CASE PRESENTATION

I. IDENTITY

No medical records : 894 582

Date of hospital entry : October 5th, 2015

Name : Mr. M

Age : 43 years

Gender : Male

Occupation : Labor

Address : Gegesik Kulon

Religion : Islam

Marital status : Married

II. ANAMNESIS

Main Complaint

Patients complain of a lump in the groin right since 5 months ago.

History of Disease

Patient came to RSUD Arjawinangun with complain of a lump in the groin right since

5 months ago. At first the patient felt a lump arise when standing and heavy lifting,

then disappear at rest. But over time the lump getting bigger and can not be put back.

Oval-shaped lumps and no pain when pressed. No complaints of fever, nausea,

vomiting, and bloating. Urinating dan defecating in the normal range.

History of Past Disease

Patient said he had never experienced the same symptoms before. Patients had no

previous operating history. Patient denied any history of diabetes, hypertension,

asthma, heart disease, and hemorrhoids.

History of Family Disease

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Patients said that no family members with the same disease as patients. There is no

family who suffer diabetes, hypertension, asthma, and heart disease.

History of Habits and Socio-Economic

The patient was a man with enough nutritional status. Patients are active smokers.

Patients have a lower economic status.

III. PHYSICAL EXAMINATION

a. Present Status

General Condition : Mild Pain

Awareness : Compos mentis

Blood Pressure : 140/80

Pulse : 90 x/minute

Breathing : 24 x/minute

Temperature : 36,8 ºC

Head

Form : Normocephale, Symmetrical

Hair : Black, No hair fall

Eye : Anemic Conjungtivas (-/-), Icteric Schleras (-/-),

Light Reflexes (+/+), isochore pupil right = left

Ear : Normal form, cerumen (-), thympany membrane

intact

Nose : Normal form, no septum deviation, epitaxis (-/-)

Mouth : Normal

Neck

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Enlargement of lymph nodes (-)

Trachea is in the middle

No mass found

Thorax

Lungs - pulmonary

Inspection : The chest shape is symmetrical both left and right

Palpation : Fremitus and vocale tactile both symmetrical left

and right, crepitation (-), tenderness (-), rebound

tenderness (-)

Percussion : Resonance sound in both lung fields

Auscultation : Vesicular and bronchial sound in the entire lung

field, rhonchi (-/-), wheezing (-/-)

Abdomen

Inspection : Flat, symmetrical, mass (-)

Palpation : Tenderness (-), rebound tenderness (-) a/r iliaca

dextra,

Percussion : Tympanity sound in four quadrants

Auscultation : Bowel sound (+)

Extremities

Upper

Muscle Tone : normal

Movement : active / active

Mass : - / -

Strenght : 5/5

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Oedema : - / -

Lower

Muscle Tone : normal

Movement : active / active

Mass : - /-

Strenght : 5/5

Oedema : - / -

Genitalia

No abnormalities

b. Localized Status

Regio : Inguinalis Dextra

Inspection : mass appears elliptical with ± 7x5 cm size, same

color as the surrounding skin, and there are no signs

of inflammation.

Palpation : palpable masses with flat surfaces, supple and can

not be entered manually using the finger. Finger tip

test: palpable lump in the fingertips.

Auscultation : there is no intestinal peristalsis sound.

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c. Laboratory Examination

Routine Blood

Test Result Unit

WBC 5,1 10e3/µL

RBC 4,71 10e6/

µL

HGB 13,7 g/dL

HCT 40,7 %

MCV 86,4 fL

MCH 29,1 Pg

MCHC 33,7 g/dl

RDW 12,6 %

PLT 171 10e3/

µL

Neut 56,6 %

Lymph 34,6 %

Mono 8,8 %

Eos 0 %

Baso 0 %

Test Result Unit

Ureum 25,5

Creatinin 0,66

Test Result Unit

HbsA

g

0,02

Anti

HIV

Non

Reaktif

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IV. DIAGNOSIS

Hernia Inguinalis Dextra Ireponible.

V. DIFFERENTIAL DIAGNOSIS

Hernia Inguinalis Medialis Dextra

Limfadenopati Inguinal Dextra

VI. TREATMENT

Operative

Hernioraphy

Medicamentosa

Inj. Ceftazidin 2x1 gr

Inj. Ranitidin 2x1 amp

Inj. Ketorolac 2x1

Post operative education

Total bed rest and fasting until the bowel sounds (+)

VII. PROGNOSIS

Ad vitam : ad bonam

Ad sanationam : ad bonam

Ad fungsionam : ad bonam

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LITERATURE REVIEW

I. DEFINITION

A hernia is a protrusion or protrusion of the contents of a cavity through a defect or weak parts of

the wall in question. Abdominal hernia, abdominal contents protrude through a defect or weak

parts of the musculo-aponeurotik layers of the abdominal wall. Hernia consists of rings, bags,

and fill hernia.

II. EPIDEMIOLOGY

Seventy-five percent of all cases of a hernia in the abdominal wall appears around the groin.

Hernias occur more often the right side than the left side. Hernia more indirect than direct hernia

is 2: 1, the ratio of male: female in indirect hernia is 7: 1. It happened femoral hernias less than

10% of all hernias but 40% of the emergency cases appear to inkaserasi or strangulation.

Femoral hernias are more common in older people and men who have undergone hernia inguinal

surgery.

III. ETIOLOGY

The cause of hernia is :

a) The weakness of the abdominal cavity wall. Can be from birth or acquired later in life

b) As a result of previous surgery

c) Congenital

Perfect Congenital Hernias

Baby has a hernia due to a defect in certain places.

Imperfect Congenital Hernias

Babies are born normal (abnormalities not visible) but have a defect in certain places

(predisposition) and a few months (0-1 years) after birth will occur through a defect is

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due to be affected by the increase in intra-abdominal pressure (straining, coughing,

crying).

d) Akuisital is a hernia which is not due to a congenital defect but due to other factors of human

experience, among others:

Intra-abdominal pressure is high, namely in patients with frequent straining during bowel

movement or urination.

Constitutional body. On the thin hernia because the network binding slightly, while in

obese people due to fatty tissue much so that adds to the burden of connective tissue

backers.

Distension of the abdominal wall due to increased intra-abdominal pressure.

Diseases that weaken the abdominal wall.

Smoking.

Diabetes mellitus.

IV. PART OF HERNIA

Parts of the hernia by:

a) The bags hernia. In the form of the parietal peritoneum abdominal hernia. Not all hernias

have a bag, for example, incisional hernia, adipose hernia, hernia internalizers.

b) Fill hernia: in the form of an organ or tissue out through the hernia bag, for example, gut,

ovaries and intestines buffer network (omentum).

c) Door hernia: a part minoris resistance locus through which the hernia bag.

d) Neck hernia: hernia bag narrowest part.

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V. CLASSIFICATION OF HERNIA

According to the nature and circumstances of the hernia can be divided into three:

a. Hernia reponibel: if the hernia contents can be out. Gut out when standing or straining

and enter again when lying down or pushed in the stomach, no pain or symptoms of

intestinal obstruction.

b. Hernia ireponibel: if the contents of the bag can not be repositioned back into the

abdominal cavity. This is usually caused by the contents of the bag attachment on

peritoneal hernia bag.

c. Incarcerated hernia or Strangulated: when it sandwiched by hernia ring so that the bag

is trapped and can not get back into the abdominal cavity. As a result, interference

occurs vascularization. Bowel resection should be done immediately to remove parts

that might necrosis.

According to Erickson (2009) in Muttaqin 2011, there are several hernia classifications are

divided based on the regio, namely: inguinal hernia, femoral hernia, umbilical hernia, and hernia

skrotalis.

a. Inguinal Hernia, namely: prostrusi conditions (protrusion) intestinal organs into the

cavity through a defect or parts of the walls are thin or weak of the inguinal ring.

Incoming material more often is the small intestine, but can also be a tissue or

omental fat. Predispose to inguinal hernia defect or abnormality is found in the form

of partial cavity wall is weak. The exact cause of inguinal hernia lies in the weakness

of the wall, as a result of changes in the physical structure of the wall cavity (old age),

an increase in intra-abdominal pressure (obesity, chronic cough strong and, straining

due to constipation, etc.).

b. Femoral Hernia, namely: a protrusion of intestinal organs that go through funnel-

shaped femoral canal and out of the fossa ovalis in the groin. Causes of femoral

hernia as inguinal hernia.

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c. Umbilical hernia, namely: a protrusion (prostrusi) when the contents of an abdominal

organ in through the anterior canal bordered by the linea alba, posteriorly by the

fascia umbilicus and lateral rectus. A hernia occurs when tissue fascia of the

abdominal wall at the umbilicus area experienced weakness.

d. Hernia Skrotalis, namely: lateral inguinal hernia contents into the scrotum complete.

This hernia should be carefully distinguished from the hydrocele or elevantiasis

scrotum.

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VI. PATOPHYSIOLOGY

Inguinal canal in the normal channels to the fetus. On the 8th month of pregnancy, there

desensus vestikulorum through the canal. Testicular descent will attract the peritoneum into the

scrotum causing the bulge area peritoneum called the processus vaginalis pritonea. When the

baby is born generally processes have undergone obliteration, so that the contents of the

abdominal cavity can not pass through the canal. But in some ways often not closed, because the

left one down first from the right, then the right inguinal canal are more often exposed. Under

normal circumstances, this open canal will close at 2 months.

When the process of the open portion, then the resulting hydrocele. When the canal is open

continuously, because rosesus not berobliterasi will arise lateral congenital inguinal hernia.

Hernia in adults usually happens because the bartambahnya age, the body's organs and tissues

undergo a process of degeneration. In older people the canal has been closed. Namuan because

this region is the locus minoris resistance, then the circumstances that led to increased intra-

abdominal pressure such as chronic coughing, sneezing strong and lifting heavy items, push.

Channel that has been closed can be reopened and the lateral inguinal hernia arises due to the

body's tissues and encouraged something and out through the defect. Finally punched in the wall

cavity which has been weakened as a result of trauma, prostatic hypertrophy, ascites, pregnancy,

obesity, and congenital anomalies and may occur at all.

Men more than women, because of the differences in the process of development of male and

female reproductive organs during fetal. Potential complications of adhesions occur between the

contents of the hernia hernia pouch wall so that the hernia contents can not be put back.

Suppression of the hernia ring, due to the increasing number of incoming rings intestinal hernia

becomes narrower and cause interference distribution of intestinal contents. The incidence of

edema in case of necrosis. If there is a blockage and bleeding will occur flatulence, vomiting,

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constipation. When incarcerated left, then over time there will be edema resulting in suppression

of blood vessels and necrosis.

VII. DIAGNOSIS

Physical examination

1. Finger Test

Using a finger or fingers into 2 to 5, inserted through the

scrotum through the external annulus into the inguinal

canal, the patient was told to cough. When the tip of the

finger impulse means ingunalis lateral hernia, when the

impulse in addition to finger inguinal hernia medialis.

2. Ziemen Test

Lying position, if there is a bump first insert, right hernia

checked with the right hand, the patient was told to

cough when stimulation of the finger-2 ingunalis lateral

hernia, 3rd finger medial inguinal hernia, 4th finger

femoral hernia.

3. Thumbs Test

Annulus is pressed with the thumb and the patient was

told to push, when out bumps mean medial inguinal

hernia, if not out bumps mean lateral inguinal hernia.

Supporting examination

a. Leukocyte> 10000-18000 / mm3

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b. Serum electrolyte rise

c. Radiological examination

d. Ultrasound is also useful to distinguish between hernia incaserata of a pathological

lymph nodes or other causes of a palpable mass in the groin.

e. CT scans can be used to evaluating pelvis to find the obturator hernia.

VIII. DIFFERENTIAL DIAGNOSIS

a. Malignancy: lymphoma, retroperitoneal sarcoma, metastasis, tumor testicular

b. Primary testicular disease: varicocele, epididymitis, testicular torsion, hydrocele, ectopic

testis, testicular undescenden

c. The femoral artery aneurysm

d. Lymph nodes

e. Lymph cyst

f. Sebaceous cysts

g. Psoas abscess

h. Hematoma

i. Ascites

IX. PENATALAKSANAAN

Elective surgery is done to reduce the symptoms and prevention of complications such as

inkeserasi and strangulation. Non-operative treatment is recommended only in asymptomatic

hernia. The main principle of operation is herniotomy hernia: open hernia and cut the bag.

Herniorraphy: repair the posterior abdominal wall canal ingunalis.

Herniotomy

Incision of 1-2 cm above the inguinal ligament and aponeurosis external obliqus opened all

external inguinal canal. Hernia pouch separated from m.creamester carefully up to the internal

inguinal canal, hernia pouch is opened, check the contents and return to the abdominal cavity

then the hernia is cut. In children quite simply do herniotomy and does not require herniorrhapy.

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Herniorrhapy

Dinding posterior di perkuat dengan menggunakan jahitan atau non-absorbable mesh dengan

tekhnik yang berbeda-beda. Meskipun tekhnik operasi dapat bermacam-macam tekhnik bassini

dan shouldice paling banyak digunakan. Teknik operasi liechtenstein dengan menggunakan mesh

diatas defek mempunyai angka rekurensi yang rendah.

X. PROGNOSIS

Depending on the age of the patient, the size of the hernia and the condition of the contents of the

hernia bag. The prognosis is good if the wound infection, bowel obstruction immediately

addressed. Post-surgical complications such as postoperative pain herniorraphy, testicular

atrophy and hernia recurrence can generally be overcome.

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BIBLIOGRAPHY

A. Mansjoer, Suprohaita, W.K Wardhani, W. Setiowulan. Kapita Selekta Kedokteran. Edisi III,

jilid II. Penerbit Media Aesculapius, Fakultas Kedoktern Universitas Indonesia. Jakarta.

2000.

Brian W. Ellis & Simon P-Brown. Emergency Surgery. Edisi XXIII. Penerbit Hodder Arnold.

2006.

Nicks, BA. Hernia. http//www.emedicine.com

R. Sjamsuhidrajat & Wim de Jong. Buku Ajar Ilmu Bedah. Edisi I. Penerbit buku kedokteran

EGC. Jakarta. 1997.

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