SGD SURGERY Case 2

1. SGD SURGERY Case 2 Subsec D2

2. A 25-year old male waiter comes to the Emergency Room because of a R inguinal mass. Since two years ago, the mass would appear when lifting heavy objects, coughing, or sneezing and spontaneously disappear upon lying down aided by gentle manual manipulation

3. SALIENT FEATURES • 25 y/o • Male • Waiter • Right inguinal mass • 2 years ago, the mass would appear whenlifting heavy objects, coughing, or sneezing • Spontaneously disappear upon lying down aided by gentle manual manipulation

4. What is your diagnosis? Inguinal Hernia

5. INGUINAL HERNIAS • Inguinal hernias are classified as either direct or indirect. • INDIRECT • The sac passes from the internal inguinal ring obliquely toward the external inguinal ring and ultimately into the scrotum • DIRECT • The sac protrudes outward and forward and is medial to the internal inguinal ring and inferior epigastric vessels • Although it sometimes can be difficult to distinguish between an indirect and a direct inguinal hernia, this distinction is of little importance because the operative repair of these types of hernias is similar • Pantaloon-type hernia • Occurs when there is an indirect and direct hernia component

7. INCIDENCE • Hernias are a common problem; however, their true incidence is unknown. • It is estimated that 5% of the population will develop an abdominal wall hernia, but the prevalence may be even higher • About 75% of all hernias occur in the inguinal region • Two thirds of these are indirect, and the remainder are direct inguinal hernias

8. Men are 25 times more likely to have a groin hernia than are women • INDIRECT INGUINAL HERNIA • Most common hernia, regardless of gender • In men, indirect hernias predominate over direct hernias at a ratio of 2 : 1 • Direct hernias are very uncommon in women • The female-to-male ratio in femoral and umbilical hernias, however, is about 10 : 1 and 2 : 1, respectively • Although femoral hernias occur more frequently in women than in men, inguinal hernias remain the most common hernia in women. • Femoral hernias are rare in men. Ten percent of women and 50% of men who have a femoral hernia either have or will develop an inguinal hernia

9. Both indirect inguinal and femoral hernias occur more commonly on the right side • This is attributed to a delay in atrophy of the processus vaginalis after the normal slower descent of the right testis to the scrotum during fetal development • The predominance of right-sided femoral hernias is thought to be due to the tamponading effect of the sigmoid colon on the left femoral canal

10. The prevalence of hernias increases with age, particularly for inguinal, umbilical, and femoral hernias • Strangulation, the most common serious complication of a hernia, occurs in only 1% to 3% of groin hernias and is more common at the extremes of life • The likelihood of strangulation and need for hospitalization also increase with aging • Most strangulated hernias are indirect inguinal hernias; however, femoral hernias have the highest rate of strangulation (15%-20%) of all hernias, and for this reason, it is recommended that all femoral hernias be repaired at the time of discovery

11. Anatomy of the important preperitoneal structures in the right inguinal space.  (From Talamini MA, Are C: Laparoscopic hernia repair. I n Zuidema GD, Yeo CJ [eds]: Shackelford's Surgery of the Alimentary Tract, 5th ed. Philadelphia, WB Saunders, 2002, vol 5, p 140.)

13. SIGNS AND SYMPTOMS • A bulge in the area on either side of your pubic bone • Pain or discomfort in your groin, especially when bending over, coughing or lifting • A heavy or dragging sensation in your groin • Occasionally, in men, pain and swelling in the scrotum around the testicles when the protruding intestine descends into the scrotum

14. CAUSES • Some inguinal hernias have no apparent cause. But many occur as a result of: • Increased pressure within the abdomen • A pre-existing weak spot in the abdominal wall • A combination of the two • The abdominal wall weakness that leads to an inguinal hernia occurs at birth when the abdominal lining (peritoneum) doesn't close properly.

15. Other inguinal hernias develop later in life when muscles weaken or deteriorate due to factors such as aging, strenuous physical activity or coughing that accompanies smoking. • In men, the weak spot usually occurs along the inguinal canal. This is the area where the spermatic cord, which contains the vas deferens, the tube that carries sperm, enters the scrotum.

16. In the male fetus, the testicles form within the abdomen and then move down the inguinal canal into the scrotum. Shortly after birth, the inguinal canal closes almost completely, leaving just enough room for the spermatic cord to pass through, but not large enough to allow the testicles to move back into the abdomen. • Sometimes, however, the canal doesn't close properly, leaving a weakened area.

17. In women, the inguinal canal carries a ligament that helps hold the uterus in place, and hernias sometimes occur where connective tissue from the uterus attaches to tissue surrounding the pubic bone. • There's less chance that the inguinal canal won't close after birth in female babies. In fact, women are more likely to develop hernias in the femoral canal, an opening near the inguinal canal where the femoral artery, vein and nerve pass through.

18. Weaknesses can also occur in the abdominal wall later in life, especially after an injury or certain operations in the abdominal cavity. • Whether or not you have a pre-existing weakness, extra pressure in your abdomen can cause a hernia. This pressure may result from: • Straining during bowel movements or urination • Heavy lifting • Fluid in the abdomen (ascites) • Pregnancy • Excess weight • Even chronic coughing or sneezing can cause abdominal muscles to tear.

19. Six hours prior to admission, upon lifting a case of beer, the mass protrudes to its largest size and cannot be pushed back anymore even with manipulation. The mass this time becomes painful and tender rendering him unable to walk. • What would you recommend for him?

20. Herniorrhaphy • In this procedure, your surgeon makes an incision in your groin and pushes the protruding intestine back into your abdomen, then repairs the weakened or torn muscle by sewing it together. After the operation, you'll be encouraged to move about as soon as possible, but it may be as long as four to six weeks before you're able to fully resume your normal activities.

22. Hernioplasty • In this procedure, which is something like patching a tire, your surgeon inserts a piece of synthetic mesh to cover the entire inguinal area, including all potential hernia openings. • The patch is usually secured with sutures, clips or staples. • Hernioplastycan be performed conventionally, with a single long incision over the hernia. But it's often done laparoscopically, using several small incisions rather than one large one. • A fiber-optic tube with a tiny camera is inserted into your abdomen through one incision, and miniature instruments are inserted through the other incisions. Your surgeon then performs the operation using the video camera as a guide.

24. LAPAROSCOPIC REPAIR • ADVANTAGES • Less discomfort and scarring after surgery and a quicker return to normal activities • DISADVANTAGES • Increased risk of complications and of recurrence following surgery. These risks are reduced if the procedure is performed by a surgeon with extensive experience in these kinds of repairs

25. He is given a muscle relaxant – sedative parenterally after which he falls asleep. One hour later, you come back and re-evaluate him. The mass has now disappeared and he has become completely asymptomatic. He now wants to go home.

26. COMPLICATIONS • Most inguinal hernias enlarge over time if they're not repaired surgically. • Large hernias can put pressure on surrounding tissues — in men they may extend into the scrotum, causing pain and swelling. • But the most serious complication of an inguinal hernia occurs when a loop of intestine becomes trapped in the weak point in the abdominal wall (incarcerated hernia). • This may obstruct the bowel, leading to severe pain, nausea, vomiting and the inability to have a bowel movement or pass gas. • It can also diminish blood flow to the trapped portion of the intestine — a condition called strangulation — that may lead to the death of the affected bowel tissues. • A strangulated hernia is life-threatening and requires immediate surgery.

27. 3. What would you advise the patient? • The patient should be advised to undergo elective surgery because most groin hernias when left unrepaired can further enlarge and can result into further surgical failure rates. • The patient’s occupation demands strenuous activities which he is constantly exposed to. This can increase the incidence of recurrent Inguinal hernia • Furthermore, delaying surgical management can increase the incidence of incarceration as well as strangulation

28. Strangulated Inguinal Hernia Patient will present with acute, painful, non-reducible inguinal hernia. It's worthmentioning that in spite of rapid diagnosis and prompt surgical exploration, gangrenous bowel was identified. This highlights the potential seriousness of this condition.

29. 4. Do you agree with how the patient was managed in the ER? Why or Why not? • The patient is presents with incarcerated hernia, which is a constriction of the hernial sac rendering the hernia irreducible. • This condition is initially managed with sedation, Trendelenberg position, ice packs and taxis (Manual Manipulation). • The patient should be further observed, if there is failure of taxis with no progress within 6-8 hrs, or if signs of complete bowel obstruction, peritonitis or sepsis happened, immediate surgery is recommended

30. Trendelenburg position

31. THANK YOU

32. REFERENCES • Sabiston Textbook of Surgery, 18th ed. • Mayoclinic.com