Complicated hernia
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Describes the various clinical presentations of hernia complications, their pathophysiology and principles of management.
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Complicated hernia
- 1. Complicated Hernia Chea Chan Hooi General Surgeon Sibu Hospital
- 2. Content • Definition • Epidemiology • Classification • Clinical presentation • Investigations • Treatment
- 3. Definition • Hernia • Abnormal exit of tissue/organ through the wall of the cavity in which it normally resides • Complicated • Obstructed • Strangulated • Incarcerated • Recurrent
- 4. Epidemiology • 5 - 10% in the US • IH > FH > others • Men 8x more likely to develop hernia and 20x more likely to need repair compared with women • Women manifest groin hernias at a later age
- 5. Classification External • Ventral • Epigastric • Spigelian • Umbilical • Umbilical per se • Paraumbilical • Groin • Inguinal • Femoral • Obturator • Incisional • Dorsal • Lumbar • Sciatic Internal • Cerebral • Hiatal
- 6. Clinical presentation • Uncomplicated • Impulse on coughing/straining • Reducible • Extent • Bubonocele - within inguinal canal • Funicular - exited superficial ring • Complete inguinoscrotal - into scrotal sac
- 7. Complicated • Obstructed • Features of intestinal obstruction • Irreducible • Strangulated • Irreducible • Tender, indurated, erythematous skin • Sepsis • Features of intestinal obstruction • Incarcerated • Irreducible • Relatively well • No features of obstruction/strangulation • Recurrent • Evidence of prior repair
- 10. • FBC - leukocytosis • BUSEC - electrolyte derangements, AKI • ABG - acid-base imbalance • PT/PTT - sepsis with coagulopathy • Blood C+S - sepsis • GSH
- 12. Management of Complicated Inguinal Hernia • Resuscitation • Volume • Perfusion • Acid-base disturbance • Electrolyte imbalance • Symptomatic relief • Ryle's tube • Analgesics • Antipyretic • Antibiotics • Closed loop obstruction • Strangulation • Bowel perforation
- 13. Manual reduction • Rule out strangulation • Cold pack for 30 mins • Adequate analgesia and sedation • Trendelenburg position • Patient group • Adults • Pressure to fundus of the hernia while guiding the proximal portion into the abdomen through the fascial defect • Only 1 - 2 attempts • Controversial • Children • Ipsilateral frog leg position • Deep ring in infants is more medial, i.e. the canal more vertical • First choice treatment
- 15. • Ultrasonography • Identify the nature of hernia content • Helps locate the deep ring • Gives the operator an inside 'view' on the forces & direction for reduction • Possible complications • Unrecognised strangulated hernia --> bowel perforation • Reduction en masse • Retroperitoneal haematoma
- 16. Reduction en-masse • Migration of a hernial sac along with its entrapped content into the properitoneal space • Usually due to forceful reduction of a hernia • Although non-visible, the pathologic process is on-going • Patient does not improve or continues to deteriorate after 'reduction'
- 17. Transferring to another hospital • Resuscitation • NG tube • CBD • Adequate analgesia • Blood investigations • Empirical antibiotics • Trendelenburg position
- 18. Surgery • Anticipate omental & bowel resection • Mode depends on hernia content involved, degree of contamination, available equipments & expertise • Modes • Open • Hernioplasty, herniorraphy, herniotomy • Laparotomy • Laparoscopic • Minimal bowel dilatation • No overt, generalised peritonitis • Esp. if suspect complicated omentocele
- 21. Femoral hernia • About 10% of groin hernias • More commonly occur in females (gynecoid pelvis) • More commonly present with complications
- 22. Problems • Signs not clear-cut • Location of fundus tends to vary • Variety of differential diagnoses - LN, pseudoaneurysm, saphena varix, psoas abscess pointing, soft tissue tumour/abscess • Commonly present with complication
- 23. Management • Identify complicated FH • Resuscitate • Empirical antiobiotics • Investigations • Abdominal x-ray • Ultrasonography • In ambiguous cases TRO other differentials • Blood tests • Surgery • NO ROLE OF MANUAL REDUCTION
- 24. Surgery • Anticipate bowel resection • Modes • Laparoscopic • Open • High approach • Better access & visualisation • Trans-inguinal approach • Infra-inguinal approach
- 25. Obturator hernia • Typically an elderly, frail lady who had lost significant body fat thus opening up the obturator foramen • Pain • In medial thigh/region of greater trochanter • Relieved by thigh flexion • Worsened by lateral rotation & extension of ipsilateral hip (Howship-Romberg sign) • Intestinal obstruction • Sepsis from strangulated bowel +- perforation
- 26. Diagnosis • Pre-op: high index of clinical suspicion, notorious to be missed on x-ray, confirmed on CT scan • Intra-op: during exploratory laparotomy
- 27. Treatment • NO ROLE FOR MANUAL REDUCTION • Emergency laparotomy • Bowel gangrene is common • Elderly patient with multiple significant co-morbidities • Effects of pneumoperitoneum • Elective repair • Laparoscopic or open
- 28. Conclusion • Groin hernias are common --> patients presenting with complications therefore proportionately high • Potentially life-threatening • FH & OH might present with diagnostic dilemma • Surgical exploration, resection of devitalised tissue and repair is the main-stay treatment • Laparoscopic repair is feasible in well-selected emergency patients