Case Report

• Nama : An. Alfath

• Umur : 1 tahun
• Jenis Kelamin : Laki laki
• Agama : Islam
• Suku : Betawi
• Alamat : Jakarta timur
 Anamnesis
• Keluhan Umum : Sesak Nafas
• RPS :
Pasien datang dengan keluhan sesak nafas
sejak semalam namun memberat dalam 2 jam
SMRS. Demam tinggi sejak 2 hari lalu, mendadak,
terus-menerus. Batukdan pilek sejak 2 hari lalu.
Batuk berdahak dan 2x diakhiri muntah. Batuk
panjang disangkal. Sudah berobat tapi belum ada
perubahan. Selain itu terdapat benjolan di kantung
buah zakar sebelah kanan Berwarna kemerahan.
BAB Mencret , BAK sedikit
• RPD : hydrocelle  Operasi jabulay (1 bulan
SMRS)
• RKP
 Pemeriksaan Fisik
• KU : TSS
• Kesadaran : Composmentis GCS E4V5M6
• TD : RR: 60x
• Nadi : 130x S :36,5 BB=8kg
• Kepala : Normocephali
Leher : KGB tidak teraba membesar
Thorax : I : Pergerakan dinding dada simetris
kanan dan kiri, retraksi sela iga +
P: Vocal fremitus simetris kanan & kiri
P : Sonor simetris kanan & kiri
A : BND bronkhovesikuler Rh -/- wh -/-
Abdomen : I : Perut tampak datar
A : BU 4x/menit
P : Supel, NT (-)
P : Timpani, NK (-)
Ekstremitas : Akral hangat, CRT < 2”
 Status Lokalis
• Regio scrotalis
– I : Benjolan bentuk lonjong, hiperemis
– Pa : Testis teraba, konsistensi kenyal, NT (+), batas
tegas
– Transiluminasi : (-)
Foto klinis
TINJAUAN PUSTAKA
Inguinal Hernias
Historical Hernias

Hernias have been

documented
throughout history
with varying success
at either reduction or
repair.
Trusses & Techniques
 Anatomic Considerations
• The inguinal region must be understood with regard to
its three-dimensional configuration
• A knowledge of the convergence of tissue planes is
essential
• If repairing the hernia laparoscopically, the anatomy
must be well understood from the peritoneal surface
outward
• There is a considerable amount of anatomic variability
with regard to:
– Size and location of the hernia
– Degree of adipose tissue
 Anatomic Considerations
• The surgeon must also be aware of the
precise location of the:
– Femoral nerve
– Genitofemoral nerve
– Lateral femoral cutaneous nerves
 Pelvic & Inguinal Anatomy
Both the ilioinguinal
nerve and the
genitofemoral nerve
traverse the usual
hernia-repair
operative field. The
femoral vein also runs
just deep to the
inguinal floor laterally.
 Myopectineal Orifice of Fruchaud
The MPO is bordered:
• Above by the arching fibers of the internal oblique
and transversus abdominus Muscles,
• Medially (towards the center or to the right) by the
Rectus Abdominus Muscle and its fascial Rectus
Sheath
• Inferiorly by Coopers Ligament, and
• Laterally by the Ileopsoas Muscle
• Running diagonally thru the MPO is the inguinal
ligament
Myopectineal Orifice of Fruchaud
Hesselbach's triangle

Boundaries:
Medial:
Rectus abdominis
muscle medially,

Inferiorly:
Inguinal ligament

Laterally:
Inf. Epigastrics
 Diagnosis
• The patient usually presents (for groin hernia) with
the complaint of a bulge in the inguinal region
• They may describe minor pain or vague discomfort
associated with the bulge
• Extreme pain usually represents incarceration with
intestinal vascular compromise
• Paresthesias may be present if inguinal nerves are
compressed
 Diagnosis

• Physical exam
– The patient should be standing and facing the
examiner
– Visual inspection may reveal a loss of symmetry in the
inguinal area or bulge
– Having the patient perform valsalva’s maneuver or
cough may accentuate the bulge
– A fingertip is then placed in the inguinal canal; Valsalva
maneuver is repeated
– Differentiation between indirect and direct hernias at
the time of examination is not essential
Hernia Exam
 Diagnosis
• Physical exam
– Incarcerated hernias sometimes can be reduced
manually
– Gentle continuous pressure on the hernial mass
towards the inguinal ring is generally effective
(Trendelenburg)
 Nyhus Classification
• Type I: Indirect inguinal hernia Internal
inguinal ring normal (simple pediatric
hernia)

• Type II: Indirect inguinal hernia

Internal inguinal ring dilated but posterior
inguinal wall intact (inferior deep epigastric
vessels not displaced)
 Nyhus Classification
• Type III: Posterior wall defect
– A. Direct inguinal hernia
– B. Indirect inguinal hernia- internal inguinal ring dilated
(massive scrotal or sliding hernia)
– C. Femoral hernia
• Type IV: Recurrent hernia
– A. Direct
– B. Indirect
– C. Femoral
– D. Combined
 Inguinal Hernia
• Indirect inguinal hernia
– Is a congenital lesion
– Occurs when bowel, omentum or other
abdominal organs protrudes through the
abdominal ring within a patent processus vaginalis
– If the processus vaginalis does not remain patent
an indirect hernia cannot develop
– Most common type of hernia
 Indirect Hernia Route

Note:
The hernia sac
passes outside the
boundaries of
Hesselbach's
triangle and follows
the course of the
spermatic cord.
 Inguinal Hernia
• Direct inguinal hernia
– Proceeds directly through the posterior inguinal wall
– Direct hernias protrude medial to the inferior epigastric
vessels and are not associated with the processus vaginalis
– They are generally believed to be acquired lesions
– Usually occur in older males as a result of pressure and
tension on the muscles and fascia
 Direct Hernia Route
Note:
The hernia sac
passes directly
through
Hesselbach's
triangle and may
disrupt the floor
of the inguinal
canal.
 Incidence
• Approximately 700,000 hernia repairs are performed
as an outpatient procedure each year
• Approximately 75% of all hernias occur in the
inguinal region
• Approximately 50% of hernias are indirect inguinal
hernias
• A vast majority occur in males
• Hernias more commonly occur on the right side
 Causes of Groin Hernias
• Divided into two categories: congenital &
acquired defects
– Congenital factors are responsible for the majority of groin
hernias
– Prematurity and low birth weight are significant risk
factors
– Direct hernias are attributed to the wear and tear stresses
of life
– Groin hernias have been demonstrated to occur more
frequently in smokers than nonsmokers especially women
 Specific Surgical Procedures
• Lichenstein (Tension Free) Repair

• McVay (Cooper’s Ligament) Repair

• Shouldice (Canadian) Repair

• Laproscopic Hernia Repair

• Bassini Repair
 Bassini Repair

– Is frequently used for indirect inguinal hernias

and small direct hernias
– The conjoined tendon of the transversus
abdominis and the internal oblique muscles is
sutured to the inguinal ligament
Bassini Repair
 McVay Repair
• AKA: Cooper’s ligament Repair
– Is for the repair of large inguinal hernias, direct
inguinal hernias, recurrent hernias and femoral
hernias
– The conjoined tendon is sutured to Cooper’s
ligament from the pubic cubicle laterally
 McVay Repair

Note:
This repair
reconstructs the
inguinal canal
without using a
mesh prosthesis.
 Shouldice Repair
• AKA: Canadian Repair
– A primary repair of the hernia defect with 4
overlapping layers of tissue.
– Two continuous back-and-forth sutures of
permanent suture material are employed.
The closure can be under tension, leading to
swelling and patient discomfort.
Shouldice Repair
 Lichtenstein Repair

AKA: Tension-Free Repair

One of the most commonly
performed procedures
A mesh patch is sutured over the
defect with a slit to allow
passage of the spermatic cord
 Lichtenstein Repair

Note:
Open mesh repair.
Mesh is used to
reconstruct the
inguinal canal.
Minimal tension is
used to bring
tissue together.
 Laparoscopic Hernia Repair
– Early attempts resulted in exceptionally high
reoccurrence rates
– Current techniques include
• Transabdominal preperitoneal repair (TAPP)
• Totally extraperitoneal approach (TEPA)
 Laparoscopic Mesh Repair
Note:
Viewed from inside the
pelvis toward the direct
and indirect sites. A broad
portion of mesh is stapled
to span both hernia
defects. Staples are not
used in proximity to
neurovascular structures.