Hernia in Adult

Hernia is
A rupture ( Latin word)
Penonjolan bagian organ atau jaringan
melalui lubang abnormal (kamus
kedokteran Dorland)
An abnormal protrusion of an organ or
tissue through a defect in its surrounding
walls (Sabiston)
An area of weakness or complete
disruption of the fibromuscular tissues of
the body wall (Mangiots)

Tiga komponen:
1. Defek ~ Cincin
2. Kantong hernia
(peritoneum)
3. Isi
1.
2.
3.
4.
5.
6.
7.

Intestine
Colon
Omentum
Buli
Ovarium
Uterus
Appendiks

Cause
Faktor Etiologi:
Kelemahan dinding
abdomen

Faktor Pencetus:
Excessive straining
LUTS
BPH
Urethral stricture

Chronic cough
Constipation
Lift/push weight

Ventral Hernia

TYPES

Abdominal Wall Layers

INGUINO-SCROTAL
REGION

Hesselbachs Triangle

Hesselbachs Triangle

Hesselbachs Triangle

The Myopectineal Orifice of

Fruchaud

Female Ingiunal Canal =

Canal of Nuck

Inguinal Hernia >< Scrotal Hernia

DIRECT HERNIA >< INDIRECT

HERNIA

Indirect Hernia VS Direct

Hernia
Indirect Hernia

Direct Hernia

a.k.a. hernia lateral

Defect: deep (internal)
inguinal ring
spermatic cord
(inguinal canal)
superficial (external)
inguinal ring
scrotum

a.k.a. hernia medial

Defect: Hesselbachs
triangle

Indirect Hernia VS Direct

Hernia
Pantaloon Hernia: if indirect and
direct hernia occurs at the same time

Groin Hernia

INGUINAL HERNIA ><

FEMORAL HERNIA

Inguinal Hernia VS
Femoral Hernia

Inguinal Hernia VS
Femoral Hernia

Inguinal
Hernia

Femoral
Hernia

Above inguinal
ligament
Mostly
Defect:
deep inguinal ring or
Hesselbachs triangle

Below
inguinal
ligament
Mostly
Defect:
femoral ring

Differentiating Hernia Type

PHYSICAL EXAMINATION

Digital Examination

Digital
Examination

The examiner should place

the tip of the index finger at
the most dependent part of
the scrotum, direct it into
the external inguinal ring
The patient is then asked to
strain
Indirect hernia will push
against the fingertip
Direct hernia will push
against the pulp of the
finger

3 Fingers Examination

Hernias

TERMINOLOGY

Terminology
Reducible/Reponible
Isi kantong dapat keluar-masuk
Irreducible/Irreponible
Isi kantong tidak dapat masuk kembali, namun tidak
ada gejala dan tanda strangulata
Incarcerate ???
Strangulate
Isi kantong hernia terjepit sehingga menyebabkan
gangguan
Sirkulasi iskemiknyeri
Pasase ususobstruksi usus mekanik

Irreduci
ble

Inguino-scrotal Hernia

STRANGULATE!

What is the Diagnose?

Mechanical Bowel
Obstruction
Trias obstruksi:
1. Perut semakin membuncit
2. Muntah setiap makan-minum
3. Tidak bisa flatus maupun BAB
PF regio abdomen:
I: distention, bowel contour, bowel movement
P: NT
P: hypertympanic
A: hyperperistaltic, metallic sound
RT: ampula recti kolaps

Mechanical Bowel
Obstruction
Abdominal radiograph
is it NECESSARY?

Strangulated Scrotal
Hernia

4T
1.Tense
2.Tender
3.Temperature
4.Tone
(Hyperemia)

Viability of the Intestine

4C
1. Consistency
2. Color
3. Capillary
4. Contractility
~ Peristaltic

Proses strangulasi

Vaskularisasi intestine/colon
terganggu

Lapisan mukosa yang paling

menderita
(o.k. letaknya paling profunda,
paling jauh dari pembuluh
darah)

Mucosal slough

Klinis: hematoschezia

Spontaneously Reduce
Strangulated Scrotal Hernia En Masse
Reduction en-masse of inguinal hernia, means
reduction/migration of a hernial sac along with
the incarcerated bowel into the properitoneal
space and is likely produced by forcible attempts
at reduction
Occasionally, it can also be spontaneous
There is usually a history of difficult reductions,
the last one being especially difficult, after which
the symptoms of intestinal obstruction occur
The hernia appears to have been reduced but
the signs of bowel obstruction persist

Spontaneously Reduce
Strangulated Scrotal Hernia En Masse

Reduction en-masse of
inguinal/femoral hernia can be
defined as reduction of the hernial
sac together with its intestinal
contents so that the bowel still
remains incarcerated
It has been quoted by Pearse to occur
in approximately 1 of 13,000 hernias

Spontaneously Reduce
Strangulated Scrotal Hernia En Masse
Casten and Bodenheimer postulated that reduction
en masse can occur only if there is a relatively
unyielding neck of the sac and a lax internal ring
Fibrosis is probably produced by recurrent trauma
from difficult reductions
Pearse concluded that a preformed space between
the parietal peritoneum and anterior abdominal
wall, the properitoneal sac, or diverticulum was
present in many cases
Millard suggested that such a sac was equally likely
to be produced by forcible attempts at reduction

Spontaneously Reduce
Strangulated Scrotal Hernia En Masse

Reduction en-masse of hernia

should be considered as a cause
of acute intestinal obstruction in
patients with persistent bowel
obstruction following reduction
of inguinal/femoral hernias!!!

A hernial sac is seen

containing incarcerated bowel
loop between
the parietal peritoneum and
anterior abdominal wall, the

(a) CT scan of the abdomen

demonstrating dilated
small bowel loops
suggestive of bowel
obstruction
(b)The hernial sac [arrow]
containing thickened bowel
loop and mesenteric fat
[arrowhead] is seen in the
properitoneal space,
superior to the left inguinal
region
(c) A fibrous constriction band
is seen around the neck of
the hernial sac [arrow].
Note enhancement of
bowel wall [arrowhead]
(d)The inferior aspect of the
hernial sac containing
bowel [arrow]
(e) Fluid in the hernial sac
[arrow]. Wall enhancement
of the bowel loop and fluid
in the hernial sac suggest

Hernia
Type

Sliding Hernia

Any hernia in which part of the sac is the wall of a

viscus

Hernia dimana dinding viskus tersebut

membentuk
Sebagian dari kantong hernia,
bagian lain kantong hernia dibentuk oleh

Littres Hernia

Richters Hernia

Amyands Hernia

Spigelian Hernia

Interstitial Hernia

Supravesical Hernia

Lumbar Hernia

Maydls Hernia

Differential
Diagnosis for
Scrotal
Enlargement

DD/: Hidrocele

Bottle Neck Procedure

DD/: Testicular Tumor

DD/: Orchitis

DD/: Testicular Torsion

DD/: Pembesaran Skrotum

Anamnesis

Pemeriksaan Fisik

Hernia

Benjolan keluar
masuk

Batas atas tidak jelas

Testis teraba
(terletak inferior, o.k. terdorong
massa hernia)

Hidrokel

Benjolan yang
menentap dan
semakin membesar

Batas atas jelas

Transiluminasi (+)
Testis tidak teraba

Tumor
Testis

Benjolan yang
menentap dan
semakin membesar

Batas atas jelas

Transiluminasi (-)
Testis tidak teraba
(sudah menjadi tumor)

Orkhitis

Gejala-gejala proses
inflamasi (nyeri,
demam)

Ukuran testis membesar, NT (+)

Tanda-tanda inflamasi
(tumor,dolor,calor,rubor,functio
laesa)

Torsio
Testis

Riwayat trauma

Posisi testis horizontal

Prehns test

When to

Operation Timing
Elective
Reducible
Irreducible

Emergency
Strangulate

 Herniorrhaphy: hernia repair-operation

Herniotomy: high ligation of the sac
or
reduction of the sac into the
preperitoneal space without
excision
Hernioplasty: reconstruction of the
posterior wall/
inguinal floor

Hernioplasty
Tension:
Bassini plasty
Shouldice
Nyhus
Condon
Stoppa

Tension-free:
Lichtenstein
Perfix mesh plug (Rutkow-Robbins)
Kugel
Laparascopic

Bassini plasty

Lichtenstein

Mesh

Mesh

Complication after
Herniorraphy

Pain
Wound infection
Orchitis
Seroma/hematoma in distal hernia
sac
Inguinodynia
Recurrent

Inguinodyna
Chronic groin pain or
neuropathic pain
Debilitating pain with
prolonged suffering and
distress
Characterized by
hyperesthesia along the
corresponding dermatome,
and exquisite pain at the site
of a neuroma or trapped
nerve; and contact
dysesthesia
Patient describing as painful
exacerbations similar to an
electric shock, paroxysms of
burning and shooting
pains

community by
operating on hernia
cases,
and seeing that is
recurrence rate is
lower,
than he can by
operating on cases-Wakelyof

Hernia Permagna

Hernia Permagna
Tipe hernia yang apabila isi kantung
hernia dikembalikan ke rongga
peritoneum dapat menimbulkan
keadaan abdominal compartment
syndrome

Abdominal Compartment
Syndrome
Peningkatan tekanan intraabdomen

Aliran darah ke organ-organ terganggu

Gangguan fungsi pulmonar,

kardiovaskular, renal, dan gastrointestinal

Multiple organ dysfunction

Hernia Simtomatik Skrotalis Bilateral

Ireponibilis
& Hernia Simtomatik Umbilikalis
Ireponibilis
e.c. Asites Masif

Thank
You.