Groin Main[

8/14/2019 Groin Main[

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BISMILLAH AL REHMAN ALBISMILLAH AL REHMAN AL

RAHIM.RAHIM.


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GROIN HERNIASGROIN HERNIASINGUINAL HERNIAINGUINAL HERNIA

FEMORAL HERNIAFEMORAL HERNIA

By ;By ;

Abrar Hussain ZaidiAbrar Hussain Zaidi


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CONTENTSCONTENTS

AAnatomynatomy

ExaminationExamination Surgical problemsSurgical problems


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GroinGroin::

The area where the upper thigh meets theThe area where the upper thigh meets the

trunk. More precisely, the fold ortrunk. More precisely, the fold or

depressiondepression marking the junction of themarking the junction of thelower abdomen and the inner part of thelower abdomen and the inner part of the

thigh.thigh.


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INGUINAL CANAL


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DefinitionDefinition

TheThe oblique passage in the anterioroblique passage in the anterior

abdominal wallabdominal wall,, through which passesthrough which passes

the spermatic cord in the male and thethe spermatic cord in the male and theround ligament of the uterus in theround ligament of the uterus in the

femalefemale

AA conduitconduit in the abdominal wall throughin the abdominal wall through

which a testis descends into the scrotum.which a testis descends into the scrotum.


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INGUINAL CANAL -INGUINAL CANAL -

ANATOMYANATOMYSiteSiteThe inguinal canal is situated justThe inguinal canal is situated just

above the medial half of the inguinalabove the medial half of the inguinal

ligament.ligament.LengthLength

Approximately 4cm (1.57 inches).Approximately 4cm (1.57 inches).

DirectionDirectionIt is oblique, directed inferiorly, anteriorlyIt is oblique, directed inferiorly, anteriorly

and medially.and medially.


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INGUINAL CANAL-ANATOMYINGUINAL CANAL-ANATOMY


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INGUINAL CANAL-ANATOMYINGUINAL CANAL-ANATOMY


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Boundaries- Anterior wallBoundaries- Anterior wall

External oblique aponeurosisExternal oblique aponeurosis

Reinforced in lateral 1/3 by internalReinforced in lateral 1/3 by internal

oblique muscleoblique muscle


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Boundaries- LateralBoundaries- Lateral

Deep inguinal ringDeep inguinal ring

Opening in fascia transversalisOpening in fascia transversalis

1 cm above the inguinal ligament1 cm above the inguinal ligament Midway between anterior superiorMidway between anterior superior

iliac spine and symphysis pubisiliac spine and symphysis pubis

Medial to it lie the Inferior EpigastricMedial to it lie the Inferior Epigastricvesselsvessels


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Boundaries-MedialBoundaries-Medial

Superficial inguinal ringSuperficial inguinal ring

Triangular defect in externalTriangular defect in externaloblique aponeurosisoblique aponeurosis

Overlies the pubic crest whichOverlies the pubic crest which

forms the base of the openingforms the base of the opening


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Boundaries-Posterior wallBoundaries-Posterior wall

Fascia transversalisFascia transversalis

Reinforced in medial 1/3 byReinforced in medial 1/3 byconjoint tendonconjoint tendon


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Boundaries- FloorBoundaries- Floor

Inguinal ligamentInguinal ligament

Lower border of external obliqueLower border of external oblique

aponeurosisaponeurosis

Medially is continuous with lacunarMedially is continuous with lacunar

ligamentligament

Gives attachment to fascia lata on theGives attachment to fascia lata on theinferior borderinferior border


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Boundaries- RoofBoundaries- Roof

Arched fibers of conjoint tendonArched fibers of conjoint tendon


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Contents of inguinal canalContents of inguinal canal

Spermatic cord and ilioinguinal nerveSpermatic cord and ilioinguinal nerve

in malesin males

Round ligament of uterus andRound ligament of uterus andilioinguinal nerve in femalesilioinguinal nerve in females


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Spermatic cordSpermatic cord

VAS DEFERENCEVAS DEFERENCE

VESSELSVESSELS COVERINGSCOVERINGS


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The abdominal wall in the groin areaThe abdominal wall in the groin area

is made up of different structuresis made up of different structures


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From deep to superficial layers;From deep to superficial layers;

PeritoneumPeritoneum - the lining of the abdominal cavity- the lining of the abdominal cavity

(becomes the hernia sac)(becomes the hernia sac)

Subperitoneal fatSubperitoneal fat - fat beneath the peritoneum- fat beneath the peritoneum Transversalis fasciaTransversalis fascia - sheet of fibrous tissue tha- sheet of fibrous tissue tha

envelops the peritoneumenvelops the peritoneum Transversus abdominis muscleTransversus abdominis muscle

Internal oblique muscleInternal oblique muscle External oblique muscleExternal oblique muscle Subcutaneous fatSubcutaneous fat SkinSkin


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Spermatic cord-CoveringsSpermatic cord-Coverings

Each anterior abdominal wall layerEach anterior abdominal wall layergives itgives it

a covering to sheatha covering to sheath

From within outwards the coverings areFrom within outwards the coverings arederived as followsderived as followso Internal Spermatic fasciaInternal Spermatic fascia from fasciafrom fascia

transversalistransversaliso Cremasteric fasciaCremasteric fascia from internalfrom internal

obliqueobliqueo External spermaticExternal spermatic fascia fromfascia from

external obliqueexternal oblique


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Spermatic cord - ContentsSpermatic cord - Contents

Vas deferensVas deferens Artery to vas deferens (branch of inferiorArtery to vas deferens (branch of inferior

vesical artery)vesical artery) Testicular artery (branch of abdominalTesticular artery (branch of abdominal

aorta)aorta) Testicular veinTesticular vein Testicular lymphaticsTesticular lymphatics Testicular nerve fibersTesticular nerve fibers Processus vaginalisProcessus vaginalis Cremasteric artery (branch of inferiorCremasteric artery (branch of inferior

Epigastric artery)Epigastric artery) Nerve to cremaster (genital branch ofNerve to cremaster (genital branch of

genitofemoral nerve)genitofemoral nerve)


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INGUINAL HERNIAINGUINAL HERNIA


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DEFINITIONDEFINITION

Protrusions of abdominal cavityProtrusions of abdominal cavity

contentscontentsthrough the inguinal canal.through the inguinal canal.

They are very common - 7% of theThey are very common - 7% of thepopulationpopulation

Hernia repair is one of the mostHernia repair is one of the most

frequently performed surgicalfrequently performed surgical


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INGUINAL HERNIA-INGUINAL HERNIA-

PathologyPathology A defect in the wallA defect in the wall

A sacA sac CoveringsCoverings

Contents inside the sacContents inside the sac


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Defect in the wallDefect in the wall

Congenital Inguinal CanalsCongenital Inguinal Canals

-umbilicus-umbilicus

AcquiredAcquired

Traumatic/operativeTraumatic/operativeWeakness of wallWeakness of wall

CombinationCombination


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A hernia consists of:A hernia consists of: A sacA sac

Its coveringsIts coverings Its contentsIts contents


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TYPES OF INGUINAL HERNIASTYPES OF INGUINAL HERNIAS DIRECTDIRECT

INDIRECTINDIRECT


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Hernias can be:Hernias can be:

ReducibleReducible

IrreducibleIrreducible Obstructed or incarceratedObstructed or incarcerated

StrangulatedStrangulated


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CAUSATIVE FACTORSCAUSATIVE FACTORS

CONGENITALCONGENITAL AQUIREDAQUIRED

WEAK ANT ABDOMINAL WALLWEAK ANT ABDOMINAL WALLCOUGHCOUGH

CONSTIPATIONCONSTIPATION

WIEGHT LIFTINGWIEGHT LIFTINGPREVIOUS SURGERYPREVIOUS SURGERY

RRaised intra-abdominal pressureaised intra-abdominal pressure


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CLINICAL PRESENTATIONCLINICAL PRESENTATION

Bulge in the groin areaBulge in the groin area that canthat canbecome more prominent whenbecome more prominent when

coughing, straining, or standing up.coughing, straining, or standing up.

Often painful, and the bulge commonlyOften painful, and the bulge commonly

disappears on lying down.disappears on lying down.


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The hernia often increases in size onThe hernia often increases in size on

coughing or straining -cough impulsecoughing or straining -cough impulse

+VE+VE

ItIt reduces in sizereduces in size or disappearsor disappears

when relaxed or supinewhen relaxed or supine


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TheThe inability to "reduceinability to "reduce", or place the", or place the

bulge back into the abdomen usuallybulge back into the abdomen usually

means the hernia is "means the hernia is "incarcerated,"incarcerated,"/obstructed /strangulated --/obstructed /strangulated --necessitating emergency surgery.necessitating emergency surgery.


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Irreducible hernias have either aIrreducible hernias have either a

narrow necknarrow neckor the contentsor the contents adhereadhere

to the sac wallto the sac wall

Obstructed hernias containObstructed hernias contain

obstructed but viable intestineobstructed but viable intestine


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Irreducible but non-obstructedIrreducible but non-obstructed herniasherniasmay cause little pain,may cause little pain,

Content are usually -omentumContent are usually -omentum

If the hernia causesIf the hernia causes obstruction:obstruction:

colicky abdominal pain, distension andcolicky abdominal pain, distension andvomiting may occurvomiting may occur

The hernia will be tense tender andThe hernia will be tense tender andirreducibleirreducible


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If strangulation occursIf strangulation occurs

Blood circulation is compromisedBlood circulation is compromised The lump will become red and tenderThe lump will become red and tender

Patient is ill ,toxic and has clinicalPatient is ill ,toxic and has clinical

signssignsof intestinal obstructionof intestinal obstruction


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DiagnosisDiagnosis

Diagnosis is based on clinicalDiagnosis is based on clinical

featuresfeatures

Herniography Ultrasound or CTHerniography Ultrasound or CT

Rarely requiredRarely required

In occult herniaIn occult hernia


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HistoryHistory

Define any causative factorDefine any causative factor

General assessmentGeneral assessment


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EXAMINATIONEXAMINATION

Standing positionStanding position

Lying positionLying position

InspectionInspection

PalpationPalpation

PercussionPercussion AuscultationAuscultation

G


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EXAMINATIONEXAMINATION

Describe the swellingDescribe the swelling

Cough impulseCough impulse

ReducibilityReducibility ContentsContents

Abdominal examination/+PR.Abdominal examination/+PR. Systemic examinationSystemic examination


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INGUINAL HERNIA EXAMINATIONINGUINAL HERNIA EXAMINATION


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TREATMENTTREATMENT CORRECTION OF CAUSATIVECORRECTION OF CAUSATIVE

/AGGRAVATING FACTORS/AGGRAVATING FACTORS

PREPARATIONPREPARATION

SURGERY open / LaparoscopicSURGERY open / Laparoscopic

POST OPERATIVE CAREPOST OPERATIVE CARE


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SURGICAL TREATMENTSURGICAL TREATMENT

PRINCIPLESPRINCIPLES

Mange the contentsMange the contents Excise the sacExcise the sac

Strengthen the posteriorStrengthen the posterior

wallwall


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SURGICAL TREATMENTSURGICAL TREATMENT

Surgical ProceduresSurgical Procedures

HERNIOTOMYHERNIOTOMY HERNIORRHAPHYHERNIORRHAPHY

HERNIOPLASTYHERNIOPLASTY

ELCTIVE VS EMERGENCYELCTIVE VS EMERGENCY

SURGERYSURGERY


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Surgical repair - techniquesSurgical repair - techniques

Bassini +/- Tanner SlideBassini +/- Tanner SlideDarnningDarnning

ShouldiceShouldice


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Surgical repair - techniquesSurgical repair - techniques

Lichtenstein / mesh reairLichtenstein / mesh reair

Shouldice or Liechtenstein nowShouldice or Liechtenstein nowregarded as 'gold standard' as judgedregarded as 'gold standard' as judged

by low risk of recurrenceby low risk of recurrence

Laparoscopic repairLaparoscopic repair


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HERNIORRHAPHYHERNIORRHAPHY

1) Reflected medial leaf after a strip has been separated; 2) Internal oblique muscle1) Reflected medial leaf after a strip has been separated; 2) Internal oblique muscle

seen through the splitting incision made in the medial leaf; 3) Interrupted suturesseen through the splitting incision made in the medial leaf; 3) Interrupted sutures


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seen through the splitting incision made in the medial leaf; 3) Interrupted suturesseen through the splitting incision made in the medial leaf; 3) Interrupted sutures

between the upper border of the strip and conjoined muscle and internal obliquebetween the upper border of the strip and conjoined muscle and internal oblique

muscle; 4) Interrupted sutures between the lower border of the strip and the inguinalmuscle; 4) Interrupted sutures between the lower border of the strip and the inguinal

ligament; 5) Pubic tubercle; 6) Abdominal ring; 7) Spermatic cord; and 8) Lateral leaf.ligament; 5) Pubic tubercle; 6) Abdominal ring; 7) Spermatic cord; and 8) Lateral leaf.


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Pain managementPain management

Prophylaxis against infectionProphylaxis against infection Preventive measures againstPreventive measures against

recurrencerecurrence


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INGUINAL HERNIAINGUINAL HERNIA?


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FEMORALFEMORAL

HERNIAHERNIA


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FEMORAL HERNIAFEMORAL HERNIA

Femoral hernias occur just belowFemoral hernias occur just below

the inguinal ligamentthe inguinal ligament

Abdominal contents passAbdominal contents pass

through a naturally occurringthrough a naturally occurring

weakness called theweakness called the femoralfemoral

canalcanal..


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Femoral CanalFemoral Canal

locatedlocated below the inguinalbelow the inguinal

ligamentligament onon

the lateral aspect of the pubic tubercle.the lateral aspect of the pubic tubercle. PassagewayPassageway by which many lymphaticsby which many lymphatics

from lower limb pass to abdomen.from lower limb pass to abdomen.


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Boundaries - Femoral CanalBoundaries - Femoral Canal

Anterior --Inguinal ligament,Anterior --Inguinal ligament,

Posterior--Pectineal ligamentPosterior--Pectineal ligament

Medial ---Lacunar ligamentMedial ---Lacunar ligament

laterally --Femoral vein.laterally --Femoral vein.


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Femoral CanalFemoral Canal - CONTENTS- CONTENTS

It normallyIt normally containscontains a fewa fewlymphatics, loose areolarlymphatics, loose areolartissue and occasionally atissue and occasionally a

lymph node called Cloquet'slymph node called Cloquet'snode.node.

TheThe functionfunction of this canalof this canal

appears to be to allow theappears to be to allow thefemoral vein to expandfemoral vein to expand whenwhennecessary to accommodatenecessary to accommodateincreased venous return fromincreased venous return from

the leg during periods ofthe leg during periods of


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Femoral Hernia-DefinitionFemoral Hernia-Definition

Protrusion of AbdominalProtrusion of Abdominal

contents through thecontents through the femoralfemoral

canalcanal..


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Femoral Hernia-Clinical FeaturesFemoral Hernia-Clinical Features

SymptomsSymptoms More common inMore common in womenwomen, usually, usually elderlyelderly

andand

frail (although they can happen infrail (although they can happen inchildren).children).

Typically present as a groin lumpTypically present as a groin lump.. May or may not be associated withMay or may not be associated with

pain.pain. Often, they present with aOften, they present with a

complicationcomplication;;

irreducibility , intestinal obstructionirreducibility , intestinal obstruction


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Femoral Hernia-ClinicalFemoral Hernia-Clinical

FeaturesFeaturesSignsSigns

The obvious finding -- a lump in the groin.The obvious finding -- a lump in the groin. Cough impulse is often absent and should notCough impulse is often absent and should not

be reliedbe relied

onon

The lump is more globular than the pearThe lump is more globular than the pearshaped lumpshaped lump

of the inguinal hernia.of the inguinal hernia. The bulk of a femoral hernia lies below theThe bulk of a femoral hernia lies below the

inguinalinguinal


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The incidence of strangulationThe incidence of strangulation inin

femoralfemoral

hernias is high.hernias is high.

A femoral hernia has often been found toA femoral hernia has often been found to

be the cause ofbe the cause ofunexplained smallunexplained smallbowel obstruction.bowel obstruction.


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Femoral Hernia-Differential DiagnosesFemoral Hernia-Differential Diagnoses

2.2. Inguinal herniaInguinal hernia

3.3. Enlarged inguinal lymph nodeEnlarged inguinal lymph node

4.4. Aneurysm of the femoral arteryAneurysm of the femoral artery

5.5. Saphena varixSaphena varix

6.6. Psoas abscessPsoas abscess7.7. Undescended testis/Ectopic testisUndescended testis/Ectopic testis

l h i


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Femoral hernia -Femoral hernia -

ManagementManagement Uncomplicated femoral hernias - repairedUncomplicated femoral hernias - repaired

as an EARLY elective procedureas an EARLY elective procedure

Often require emergency surgeryOften require emergency surgery


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Femoral hernia - ManagementFemoral hernia - Management

Three classical approaches to the femoralThree classical approaches to the femoral

canalcanal

Low (Lockwood)Low (Lockwood)

Transinguinal (Lotheissen)Transinguinal (Lotheissen)

High (McEvedy)High (McEvedy)

l h i


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Femoral hernia - ManagementFemoral hernia - Management

Irrespective of approach the operative aimsIrrespective of approach the operative aimsare;are;

Dissection of the sacDissection of the sac

Reduction / manage the contentsReduction / manage the contents

Ligation of the sacLigation of the sac

Approximation of the inguinal and pectinealApproximation of the inguinal and pectinealligamentsligaments


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FEMORAL HERNIA REPAIR



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Pain managementPain management Prophylaxis against infectionProphylaxis against infection

Preventive measuresPreventive measures

Manage associated problemsManage associated problems


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FEMORA L HE RNIA -EMORA L HE RNIA - ?


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Littre's herniaLittre's hernia

Strangulated Meckel's diverticulumStrangulated Meckel's diverticulum Can cause small bowel fistulaCan cause small bowel fistula


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Mortality of elective hernia repairMortality of elective hernia repair

The mortality of elective hernia repairThe mortality of elective hernia repairincreases with ageincreases with age

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