6. Treatment of Oblique and Direct inguinal hernia Flashcards
(86 cards)
1
Q
Treatment of Oblique inguinal hernia
A
- Truss
2. Surgical treatment
2
Q
Disadvantage of Truss in Treatment of Oblique inguinal hernia
A
Predispose to:
- Strangulation
- Hydrocele of hernial sac
3
Q
Surgical treatment in Treatment of Oblique inguinal hernia
A
- The only curative treatment
- Modalities
- Surgical details
4
Q
Modalities of Surgical treatment in Treatment of Oblique inguinal hernia
A
- Herniotomy
- Herniorrhaphy
- Hernioplasty
5
Q
Herniotomy in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia
A
- Principle
* Indication
6
Q
Principle of Herniotomy in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia
A
Excision of the hernial sac up to the neck.
7
Q
Indication of Herniotomy in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia
A
This is sufficient in children with congenital hernia when the musculature is good & the only problem is performed sac
8
Q
Principle of Herniorrhaphy in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia
A
Repair of the defect by sutures with herniotomy (better) or without herniotomy.
9
Q
Hernioplasty in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia
A
- Alternative name
- Principle
- Advantages
10
Q
Alternative name of Hernioplasty in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia
A
Lichntenstein repair ليخنشتاين
11
Q
Principle of Hernioplasty in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia
A
Repair with mesh
12
Q
Advantages of Hernioplasty in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia
A
Tension free repair )> no recurrence
13
Q
Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
- Preoperative preparation :
* Operative
14
Q
Preoperative preparation in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
Treat first any predisposing factor as COPD, BPH
15
Q
Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
- Anesthesia
- Position
- Sterilization
- Incision
- Steps
16
Q
Anesthesia in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
General / spinal or epidural / local anesthesia
17
Q
Position in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
Supine.
18
Q
Sterilization in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
Betadine from umbilicus to mid-thigh.
19
Q
Incision in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
1 inch above & parallel to the medial 2/3 of the inguinal ligament
20
Q
Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
- Divide skin, S.C tissue & Scarpa’s fascia.
- Divide the external oblique aponeurosis in the direction of its fibers
- Reflect the ext oblique aponeurosis upwards & downwards.
- Identify the ilioinguinal nerve & reflect it over the aponeurosis
- The cord is delivered & lifted over a gauze tape.
- Divide the cremasteric muscle & internal spermatic fascia
- Manipulation of the sac
- Herniotomy alone is enough in congenital hernia in infants and children
- Herniorrhaphy
or
- Hernioplasty
21
Q
The direction of its fibers in Division of the external oblique aponeurosis in the direction of its fibers in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
from the external ring extending laterally till the internal ring
22
Q
Reflection of the external oblique aponeurosis upwards in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
to expose the conjoint tendon
23
Q
Reflection of the external oblique aponeurosis downwards in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
to expose the superior surface of the inguinal ligament.
24
Q
Identification of the ilioinguinal nerve & its reflection over the aponeurosis in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
A
as injury of the ilioinguinal nerve at this level causes hypoesthesia in the scrotum only without any paralysis.
25
Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
1. Identification of The sac
2. Identification of The neck
3. Dissection of the sac by sharp & blunt dissection until its neck
4. Twisting of the sac and its transfixation
5. Excision of the redundant sac
26
Identification of The sac in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
The sac is known by:
* Pearly white in colour.
* Antero-lateral to the vas.
27
Identification of The neck in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
The neck is known by:
* Lateral to the inferior epigastric vessels
* The narrowest Part of the sac.
* Extra-peritoneal fat around it
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Twisting of the sac and its transfixation in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* if the sac is not the Processus vaginalis
| * if the sac is the Processus vaginalis
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if the sac is not the Processus vaginalis in Twisting of the sac and its transfixation in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Transfixation at the deep ring
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if the sac is the Processus vaginalis in Twisting of the sac and its transfixation in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Transfixation of the proximal part
| * Eversion of the distal part as in hydrocele.
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Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Indication
| * Principle
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Indication of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Done in adults with good musculature
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Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Herniotomy
| * Repair of the weak posterior wall of the inguinal canal.
34
Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Type of sutures used
* Modalities
* Note on the modalities
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Type of sutures used in Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
interrupted non- absorbable prolene sutures
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Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
1. Shouldice Repair
2. Marcy repair
3. Bassini repair
4. Lytle repair
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Shouldice Repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Repair is done by double breasting of the fascia transversalis
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double breasting of the fascia transversalis in Shouldice Repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
1. The fascia transversalis is opened in the length of the floor of inguinal canal from the pubic tubercle to the internal ring; this creates 2 flaps.
2. The lower flap is sutured to the undersurface of the upper flap.
3. The upper flap is sutured to the shelving edge of the inguinal ligament
4. Finally the fascial part of the conjoint tendon is sutured to the inguinal ligament.
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the shelving edge of the inguinal ligament in double breasting of the fascia transversalis in Shouldice Repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
It's the natural extension of the fascia transversalis below
40
Marcy repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
The transversus abdominis aponeurotic arch is sutured inferiorly to the iliopubic tract
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The iliopubic tract in Marcy repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Alternative name
| * Definition
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Alternative name for The iliopubic tract in Marcy repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Thomson's ligament
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Definition of The iliopubic tract in Marcy repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
The thickened lower part of fascia transversalis.
44
Bassini repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Principle
| * Disadvantages
45
Principle of Bassini repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
The inguinal ligament is sutured to the conjoint tendon & arched fibres of internal oblique and transversus abdominis muscle
46
Disadvantages of Bassini repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
i. Tension atrophy of conjoint tendon
ii. Interferes with the normal shutter mechanism.
iii. Union & healing is unlikely to occur between the fleshy fibers of the conjoint tendon & the fibrous tissue of the inguinal ligament in the lateral part of the repair.
47
Principle of Lytle repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Narrowing of the internal ring.
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Note on the modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
It is recommended to do Tanner's slide release incision
49
Tanner's slide release incision in Note on the modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* a relaxing incision in the anterior rectus sheath
| * to avoid sutures under tension which may disrupt.
50
Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Alternative name
* Indications
* Advantages
* Mechanism of action
* Types
* Types of mesh used
* Recent trends
51
Alternative name of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Lichtenstein repair
52
Indications of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Done in patients with weak musculoaponeurotic boundaries or wide defect.
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Advantages of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Most surgeons prefer it now as
* it is tension free
* recurrence is rare.
54
Mechanism of action of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
The interstices of the mesh will be impregnated with a dense sheet of fibrous tissue.
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Types of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
(A) Onlay hernioplasty :
(B) Inlay hernioplasty
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Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Site of mesh used
* Fixation of the mesh
* Gilbert hernioplasty
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Site of mesh used in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
On the fascia transversalis
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Fixation of the mesh in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Superior
| * Inferior
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Superior Fixation of the mesh in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
It is sutured to the transversus abdominis aponeurotic arch
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Inferior Fixation of the mesh in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
It is sutured to the iliopubic tract and inguinal ligament .
61
Gilbert hernioplasty in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Some surgeons recommend application of a mesh plug in the internal ring with lateralization of the cord .
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lateralization of the cord in Gilbert hernioplasty in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
As the hernia normally descends downwards forwards and medially
So lateralization of the cord is recommended to prevent the descent of hernia
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Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Alternative names
* Site of mesh used
* Approach
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Alternative names for Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Preperitoneal Hernioplasty
| * Stoppa repair
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Site of mesh used in Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
The mesh is placed in the space of Bogros
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Space of Bogros in Site of mesh used in Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
between the fascia transversalis and the peritoneum
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Approach of Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
a) Open surgery "stoppa repair"
| b) Laparoscopic hernioplasty
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Techniques of Laparoscopic hernioplasty in Approach of Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Done by 2 techniques
* TAPP : Trans-abdominal pre-peritoneal repair.
* TEP : Totally extra peritoneal repair
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Trans-abdominal pre-peritoneal repair in Techniques of Laparoscopic hernioplasty in Approach of Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Laparoscope enters Abdominal cavity then finally the preperitoneal plane
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Totally extra peritoneal repair in Techniques of Laparoscopic hernioplasty in Approach of Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Laparoscope Directly reach preperitoneal plane
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Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
1- Prolene mesh
2- Vicryl mesh
3- Vypro mesh
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Advantages of Prolene mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Strong & inert
| * Most commonly used
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Most commonly used mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Prolene mesh
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Indication of Vicryl mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Used in cases of burst abdomen when there is big muscular defect.
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Vypro mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Composition
| * Advantages
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Composition of Vypro mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
composed of Vicryl + Prolene
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Advantages of Vypro mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Easily handled and sutured.
| * Vicryl will be absorbed within 3 months leaving prolene only
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Recent trends in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
Prolene hernia system (PHS)
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Prolene hernia system (PHS) in Recent trends in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
* Components
| * Mechanism of action
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Components of Prolene hernia system (PHS) in Recent trends in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
This system consists of an anterior oval prolene mesh connected to a circular posterior prolene mesh.
81
Mechanism of action of Prolene hernia system (PHS) in Recent trends in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia
The anterior component is inserted on the fascia transversalis & the posterior component is laid pre-peritoneal.
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Treatment of Direct inguinal hernia
* The only curative Treatment is surgery after correction of any predisposing factors.
* Operations
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Operations in Treatment of Direct inguinal hernia
As for OIH with the following differences
1- Herniotomy MAY BE NOT NEEDED in the lateral type as the neck is wide (but herniotomy is needed in the medial type)
3. Invagination of the sac by the repair is enough .
2- Hernioplasty: Best.
84
Pantaloon hernia
* Alternative names
| * Definition
85
Alternative names for Pantaloon hernia
saddle-bag hernia
86
Definition of Pantaloon hernia
sometimes, the patient may have 2 sacs at the same time; one sac passing through the internal ring (oblique) and the other passes through the posterior wall (Direct)
with the inferior epigastric vessels between the 2 sacs
