEL AND ALSO OCCURE IN
LARGE BOWEL .
•OCCASIONALLY STRANGULATED
OMENTOCELE CAN ALSO OCCURE WITHOU
ANY INTESTINAL OBSTRUCTION
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16. •STRANGULATION CAN OCCUR IN
•INGUINAL
•FEMORAL
•OBTURATOR
•UMBLICAL
•ANY OTHER HERNIA
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17. •BUT INDIRECT INGUINAL HERNIA IS MORE
PRONE FOR STRANGULATION BECAUSE OF
CONSTRICTING AGENTS
1. NECK OF SAC
2. SUP ING RING IN CHILDREN
3. ADHESIONS WITHIN SAC
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18. Strangulated inguinal
hernia
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19. EPIDEMIOLOGY
•INCIDENCE RATE OF STRANGULATED INGUINAL
•HERNIA VARIES BETWEEN 0.29%AND 2.9%
•MORTALITY RATE RANGES BETWEEN 2.6% TO 9%
BUT A DELAY OF 12H INCREASE
CHANCE OF INTESTINAL RESECTION RATE.
•ABOUT 95% OF INGUINAL HERNIA PATIENT PRESENT
•AT CLINICS AND ONLY 5% PRESENT AS AN
•EMERGENCY WITH IRREDUCIBLE HERNIA WHICH
•PROGRESS TO STRANGULATION
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20. MORTALITY RISK IS SEVEN TIME HIGHER
IN CASES AFTER EMERGENCY
STRANGULTED INGUINAL HERNIA
SURGERY AND 20 TIME HIGHER IF BOWEL
RESECTION WAS UNDERTAKEN
DURING INFANCY
INCIDENCE IS 4%
FEMALE TO MALE RATIO IS 5;1
IN FEMALE INFANTS THE CONTENTS MAY BE OVARY
WITH OR WITHOUT FALLOPIAN TUBE25-8-2015 20

21. •STRANGULATED HERNIAS ARE
MORE FREQUENTLY SEEN IN
ELDERLY PATIENTS,AND THEIR
PREVELANCE IN THE 60 YEAR OLD
POPULATION HAS BEEN
REPORTED TO BE 9.8% COMPARED
WITH 1.8% FOR YOUNGER
PATIENTS
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22. OBSTRUCTION VENOUS RETURN IMPAIRED
CONGESTION OF THE BOWEL
FURTHER DILATATION OF THE BOWEL
WHICH BECOMES PURPLE COLOUREDCONT…
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23. FLUID COLLECT IN THE SAC
EVEVTUALLY ARTERIAL SUPPLY IS IMPAIRED
BOWEL BECOMES DARK, BROWNISH
BLACK COLOURED WITH FLABBY AND
FRIABLE WALL
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24. BACTERIA MIGRATE TRAN SEROSALLY
AND MULTIPLY IN FLUIDE OF THE SAC
PERFORATION OCCURE AT THE SITE OF
CONSTRICTION RING
PERITONITIS OCCURE25-8-2015 24

25. •E.COLI
•ANAEROBIC STREPTOCOCCI
•ANEROBIC BACTERIA
•KLEBSELLA
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26. 1.OBLIQUE INGUINAL HERNIA
2.TRUSS WORN FOR LONG TIME
3.PARTIALLY REDUCIBLE
HERNIA
1.LARGE HERNIA IN ELDERLY
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27. 1.NARROW NECK
2.ADHESIONS
3.IRREDUCIBILITY
4.LONG TIME HERNIA
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28. 1.SMALL INTESTINE (USUALLY)
2.LARGE INTESTINE (RARELYY)
3.BOTH SMALL INTESTINE
AND OMENTUM (SOMETIME)
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29. 1. HISTORY TAKING
2. EXAMINATION
3. INVESTIGATION
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30. •SEVERE PAIN INITIALLY AT HERNIAL
SITE THEN BECOME GENERALISED
•PERSISTENT VOMITING
•ABDOMINAL DISTENSION
•CONSTIPATION
•RECENT SUDDEN INC IN SIZE OF LUMP
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31. I. INSPECTION PALPATION
 SITE
 SIZE
 SHAPE
 COLOUR
 TEMP
 EXTREMELY TENDER
(MAYDLE,S HERNIA
TENDERNESS ABSENT)
 REBOUND
TENDERNESS IS
DIAGNOSTIC
 COUGH IMPULSE
ABSENT
 IRREDUCIBLE
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32. PERCUSSION AUSCULTATION
 NOT POSSIBLE DUE
TO TENDERNESS IF
DONE THEN….
 DULL IN CASE OF
OMENTUM
 RESONENT IN CASE
OF GUT
 GUT SOUNDS MAY
BE AUDIBLE IN
CASE OF
ENTEROCELE
 SILENT ABDOMEN
IN CASE OF
PERITONITIS
(PARALYTIC
PARALYSIS)
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33. BLOOD TESTS IMAGING
 CBC (TOTAL COUNT
 BLOOD SUGAR
 SERUM
ELECTROLYTES
 BLOOD UREA
 SERUM CRITININE
 PLAIN XRAY
ABDOMEN IN ERECT
POSITION IN CASE
OF OBS MULTIPLE
AIR FLUIDE LEVELS
 U/S ABDOMEN
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34. Treatment
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35. •OFTEN IN IRREDUCIBLE HERNIA,
REDUCTION OF HERNIA
IS TRIED BY
1.ELEVATION
2.SEDATION
3.TAXIS
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36. •IT IS A TRIAL TO REDUCE PARTIALLY
REDUCED OR IRREDUCIBLE HERNIA
WHILE FLEXING AND MEDIALLY
ROTATING THE HIP
•IT IS DANGEROUS IN
OBS AND MAYDLES HERNIA
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37.  PREOPERATIVE
MEASURES
 OPERATION
1. HERNIOTOMY
(SHAMIM)
2. BASSINI,S (SRB)
3. LIGHT WEIGHT
SYNTHETIC MESH
(BAILEY &LOVE)
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38. 1. PREOP TREATMENT
•PT ADMITTED
• IV CANULA
•RYLE,S TUBE (NG) ASPIRATION
•IV FLUIDS TO CORRECT
DEHYDRATION AND ELECTROLYTE
IMBALANCE
•ANTIBIOTICS
•CATHETERISATION
•SHIFT PT FOR EMERGENCY SURGERY
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39. OPERATION – NO 1.INGUINAL HERNIOTOMY
1.INCISION
•INCISION IS MADE OVER THE MOST
PROMINENT
PART OF THE SWELLING
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40. 2.DELIVERING & OPENING
OF SAC
•SAC IS EXPOSED
•CONSTRICTION RING AND SUP RING IS RELEASED
•DELIVER BODY AND FUNDUS OF SAC WITH
COVERING ONTO SURFACE
•SAC IS OPENED WITHOUT SPILLAGE OF FLUIDE
•FLUID IS SUCKED AND MOPPED
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41. 3.EXCISION OF STRANGULATED
CONTENTS
1.IN CASE OF OMENTUM
•DEVITSLISED OMENTUM IS EXCISED AFTER BEING
SECURELY LIGATED
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42. 2.IN CASE OF INTESTINE
•BOWEL IS HELD WITH FINGERS SO AS TO PREVENT
IT FROM GETTING REDUCED
•VIABILITY OF THE BOWEL IS CHECKED BY
•COLOUR
•PERISTALSIS
•PULSATION
•BLEEDING
VIABLE INTESTINE IS RETURNED TO PERITONEAL
CAVITY WHEN GANGRENOUS RESECTION AND
ANASTOMOSIS IS DONE AND DRAIN IS PLACED
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43. 4.EXCISION OF SAC
1. MODERATE SIZED HERNIAL SAC CAN
BE EXCISED AND CLOSED BY A PURSE
STRING SUTURES
2. LARGE SIZED &ADHERENT HERNIAL SAC
IS CUT ACROSS AND NECK OF SAC IS
TIED AND SUTURED
6.WOUND CLOSER
•WOUND CLOSE LAYER BY LAYER25-8-2015 43

44. NO.2 BASSINI,S REPAIR
•IT IS DONE BY PLACING INTERUPTED NON-
-ABSORBABLE SUTURES
NO.3 LIGHTWEIGHT MESH
•SOME SURGOENS STILL USE A LIGHWEIGHT
SYNTHETIC MESH COVERED BY APPROPRIATE
ANTIBIOTIC
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45. •ANESTHESIA COMPLICATIONS
•BLEEDING
•URINARY RETENTION
•SEROMA
•WOUND INFECTION
•SEPTICEMIA
•LEAK WITH FISTULA
•CHRONIC PAIN
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46. 1. BAILEY,S AND LOVE
2. SRB,S MANUAL OF SURGERY
3. ESSENTIALS OF SURGERY BY DR SHAMIM
4. WIKIPEDIA
5. TOPIC UPON HERNIA FROM UNIVERSITY OF
COLORADO HOSPITAL
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