![]() Kembara Xtra - Medicine - Hernia Areas of the abdominal wall's weakness or rupture where structures can pass The inguinal Indirect: congenital; herniation lateral to the inferior epigastric vessels through internal inguinal ring into inguinal canal. Direct: acquired; herniation through defect in transversalis fascia of abdominal wall medial to inferior epigastric vessels; frequency increases with age as fascia weakens. An "incomplete hernia" remains in the inguinal canal while a "complete hernia" descends into the scrotum. - Pantaloon: protrusion of the abdominal wall on both sides of the epigastric vessels along with a direct and indirect inguinal hernia. Femoral herniation: has a thin neck and is particularly vulnerable to imprisonment and strangling. It descends down the femoral canal deep to the inguinal ligament. - Congenital: herniation through defect in abdominal wall fascia caused by collagen deficient disease. - Incisional or ventral: herniation through a defect in the anterior abdominal wall at the site of a past surgical incision Umbilical: defect at the umbilical ring; Epigastric: protrusion through the middle line above the level of the umbilicus; Spigelian hernia: herniation through the Spigelian line (lateral border of the rectus abdominis) for a lateral ventral hernia result; Sports hernia (not a true hernia): strain or tear of soft tissue of the groin or lower abdomen; Others: Reducible: Extruded sac and its contents can be returned to intra-abdominal position spontaneously or with gentle manipulation.Irreducible or incarcerated hernias : The extruded sac and its contents cannot be brought back to their original intra-abdominal position. - Strangulated: Blood flow to the contents of the hernia sac is impeded. Richter: A portion of the bowel's diameter has been imprisoned or strangulated. Possible partial wall damage raises the risk of bowel rupture and peritonitis. - Sliding: The right side's cecum and the left side's sigmoid colon make up the wall of the inguinal hernia sac. Aspects of Geriatrics Age-related increases in abdominal wall hernias are associated with a considerable increase in risk after surgical correction. pregnant women's issues Pregnancy-related hormonal imbalances and increased intra-abdominal pressure may increase the incidence of abdominal wall hernias. Umbilical hernias are linked to numerous, protracted births. Epidemiology Incidence: 75-80% inguinal and femoral groin hernias; 2-20% incisional/ventral; dependent on whether previous operation was contaminated or infected; 3-10% umbilical; considered congenital. 6-27% lifetime risk of groin cancer in older males Most inguinal hernias occur before 1 year of age or after the age of 55. - About 50% of children under the age of 2 have a patent processus vaginalis, which drops to 40% after that age. Only 25% to 50% of cases are clinically important. - Male:female ratio of 10:1; inguinal hernia in 5% of infants - An increase in the number of individuals with abdominal aortic aneurysms - An increase in the number of preterm newborns - Femoral hernias make up 10% of all groin hernias, 40% of which require immediate surgery. Incisional/ventral: Incisional hernias complicate 10–23% of abdominal procedures, most frequently in upper midline incisions. Umbilical cord: 10-20% of infants; most are close by age 5 years; incidence ratio: males > females Prevalence Femoral and umbilical hernias are more common in women than in men, with groin and inguinal hernias being more common in men. In both men and women, indirect inguinal hernias predominate. Those who smoke and those who are obese are more likely to develop incisional/ventral hernias (IVH). Pathophysiology and Etiology A fascial deficiency in the abdominal wall is caused by a loss of tissue elasticity and strength, especially with aging or a congenital abnormality in the abdominal fascia. The majority of juvenile hernias (like patent processus vaginalis) are congenital. The tissues of the front abdominal wall have a weakened state that causes the majority of adult hernias. Genetics No genetic pattern is known High blood pressure in the abdomen, coughing, strenuous exercise, constipation, pregnancy, ascites, prostatism, obesity, advanced age (loss of tissue turgor), smoking, steroid usage, low birth weight, and preterm are risk factors. Age: Recurrent groin hernias, femoral hernias, and scrotal hernias are linked to a higher risk of acute hernia surgery. Accompanying Conditions Pregnancy, advanced age, Ehlers-Danlos syndrome, Marfan syndrome, polycystic kidney disease (PKD), osteogenesis imperfecta, Down syndrome, abdominal aortic aneurysm, chronic obstructive pulmonary disease, repeated abdominal operations, History Pain, nausea, vomiting, and bloating; improved with reclining; may suggest problem (e.g., strangling) May observe protrusion through abdominal wall during increased intra-abdominal pressure (Valsalva maneuver or cough) clinical assessment Examine the patient while they are still standing. To assess the degree of intracavitary content movement while being palpated, the patient should cough, stretch, or do the Valsalva maneuver. Repeat the examination when the patient is supine. Superior to the inguinal ligament, the inguinal - Direct inguinal hernia: Increased intra-abdominal pressure is palpable along with a deep (posterior to anterior) bulge caused by a transversalis fascia defect. - Indirect inguinal hernia: A chronic process vaginalis is discovered as a protrusion in the inguinal canal that may extend into the scrotum. Femoral (inferior to inguinal ligament): upper middle thigh bulge; the neck of the sac protrudes laterally and beneath a finger placed on the pubic tubercle. Umbilical protrusion at the umbilicus that can be felt Ventral/Incisional: palpable protrusion at the location of the previous abdominal incision or midline over the umbilicus a perceptible projection off the midline above the umbilicus, or epigastric Multiple Diagnoses Sports hernias, pelvic fractures, adductor tears, omphalomesenteric duct, urachal cyst, lipoma, varices, cryptorchidism, abscess, tumor, and lymphadenopathy Laboratory Results Plain radiography to rule out blockage; imaging rarely necessary; reserve for suspected abdominal hernia or ambiguous diagnosis Inguinal hernias can be evaluated with ultrasound (US). CT or tangential radiography for postoperative patients who complain of abdominal pain and those with incisional and abdominal wall hernias The herniography procedure is no longer advised. Tests in the Future & Special Considerations For occult hernias that are difficult to detect during an examination or with imaging, a diagnostic laparoscopy may be helpful. Elective surgical repair is associated with much reduced morbidity and death than non-elective surgical repair. Acute situation - Pain control for hernias with symptoms - Early surgical treatment of strangulated hernias is recommended to avoid complications including necrosis and viscus perforation. – Results are improved by manual reduction of incarcerated hernias because it enables elective repair after edema and inflammation have subsided. – Compared to elective surgeries, the complication risk for juvenile inguinal hernia repairs is higher. – Acute hernia repair has a poorer survival rate and increased morbidity. – Laparoscopic IVH repair is safe, has fewer complications, requires less time in the hospital, and may take less time overall. Similar to surgical repair, postoperative pain and recurrence rates exist. – Extraperitoneal laparoscopic surgery takes less time to complete for patients than open mesh repair, and the risk of complications is the same. – The FDA has recalled many products in the past, mostly because to issues with intestine perforation and obstruction. Mesh is typically recommended for hernia repairs. Medication Antibiotics: Following groin hernia procedures, prophylaxis does not prevent wound infections. Postoperative discomfort is significantly reduced by local anesthesia following surgical repair. Under local anesthetic, tension-free treatments (like Lichtenstein) can be carried out. Referral Inform patients that symptoms or indications of confinement or strangulation (acute stomach pain, fever, bloody stools) necessitate rapid assessment. Further Treatments Aspects of Geriatrics There are no studies on the effectiveness of using a truss (external supportive device) for direct inguinal hernias. Surgical Techniques Surgical correction is required for all inguinal hernias. In asymptomatic patients with major comorbidities that would preclude urgent treatment, watchful waiting is safe. The absolute indications for hernia repair are incarceration and strangulation. Patients who are not candidates for surgery due to risk considerations are considered contraindicated. - Patients who are pregnant or who have ongoing infections should not undergo elective repair. Considerations unique Usually, umbilical hernias less than 0.5 cm can be treated therapeutically. – In toddlers 2 to 4 years old, umbilical hernias often close on their own. – When comparing single-incision laparoscopic inguinal hernia repair to conventional multiport laparoscopic surgery, surgical times and complication rates are comparable. – In pregnancy, "watchful waiting" is advised. The results of elective postpartum repair are comparable, and there is no elevated risk of arrest or strangulation before or during delivery. - When compared to open surgery, laparoscopic surgery had a lower recurrence rate in women. - Ascites does not necessarily rule out repair. Inguinal hernia is the gold standard. Open: Lichtenstein with mesh (37%): lower rates of recurrence Requires general anesthesia; laparoscopic (14%) with mesh: lessened hospital stay and postoperative pain; transabdominal preperitoneal (TAPP) versus total extraperitoneal (TEP) Pediatric: A fast, secure, and reliable alternative to open surgery is laparoscopic percutaneous repair. It is linked to shorter recovery times during surgery and no rise in complication or recurrence rates. - Incisional/ventral Laparoscopic repair is effective for the majority of patients with initial or recurrent ventral hernias; there is a 10% recurrence risk. Avoid mesh in young patients (3)[B]. - Umbrella Open excision with stitch closure for children Adult: Mesh-based open repairs may prevent hernia recurrence. • Difficulties - Repeating The Seromas - Laparoscopic versus open procedure results in less postoperative discomfort, whether it be acute or chronic. - Infection of the wound - Damage to the cord structures during inguinal herniorrhage; with nerve damage, most symptoms will go away. Groin (adult): 1% per year risk of bowel strangulation without surgical treatment; 0-10% postoperative recurrence rates, depending on surgeon experience and operation type; low recurrence rates (3%) following surgery; may spontaneously resolve in newborns Postoperative incidence of incisional/ventral: 3-5% Recurrence rates after repair ranged from 2-17% to 20-46% in bigger hernias. Umbilical (pediatric) - High likelihood of spontaneous resolution - Children with larger defects and older children are less likely to have hernias that resolve completely. Umbilical (adult): postoperative recurrence up to 11% Epigastric: without surgical intervention, most end up in jail or are strangled. Due to the frequent occurrence of undetected faults during repair, recurrence is high.
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