Direct inguinal hernia
◼️Figure above is a direct inguinal hernia descended into scrotum (unusual) with gangrene and sloughing of skin.
◼️They are always acquired and result from passage of the hernial sac through a point of weakness or a defect of transversalis fascia in posterior inguinal wall usually medial to the inferior epigastric vessels.
◼️Risk factors include male gender, smoking (thought to cause acquired collage defeciency), old age, straining or heavy lifting, and injury of the Ilioinguinal nerve (previous appendicectomy/more with Gridiron incision).
◼️Patients often have elongated buldings in the abdominal wall resulting from poor lower abdominal musculature (Malgaigne's buldgings).
◼️The sac is often smaller than the observed mass indicate because of thick coverings mainly made of extraperitoneal fat.
◼️The neck is wide thus strangulation is less often.
◼️If presented unilaterally, there is a fourfold higher risk of contralateral involvement in the future.
#Hernia
#Surgery
◼️Figure above is a direct inguinal hernia descended into scrotum (unusual) with gangrene and sloughing of skin.
◼️They are always acquired and result from passage of the hernial sac through a point of weakness or a defect of transversalis fascia in posterior inguinal wall usually medial to the inferior epigastric vessels.
◼️Risk factors include male gender, smoking (thought to cause acquired collage defeciency), old age, straining or heavy lifting, and injury of the Ilioinguinal nerve (previous appendicectomy/more with Gridiron incision).
◼️Patients often have elongated buldings in the abdominal wall resulting from poor lower abdominal musculature (Malgaigne's buldgings).
◼️The sac is often smaller than the observed mass indicate because of thick coverings mainly made of extraperitoneal fat.
◼️The neck is wide thus strangulation is less often.
◼️If presented unilaterally, there is a fourfold higher risk of contralateral involvement in the future.
#Hernia
#Surgery
Repair of transversalis fascia and internal ring
◼️After exicion of the hernial sac, the deep ring may be found too stretched which risks recurrence of the hernia after operation.
◼️Repair techniques focus on simply narrowing the internal ring.
◼️One method is the Shouldice operation (shown in figure above) whereby the deep ring and transversalis fascia are incised and carefully seperated from the deep inferior epigastric vessels creating two flaps, the upper flap is pulled over the lower flap and connected together making the ring narrower.
◼️Another more simple method is the Lytle operation where by the spermatic cord is displaced laterally and the ring narrowed by sutures.
#Hernia
#Surgery
◼️After exicion of the hernial sac, the deep ring may be found too stretched which risks recurrence of the hernia after operation.
◼️Repair techniques focus on simply narrowing the internal ring.
◼️One method is the Shouldice operation (shown in figure above) whereby the deep ring and transversalis fascia are incised and carefully seperated from the deep inferior epigastric vessels creating two flaps, the upper flap is pulled over the lower flap and connected together making the ring narrower.
◼️Another more simple method is the Lytle operation where by the spermatic cord is displaced laterally and the ring narrowed by sutures.
#Hernia
#Surgery
Examination sequence for hernia
◼️Examine the groin while the patient is standing up.
◼️Examine the inguinal and femoral canals and scrotum for any buldges.
◼️Identify the anatomical relationship between the buldge and pubic tubercle and the inguinal ligament to distinguish femoral from an inguinal hernia.
◼️Palpate the external inguinal ring and along the inguinal canal for any defects. Ask the patient to cough and feel for cough impulse.
◼️Instruct the patient to lie down and see whether the hernia reduce spontaneously or not.
◼️If so, press two fingers over the internal inguinal ring (midpoint between anterior superior iliac spine and pubic symphesis about 1.25cm above inguinal ligament) and ask the patient to cough if the hernia reappears it is DIRECT and if pressure prevent it from reappearing it is INDIRECT.
◼️Examine the opposite side for possibility of asymptomatic hernia (inguinal hernia is bilateral in 12% of cases).
#Hernia
#Surgery
◼️Examine the groin while the patient is standing up.
◼️Examine the inguinal and femoral canals and scrotum for any buldges.
◼️Identify the anatomical relationship between the buldge and pubic tubercle and the inguinal ligament to distinguish femoral from an inguinal hernia.
◼️Palpate the external inguinal ring and along the inguinal canal for any defects. Ask the patient to cough and feel for cough impulse.
◼️Instruct the patient to lie down and see whether the hernia reduce spontaneously or not.
◼️If so, press two fingers over the internal inguinal ring (midpoint between anterior superior iliac spine and pubic symphesis about 1.25cm above inguinal ligament) and ask the patient to cough if the hernia reappears it is DIRECT and if pressure prevent it from reappearing it is INDIRECT.
◼️Examine the opposite side for possibility of asymptomatic hernia (inguinal hernia is bilateral in 12% of cases).
#Hernia
#Surgery
Although the internal inguinal ring is thought of as a hole in transversalis fascia, it is actually not a hole but an invagination of the transversalis fascia to form the internal spermatic fascia of the spermatic cord, so a hernia passing though this ring would normally be deep to the internal spermatic fascia which is dissected at time of operation to expose the hernial sac
#Hernia
#Surgery
#Hernia
#Surgery
#Inguinal_Triangle
◼️ Synonym=Hasselbach's triangle.
◼️Medial border is the lateral margin of rectus abdominis muscle.
◼️ Superolateral border is the inferior epigastric vessels.
◼️ Inferior border is the inguinal ligament.
◼️ It is a potential point of weakness, direct inguinal hernias occur medial to the inferior epigastric vessels in the inguinal triangle,, what is the exception to this rule?
#Hernia
#Surgery
◼️ Synonym=Hasselbach's triangle.
◼️Medial border is the lateral margin of rectus abdominis muscle.
◼️ Superolateral border is the inferior epigastric vessels.
◼️ Inferior border is the inguinal ligament.
◼️ It is a potential point of weakness, direct inguinal hernias occur medial to the inferior epigastric vessels in the inguinal triangle,, what is the exception to this rule?
#Hernia
#Surgery
Types of indirect inguinal hernia
◼️Bubonocele "Bubon is greek for groin", here the hernia is limited to the inguinal canal.
◼️Funicular "funiculus latin for small cord" Here the processus vaginalis is closed just above the epididymis, the contents of the sac can be felt seperately from the testis.
◼️ Complete (synonym = scrotal), it is rarely present at birth but commonly encountered thereafter during infancy, it can also occur in adolescents and adults, the testis appear to lie within the lower part of the hernia.
#Hernia
#Surgery
◼️Bubonocele "Bubon is greek for groin", here the hernia is limited to the inguinal canal.
◼️Funicular "funiculus latin for small cord" Here the processus vaginalis is closed just above the epididymis, the contents of the sac can be felt seperately from the testis.
◼️ Complete (synonym = scrotal), it is rarely present at birth but commonly encountered thereafter during infancy, it can also occur in adolescents and adults, the testis appear to lie within the lower part of the hernia.
#Hernia
#Surgery
Clinically an inguinal hernia can be differentiated from a femoral hernia by ascertaining the relationship between the neck of the hernia and the pubic tubercle i.e in inguinal hernia the neck is above and medial to the pubic tubercle while in a femoral hernia the neck is below and lateral to the pubic tubercle. (see figure above)
#Hernia
#Surgery
#Hernia
#Surgery
Anatomy of inguinal canal
◼️In infants the internal and external rings almost oppose each other and the obliquity of the canal is slight.
◼️In adults the canal is about 3.75cm long extending from the internal to the external ring downwards and medially.
◼️In males the canal transmit the spermatic cord, ilioinguinal nerve and genital branch of genitofemoral nerve, in females the round ligament replaces the spermatic cord.
◼️The posterior wall is formed of the transversalis fascia (black arrow) and the conjoined tendon of internal oblique and transversus abdominis muscles (yellow arrow).
◼️The anterior wall is mainly formed of external oblique aponeurosis.
◼️The inferior boundery is the inguinal ligament.
◼️The superior boundery is formed by the conjoined muscles (internal oblique and transversus abdominis).
#Hernia
#Surgery
◼️In infants the internal and external rings almost oppose each other and the obliquity of the canal is slight.
◼️In adults the canal is about 3.75cm long extending from the internal to the external ring downwards and medially.
◼️In males the canal transmit the spermatic cord, ilioinguinal nerve and genital branch of genitofemoral nerve, in females the round ligament replaces the spermatic cord.
◼️The posterior wall is formed of the transversalis fascia (black arrow) and the conjoined tendon of internal oblique and transversus abdominis muscles (yellow arrow).
◼️The anterior wall is mainly formed of external oblique aponeurosis.
◼️The inferior boundery is the inguinal ligament.
◼️The superior boundery is formed by the conjoined muscles (internal oblique and transversus abdominis).
#Hernia
#Surgery
Surgical anatomy
◼️The deep inguinal ring is a U shaped condensation of the transversalis fascia, which is the fascial envelope of the abdomen it lies between the parietal peritoneum and the muscles of the abdominal wall(see figure above).
◼️The deep inguinal ring is about 1.25 cm above the inguinal ligament midway between the symphesis pubis and the anterior superior iliac spine.
◼️The competency of the deep inguinal ring greatly depends upon the integrity of the transversalis fascia.
#Hernia
#Surgery
◼️The deep inguinal ring is a U shaped condensation of the transversalis fascia, which is the fascial envelope of the abdomen it lies between the parietal peritoneum and the muscles of the abdominal wall(see figure above).
◼️The deep inguinal ring is about 1.25 cm above the inguinal ligament midway between the symphesis pubis and the anterior superior iliac spine.
◼️The competency of the deep inguinal ring greatly depends upon the integrity of the transversalis fascia.
#Hernia
#Surgery
Surgical anatomy
◼️ The superficial inguinal ring is a triangular aperture in the aponeurosis of the external oblique.
◼️ It is bounded superomedially by the medial crus (black arrow) which is thinner and attached to the anterior aspect of the pubic symphesis AND bounded inferolaterally by a thicker crus, called the lateral or inferolateral crus (yellow arrow) , both are interconnected by the intercrural fibers (blue arrow) .
◼️The ring is bounded below by the pubic crest.
◼️The external inguinal ring lies about 1.25 cm above the pubic tubercle.
◼️Normally the external inguinal ring do not admit the tip of the little finger.
#Hernia
#Surgery
◼️ The superficial inguinal ring is a triangular aperture in the aponeurosis of the external oblique.
◼️ It is bounded superomedially by the medial crus (black arrow) which is thinner and attached to the anterior aspect of the pubic symphesis AND bounded inferolaterally by a thicker crus, called the lateral or inferolateral crus (yellow arrow) , both are interconnected by the intercrural fibers (blue arrow) .
◼️The ring is bounded below by the pubic crest.
◼️The external inguinal ring lies about 1.25 cm above the pubic tubercle.
◼️Normally the external inguinal ring do not admit the tip of the little finger.
#Hernia
#Surgery
Richter Hernia
◼️It occurs when only a portion of the intestinal circumference is involved in the hernial sac.
◼️Here complete obstruction of the intestinal lumen is not present.
◼️Strangulation of a Richter's hernia is particularly noteworthy, because the clinical features mimics gastroenteritis, the local signs of strangulation are not obvious, the patient may not vomit and may even have a diarrhea, this causes delay in diagnosis and operation is delayed so that gangrene and perforation commonly takes place before operation.
◼️Richter's hernia usually complicates a femoral hernia or rarely obturator hernia.
#Hernia
#Surgery
◼️It occurs when only a portion of the intestinal circumference is involved in the hernial sac.
◼️Here complete obstruction of the intestinal lumen is not present.
◼️Strangulation of a Richter's hernia is particularly noteworthy, because the clinical features mimics gastroenteritis, the local signs of strangulation are not obvious, the patient may not vomit and may even have a diarrhea, this causes delay in diagnosis and operation is delayed so that gangrene and perforation commonly takes place before operation.
◼️Richter's hernia usually complicates a femoral hernia or rarely obturator hernia.
#Hernia
#Surgery
Clinical features of strangulated hernia:
◼️Sudden pain starting at the hernial site followed by generalized abdominal pain, this pain is colicky in nature and mainly around the umbilicus.
◼️Nausea and vomitting.
◼️ Recent increase in the size of the hernia.
◼️Extreme tenderness over the hernia.
◼️Tense hernial sac.
◼️Irreducible hernia.
◼️Absence of expansile cough impulse.
N.B sudden spontaneous cessation of pain must be viewed with caution as this may be a sign of perforation
#Hernia
#Surgery
◼️Sudden pain starting at the hernial site followed by generalized abdominal pain, this pain is colicky in nature and mainly around the umbilicus.
◼️Nausea and vomitting.
◼️ Recent increase in the size of the hernia.
◼️Extreme tenderness over the hernia.
◼️Tense hernial sac.
◼️Irreducible hernia.
◼️Absence of expansile cough impulse.
N.B sudden spontaneous cessation of pain must be viewed with caution as this may be a sign of perforation
#Hernia
#Surgery
Pathology Of Strangulated Hernia
◼️Constriction ring develops and impairs blood supply (thin black arrow)
◼️Venous return from the involved segment is affected first.
◼️Congestion develops with transudation of serous fluid into the hernial sac.
◼️Distension of the involved loop and edema results in furthur narrowing of the ring and compromising blood supply even more.
◼️Arterial supply then becomes more and more compromised.
◼️The viability of the bowel becomes affected resulting in translocation of bacteria through the wall leading to infection of the sac.
◼️If left unrelieved, gangrene develops (usually within 6 hours) first at the seat of constriction ring (thick black arrow) then at the antemesentric border(yellow arrow) perforation is expected in these sites.
◼️Because of these pathological events peritonitis spreads from the sac to the general peritoneal cavity.
#Hernia
#Surgery
◼️Constriction ring develops and impairs blood supply (thin black arrow)
◼️Venous return from the involved segment is affected first.
◼️Congestion develops with transudation of serous fluid into the hernial sac.
◼️Distension of the involved loop and edema results in furthur narrowing of the ring and compromising blood supply even more.
◼️Arterial supply then becomes more and more compromised.
◼️The viability of the bowel becomes affected resulting in translocation of bacteria through the wall leading to infection of the sac.
◼️If left unrelieved, gangrene develops (usually within 6 hours) first at the seat of constriction ring (thick black arrow) then at the antemesentric border(yellow arrow) perforation is expected in these sites.
◼️Because of these pathological events peritonitis spreads from the sac to the general peritoneal cavity.
#Hernia
#Surgery
Types of Hernias
◼️ Reducible.. Where the hernia can be reduced when the patient lies down or by the patient himself or by the surgeon, if the contents are intestine, then there is often a gurgling sound at time of reduction, and also the first part is usually more difficult to reduce than the last part, if the contents are omentum, then it will feel as a doughy mass, the last portion is more difficult to reduce than the first one.
◼️ Irreducible.. Refer to a hernia which do not return to the abdomen in absence of any other related symptoms it may occur because of adhesions between the sac and the contents or may occur due to overcrowdening of the sac with contents, such a hernia that doesnt reduce and doesnt produce any symptoms is highly suggestive of omentocele. Note that any degree of irreducibility predispose to strangulation.
◼️Obstructed.
◼️Strangulated.. Can proceed to gangrene within only 6 hours.
◼️Inflamed
What does incarcerated hernia mean?
-See below, I have quoted it.🌚
#Hernia
#Surgery
◼️ Reducible.. Where the hernia can be reduced when the patient lies down or by the patient himself or by the surgeon, if the contents are intestine, then there is often a gurgling sound at time of reduction, and also the first part is usually more difficult to reduce than the last part, if the contents are omentum, then it will feel as a doughy mass, the last portion is more difficult to reduce than the first one.
◼️ Irreducible.. Refer to a hernia which do not return to the abdomen in absence of any other related symptoms it may occur because of adhesions between the sac and the contents or may occur due to overcrowdening of the sac with contents, such a hernia that doesnt reduce and doesnt produce any symptoms is highly suggestive of omentocele. Note that any degree of irreducibility predispose to strangulation.
◼️Obstructed.
◼️Strangulated.. Can proceed to gangrene within only 6 hours.
◼️Inflamed
What does incarcerated hernia mean?
-See below, I have quoted it.🌚
#Hernia
#Surgery
"Removing a colorectal polyp is Removing a future cancer".
Almost all colorectal cancers arise on top of a pre-existing adenomatous polyps, any adenomatous polyp may turn to a cancer, but the risk is not the same in all of them, a polyp with significant malignant potential is larger than 2 cm, have a predominantly villous architecture and has dysplastic cells, and ofcoures, the more polyps are present, the more likely cancer will occur.
#Surgery
Almost all colorectal cancers arise on top of a pre-existing adenomatous polyps, any adenomatous polyp may turn to a cancer, but the risk is not the same in all of them, a polyp with significant malignant potential is larger than 2 cm, have a predominantly villous architecture and has dysplastic cells, and ofcoures, the more polyps are present, the more likely cancer will occur.
#Surgery
Clinical features of colorectal cancer
◼️It depend upon the site of carcinoma.
◼️On the left side, tumors tend to be of annular variety, such as that they narrow the lumen and cause early intestinal obstruction, this presents with lower colicky abdominal pain and the colics are widely seperated, along with other features such as distension.
◼️The above figure demonstrate the nature of this manifestation, this is a specimen of the descending colon and shows a constricting lesion which was revealed to be an adenocarcinoma, left sided tumors also present with early fresh per rectal bleeding.
◼️If the tumor is rectal, bleeding, mucus discharge and tenesmus will manifest.
◼️If tumor is right sided, this present with anaemia due to occult bleeding, and a change in bowel habit, intestinal obstruction here is a late feature, because right sided tumors tend to be fungating and slow growing.
◼️In a minority of patients perforation causing peritonitis, fistuale, and local abscess may occur.
#Surgery
◼️It depend upon the site of carcinoma.
◼️On the left side, tumors tend to be of annular variety, such as that they narrow the lumen and cause early intestinal obstruction, this presents with lower colicky abdominal pain and the colics are widely seperated, along with other features such as distension.
◼️The above figure demonstrate the nature of this manifestation, this is a specimen of the descending colon and shows a constricting lesion which was revealed to be an adenocarcinoma, left sided tumors also present with early fresh per rectal bleeding.
◼️If the tumor is rectal, bleeding, mucus discharge and tenesmus will manifest.
◼️If tumor is right sided, this present with anaemia due to occult bleeding, and a change in bowel habit, intestinal obstruction here is a late feature, because right sided tumors tend to be fungating and slow growing.
◼️In a minority of patients perforation causing peritonitis, fistuale, and local abscess may occur.
#Surgery
Investigations used for colorectal cancer
◼️The goal is to confirm the diagnosis and obtain staging.
◼️In order to confirm the diagnosis, the investigation of choice is colonoscopy, in contrast to barium enema it is more sensitive and specific and biopsies can be obtained, and polyps removed.
◼️When colonoscopy is incomplete or could not be done due to a high risk of complications, a CT colonography is appropriate, it is also called 'the virtual colonoscopy' whereby a computer software is used to produce a 3D image of the colon (figure above shows a comparsion between CT colonography and real colonoscopy).
◼️After diagnosis is confirmed, CT of chest, abdomen and pelvis is done for staging, if the cancer is rectal, endoanal ultrasonography or pelvic MRI is used for local staging, during staging a particular focus is paid to the liver as this is the commonest site of metastasis.
◼️Carcinoembryonic antigen (CEA) is not useful for diagnosis but valuable in follow up to monitor recurrence
#Surgery
◼️The goal is to confirm the diagnosis and obtain staging.
◼️In order to confirm the diagnosis, the investigation of choice is colonoscopy, in contrast to barium enema it is more sensitive and specific and biopsies can be obtained, and polyps removed.
◼️When colonoscopy is incomplete or could not be done due to a high risk of complications, a CT colonography is appropriate, it is also called 'the virtual colonoscopy' whereby a computer software is used to produce a 3D image of the colon (figure above shows a comparsion between CT colonography and real colonoscopy).
◼️After diagnosis is confirmed, CT of chest, abdomen and pelvis is done for staging, if the cancer is rectal, endoanal ultrasonography or pelvic MRI is used for local staging, during staging a particular focus is paid to the liver as this is the commonest site of metastasis.
◼️Carcinoembryonic antigen (CEA) is not useful for diagnosis but valuable in follow up to monitor recurrence
#Surgery
Modified Duke classification for colorectal cancer
Stage A = tumor within bowel wall.
Stage B= tumor extended through bowel wall.
Stage C= Lymph nodes are involved.
Stage D = Distant metastasis, usually to liver and less commonly to lungs.
#Intestinal
#Surgery
Stage A = tumor within bowel wall.
Stage B= tumor extended through bowel wall.
Stage C= Lymph nodes are involved.
Stage D = Distant metastasis, usually to liver and less commonly to lungs.
#Intestinal
#Surgery
Hereditary factors in colorectal cancer
◼️They can be broadly classified into disorders with polyposis and without polyposis.
◼️Those involving polyps include familial adenomatous polyposis, Peutz jeghers syndrome, juvenile polyposis and MUTY homolog associated polyposis (for more informations see previous posts)
◼️Hereditary non polyposis colorectal cancer (HNPCC) or Lynch syndrome, is a result of mutations affecting DNA repair genes (microsatellite instability, see before), a subset of patients with Lynch syndrome also are predisposed to (1) Endometrial cancer, (2) Ovarian cancer, (3) Small bowel cancer, (4) Pancreatic cancer, and (5) CNS tumors, this results from a different repair gene mutation.
◼️The diagnosis of Lynch syndrome first relies on Modified amesterdam criteria (see next Post).
◼️The above figure summarizes the pathophysiologic factors involved in the development of colorectal cancer.
#Intestinal
#Surgery
◼️They can be broadly classified into disorders with polyposis and without polyposis.
◼️Those involving polyps include familial adenomatous polyposis, Peutz jeghers syndrome, juvenile polyposis and MUTY homolog associated polyposis (for more informations see previous posts)
◼️Hereditary non polyposis colorectal cancer (HNPCC) or Lynch syndrome, is a result of mutations affecting DNA repair genes (microsatellite instability, see before), a subset of patients with Lynch syndrome also are predisposed to (1) Endometrial cancer, (2) Ovarian cancer, (3) Small bowel cancer, (4) Pancreatic cancer, and (5) CNS tumors, this results from a different repair gene mutation.
◼️The diagnosis of Lynch syndrome first relies on Modified amesterdam criteria (see next Post).
◼️The above figure summarizes the pathophysiologic factors involved in the development of colorectal cancer.
#Intestinal
#Surgery