Hernia – others dolor lumbar causas

-inguinal canal 4-6 cm-spermatic cord : 3a,3v,2nNerve of inguinal region1.illioinguinal n–L12.illiohypogastric n–T12-L13.genitofemoral n–L1-24.lat.femoral cutaneous n–L2-3¤1,2–in canalCord structure3 fascia1.internal–IO–>cremasteric m2.external–EO3.superficial–fascia of Gallaudet(innominate fascia)Post perspective 1.umbilicus2.median umbilical lig3.medial umbilical lig–obliterate UV4.lat umbilical lig–inf epigastric vvBogros space-space btw peritoneum & post of TF Myoepithelial orifice of Fruchaud(Tripple triangle of groin)1.lateral triangle

femoral herniaTriangle of doom-medial=vas def -lateral=spermatic vv-apex=deep ring-content=ext illiac vv,genital of GF nTriangle of pain-medial=spermatic vv-sup=iliopubic tract-content=femoral n,femoral of GF n,lat.femoral cuta.nIliopubic tract-transaversalis fascia-ASIS to pubis-below inguinal lig

EpidermiologyInguinal hernia-75% of hernia-m 90% , f 10%-1/3 unilat = develop contralat-40yrFemoral hernia-m 30% , f 70%-most in female = inguinal hernia-below inguinal lig, lat pubic tubercleLittre hernia-meckel diverticulum in hernia sac Amyand hernia-appendix in hernia sacPost/lumbar hernia-sup lumbar triangle

Petit herniaEtiology Acquire–weakness in abdo.wallCongen–patent processus vaginalisClassificationGilbert classificationT1 small indirectT2 medium indirectT3 large indirect (>2FB)T4 directT5 diverticular directT6 combine (pantaloon)T7 femoralNyhus classificationT1 indirect hernia (congen)normal internal ringT2 indirect herniaenlarge internal ringnot extend scrotumT3a direct herniaT3b indirect herniascrotal herniaT3c femoral herniaT4 recurrent herniaIx-gold std=laparoscopic-least sens=PE-most sense=MRI

1.groin mass A.asymp=discuss conservativeB.symp=sx repairIncarcerate=open sxUnilat=open vs lapBilat=lapRecur=approach through virgin plane2.pain,discomfort A.palpable groin mass=sx repairB.no groin mass=Ix (us,CT,MRI)No hernia=conservativeHernia=sx repairSx–definite Tx repairNon sx-asymp/minimal symp inguinal hernia-yearly risk of incar/strangu = 0.3%

1.post op pain-n entrapment/scar/mesh adhere-sharp localized pain–pin&needle-numbness over cuta.distribution-formication–sens of insect crawlingInj mech-during close EOA–II-entrap in mesh–II,IH,lat.femoral cu-fix in lap–lat.femoral.cuta,GFPostherniorrhaphy pain synd1.somatic pain–lig,m inj:pain on exertion:Tx–rest,nsaid2.visceral pain–symp n plexus inj:pain during ejaculation3.neuropathic pain–n inj:localized sharp pain:Tx–nsaid,n.inject of steroid:fail

neurectomy2.cord&testis injexcess handle–hematoma/ischemia scrotal hematoma-blue/black discolorationTx–self limited/reassureIschemic orchitis-1st wk s/p sx (scapa fascia-divide EO, aware ilioinguinal n-mobilize cord structure-divide blunt cremasteric fiber-identity sac–anterolat of cord-identify vas def,vv of cord-reduction sac = hi ligation-may open sac–ensure no incarcerate1.Anterior repair (non prosthesis)1.Bassini repair-sutureTF,TA,IO (triple layer)fix to inguinal lig/periosteum 2.shouldice repair-continuous suture -multilayer recons Advantage-distribute tension over several layer-prevent herniation btw suture1st layer -sutureIP tract w medial flap (TF,TA,IO)2nd layer-suture reverse back to pubic T-sutureIO,TA w inguinal lig3.McVay repair(cooper lig repair) -relaxing incision–incision at TF Advantage-tension reducing maneuver-can both inguinal & femoral defectOcclude femoral canal-suture cooper lig w TFTransitional stitch-suture TF w inguinal lig2.Anterior repair (prosthesis)1.Lichenstein tension free henia-expose inguinal lig,pubic tubercle Area for mesh-medial–2cm medial to pubic T-lat–continuous fix to inguinal lig-tail of mesh–interrupt suture-sup–fixed to IO,rectusFemoral hernia-medial–fix to cooper lig, lat–inguinal lig2.plug & patch technic -prosthesis through internal ring3.Preperitoneum repair -divide transversalis fascia-pfannelsteil/lowr midline incision Advantage-prosthesis place btw hernia & defect-inc intra abdo P–push mesh to floor-not touch n,cord1.Read Rives repair-ant approach-groin incision-incised TF-blunt dissect preperitoneal space-identify int ring & dissect from perito-mesh 16*12 cm placed preperito:medial–cooper lig, lat–ASIS:3suture–cooper lig,pT,psoas2.giant prosthesis reinforcement visceral sac(Rives,Stoppa,Wantz repair)-pfannelsteil,lower transverse incision-divide rectus & oblique m 10 cm-exposed TF,dissect spsce-placed large mesh:umbilicus to ASIS -1 cm:height 14 cm-3 suture1.ASIS 2.linea semiluna 3.linea alba3.iliopubic tract repair-combine tissue base repair &mesh-preperitoneum approachReconstruction-suture TF w cooper lig/IP tract-mesh placed over post of TF4.Kugel repair-2-3 cm incision above internal ring-muscle splits as appendectomy-blunt dissect in preperito space-hernia sac dissection and division-mesh 8*12 cm5.prolene hernia system-mesh=2 flap:onlay–foor inguinal canal:underlay–preperitoneal space:have intervening connector-prevent mesh migration

-trendelenberg position-surgeon–contralat side to hernia1.TransAbdominal PrePerito H repair Advantage-large working space-in lower abdo.sx-in large hernia-ambiguous dx-anatomy–more obvious3 trochar-12 mm–umbilicus–camera-5 mm*2 (each lower quadrant)(aware inf epi a inj)Procedure-iden bladder,umbilical lig,EIA,IEA -iden inguinal hernia-incised perito at medial umbi.lig:3-4cm above hernia:lateral–to ASIS-dissect preperito space-expose cord structure-lat to pubic symphysis=cooper lig-iden vas def,spermatic vv:avoid grasping inj-dissect indirect H.sac from cord-dissect peritoneum inferiorly-mesh 10*15 cm over myopectineal:medial–cooper lig:lateral–ASIS, above IP tractif below IP tract:inj genital br of GF & lat.cuta.n thigh-mesh lay in preperitoneum-grasp&return peritoneal edge-avoid bowel direct contact w mesh2.Totally ExtraPeritoneum H repair Advantage-dec inj to intra abdo.organ-preserve post rectus–dec trochar H.-if whole preperito approach:not bowel obst,mesh erosion3 trocar-12 mm–umbilicus-5 mm*2 (lower midline)Procedure-dissecting balloon toward PS-slowly inflate-if tear perito–closed defect:prevent mesh erosion,gut obstr-deflated slowly under direct vision:ensure prope mesh positioning3.Intraperitoneal Onlay Mesh (IPOM)-port as TAPP-without dissect preperitoneum:dec operative time:inc neuralgia–unidentify nerve-sac not reduce-mesh direct over hernia defect-fix w suture/spiral track Use in-not safe in preperito dissection:previous sx–LRP,lap herniaMesh-polypropylene–bowel adhere,erosion-polyester coated w porcine collagen:dec p/o c/pMesh1.Polypropylene,polyester-synthetic, non absorb2.Polytetrafluoroethylene-not ingrowth into viscera-use in TAPP,IPOM-in difficult close peritoneum3.Biologic mesh-not role in routine herniorrhaphy-limit in contaminate field