Recurrence of Hernia after operation:

◼️Reports suggest that recurrence rate vary between 0.2% up to 15% depending on the technique used.

◼️Only by using meticulous technique principally concentrating on reinforcement of the posterior wall of inguinal canal with the shouldice technique or mesh hernioplasty can a recurrence rate of less than 2% be achieved.

◼️Only 50% of recurrences will become apparent within two years.

◼️In a few cases "false" recurrence occur, i.e another type of hernia occur - direct after indirect, femoral after inguinal. How ever to the patient it is recurrence!!

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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.

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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).

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#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?

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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.

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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).

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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.

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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.

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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

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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.

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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.🌚

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Bed sore score:

Grade 1: redness erythema not disappear with pressure.
Grade 2: superficial ulcer
Grade 3: superficial and subcutaneous tissue but not through fascia.
Grade 4: deep to muscles and joints.

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Reducible swellings:

1-Hernia
2-Meningocele
3-Varicocele
4-Saphena varix.

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Swellings which are brilliantly transilluminant:

1-Ranula
2-Cystic hygromaand lymph cyst
3-Hydrocele
4-Meningocele
5-Epididymal cyst (Chinese-lantern pattern)
6Hydrocele of the canal of Nuck.

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Cold Abscess:

-It is a soft fluctuant swelling without signs of inflammation, which is mistaken for a cyst.
-This is lined by granulation tissue and caseous material.
-It is due to tuberculous infection and contains tubercle bacilli.
-It is not hot.
-Brawny induration, edema and tenderness are absent.

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Acute Abdomen definition:
-Any sudden spontaneous nontraumatic disorder affecting the abdomen for which urgent operation may be necessary and undue delay in diagnosis may adversely affect the outcome.

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Swellings that move with deglutition?

1-Thyroid
2-Thyroglossal cyst
3-Subhyoid bursitis
4-Nodes attached to larynx and trachea
5-Laryngocele.

-Ascitic fluid less than 500 cc cannot be detected clinically.

-Minimal Ascites (500-1000cc).
-Moderated Ascites (1000-2000cc).
-Severe Ascitis (>2000 cc)

•Moderate amount: Shifting dullness.
•Tense: transmitted thrill.
•Minimal: knee - elbow.

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Fluctuation:
-It's the transmission of an impulse in two directions at right angles to each other, and it implies presence of fluid in the swelling.

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