25. 1 Acute pancreatitis
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Drugs
Antlcoagulants Anncoagulants restrict the further deposition of fibrin and limit the extension of the thrombus. An initial Injection of heparin 5000 units (subcutaneously) is given and Is combined with an oral anticoagulant and the latter is continued for three to six weeks.
FIbrlnolytIc drugs The most widely used agent is streptokinase, which has a thrombolytic effect. The alternative is urokinase which is claimed to Induce a more predictable thrombolytic state. Both agents act by converting plasmlnogen to plasmin, which has a specific proteolytic effect on fibrin and fibrinogen.
Streptokinase is not always successful in producing complete lysis and there are known allergic reactions.
Absolute contraindications to drug therapy include a recent history of a duodenal or gastric ulcer, gastrointestinal or cerebral haemorrhage or any haemorrhagic diathesis.
Surgery
The vast majority of patients with DVT are satisfactorily managed medically, in a small percentage, however, operation is necessary.
1. Venous thrombectomy In massive lliofemoral venous thrombosis, incising the vein in the groin and extracting the clots may rapidly relieve venous stasis. Most surgeons are, .however, not enthusiastic to perform this operation except when the limb salvage is involved, for impending venous gangrene, due to white leg. This operation should be performed within 24 hours at the onset of symptoms.
2. Venous Interruption The rationale of venous Interruption is the prevention of recurrent and potentially fatal pulmonary embolism by trapping the thrombus in the peripheral venous segment. Surgical treatment is reserved for the unusual patient who fails to respond to anticoagulant - therapy or has specific contraindications to its use.
Most fatal pulmonary emboli arise from iliac or pelvic veins and techniques
to trap emboli in the Inferior vena cava have been devised. A number of techniques have been developed which involve introduction of a luminal device (see later) designed to trap large emboli arising from the branches of the inferior vena cava, including umbrella filters, cone-shaped filter devices, and balloons.
Complications of Deep Venous Thrombosis
The following complications of DVT need consideration.
1. Pulmonary embolism
2. Postphlebitic syndrome
3. Venous ulceratlon
Pulmonary Embolism
It is suggested that 15 to 20 per cent of thrombi In the legs embollse. It is a dangerous complication and much depends upon the size of the embolus. In case of fatal pulmonary embolism, the clot isDiseases of usually found In the pulmonary trunk or as a saddle embolus occluding both pulmonary arteries. Several clinical syndromes of pulmonary embolism are recognised.
1. Acute massive pulmonary embolism The right ventricular outflow tract is obstructed and severe cardlorespiratory symptoms develop and the condition may be fatal.
2. Acute minor pulmonary embolism The patient may develop pleuritic pain, haemoptysis and a wedge-shaped shadow on chest X-ray.
3. Submassiue pulmonary embolism These are patients with massive pulmonary embolism in whom symptoms are of gradual onset. They develop increasing dyspnoea and haemoptysis over a period of several weeks.
4. Chronic pulmonary embolism This is thought to be due to recurrent small emboli which lead to a gradual onset of pulmonary hypertension.
For most patients, the treatment of pulmonary embolism is medical. The value of heparin in its treatment is well established. It is safer to administer heparin
by intravenous infusion as the patient may be in shock (with reduced absorption from subcutaneous tissues).
In acute massive pulmonary embolism, the aim of treatment is the following.
1. To achieve rapid lysis of the vascular obstruction
2. To reverse the haemodynamic disturbance
3. To achieve lysis of DVT to forestall recurrent
emboli.
Antlcoagulation limits the extension of the clot and streptokinase helps towards its lysis. Oxygen should be administered and a cardiotonic drug like dopamme is recommended. When the central venous pressure (CVP) is low, IV fluids should be administered. Acute massive embolism is associated with significant pulmonary artery occlusion and marked outflow obstruction evidenced by a significant rise in the pulmonary artery pressure. Emergency embolectomy may save the patient's life in these circumstances.
For all types of pulmonary embolism, the following is the usual outcome. 10% of patients die within the first hour before the diagnosis can be confirmed or an emergency embolectomy performed. Of the 90% or so who survive the initial Insult, the diagnosis is only confirmed in one-third.
Once the patient has survived an initial pulmonary embolus, bipedal ascending phlebograms or Doppler scans must be obtained to assess the presence and extent of any residual thrombus within the deep veins of the lower limbs. Recurrent embolism in the presence of adequate antico-agulatlon is the best indication for interrupting the Inferior vena cava.
Infralumlnal caval device To eliminate the risks of laparotomy, a transvenous catheter technique has been developed for the interruption of the Inferior vena cava. Under local anaesthesia, a small Incision is made in the right supraclavlcular region, and the right internal jugular vein is isolated. The applicator capsule containing the collapsed intraluminal device Is Inserted via a venotomy in the isolated vein and is advanced under fluoroscopic control through SVC and right atrium into the inferior
vena cava. IV heparin infusion is started 12 hours after Insertion and continued for 7 to 10 days. Oral anticoagulants are started on the third postoperative day and continued for at least 3 months.
Prognosis of a case of pulmonary embolism Death occurs in about 10 per cent of the cases of pulmonary embolism and pulmonary infarction occurs in about 15 per cent. The infarcted tissue may become infected with subsequent abscess formation. In 70 to 80 per cent. there is resolution of the embolus and improvement in pulmonary perfusion may occur by the end of the first week or two.
Chronic pulmonary hypertension is a late sequela in about 5 per cent of all cases of pulmonary embolism.
Postphlebitic Syndrome
After deep vein thrombosis, there is recanallsatlon with destruction of valves. There is development of venous hypertension in the deep venous system during exercise. The syndrome consists of pain on standing, dependent oedema and the later development of brawny, tender induration of the subcutaneous tissues of the medial lower leg. Subcutaneous flbrosis may progress to eczematous skin changes. Many patients develop secondary superficial varicose veins.
Venous (Gravitational) Ulcers
These ulcers typically occur on the lower medial aspect of the leg just above the medial malleolus and have been described earlier.
Hernia
A hernia is an abnormal protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity which contains it In this chapter we are only concerned with the external abdominal hernia. An external abdominal hernia is protrusion of abdominal viscus through a weak spot in the abdominal wall.
The common external herniae are:
1. Inguinal — about 73%;
2. Femoral — about 17%;
3. Umbilical — about 8.5%;
4. Incisional — its incidence is not included. Other 1.5% cases are rare herniae e.g.
(i) Epigastric;
(ii) Lumbar;
(iii) Spigelian;
(iv) Obturator;
(v) Gluteal.
AETIOLOGY— Mainly 2 factors play in causing a hernia:—
1. Weakness of the abdominal muscles and
2. Increased abdominal pressure which forces the content out through the normal abdominal musculature.
1. Weakness of the abdominal musculature can be either (a) congenital or (b) acquired.
(a) CONGENITAL WEAKNESS —
(i) Persistence of processus vaginalis — this causes indirect complete inguinal hernia. It is a sort of preformed sac through which the contents herniate.
(ii) Similarly patent canal of Nuck in female causes indirect inguinal hernia. (iii) Incomplete obliteration of umbilicus may lead to infantile umbilical hernia.
(b) ACQUIRED WEAKNESS—
(i) Excessive fat in the abdomen causes weakness of the abdominal musculature. Fat separates muscle fibres and thus causes weakness. This causes the appearance of direct inguinal hernia, paraumbilical hernia or hiatus hernia.
(ii) Muscle weakness may follow repeated pregnancy.
(iii) Surgical incisions may lead to division of nerve fibres and thus causes muscle weakness. Example of this is that a direct hernia may develop following appendicectomy due to division of ilio-inguinal nerve.
(iv) Incisional hernia develops through weakened abdominal muscle following a previous operation. Mostly infection in the early postoperative period or excessive fat in the abdominal wall predisposes incisional hernia.
2. Increased abdominal pressure e.g. (i) Whooping cough in children. (ii) Chronic cough in bronchitis, tuberculosis etc. (iii) Bladder neck obstruction or urethral stricture. (iv) Enlarged prostate causing dysuria.
(v) Powerful muscular effort or straining during lifting heavy weight. (vi) Vomiting. (vii) Repeated pregnancy. (viii) Constipation.
PATHOLOGY—
A hernia consists of 3 parts — (i) the sac, (ii) the contents of the sac and (iii) the coverings of the sac. (i) The sac is a pouch of peritoneum which comes out through the abdominal musculature. This sac contains abdominal viscus and it has coverings starting from the skin to the sac itself. This sac can be divided into four parts — (a) the mouth i.e. the opening of the sac through which the contents enter the sac, (b) the neck of the sac, which is the most constricted part and it is this part which passes through the abdominal musculature, (c) the body, which is the main portion of the sac and (d) the fundus which is the most redundant part of the sac. In children the sac is quite delicate, whereas in adults in longstanding cases the sac is comparatively thick.
(ii) The contents.— The viscus which lies within the sac of a hernia is called the content of a hernia. Depending on the content, the hernia is variously named e.g.
(a) When the content is omentum, the hernia is called an omentocele or epiplocele.
(b) When the content is a loop of intestine, the hernia is called enterocele.
(c) When the content is a portion of the circumference of the intestine, it is called Richter's hernia.
(d) A portion of the bladder is sometimes present in a direct inguinal or sliding inguinal or a femoral hernia.
(e) Ovary may be the content with or without the fallopian tube.
(f) When the content is Meckel's diverticulum, it is called Littre's hernia.
(g) When two loops of small intestine remain in the manner of 'W', it is known as Maydl's hernia.
(h) Fluid — slight fluid is almost always present, but it is more when it is associated with ascites. Such fluid may be blood-stained when the hernia is strangulated.
(iii) Coverings are the layers of the abdominal wall which cover the hemial sac. This includes the skin and muscles of the abdomen.
CLASSIFICATION —
A hernia, irrespective of its site may be either — (i) Reducible or (ii) Irreducible, (iii) Obstructed or incarcerated or (iv) Strangulated or (v) Inflamed.
Reducible hernia.— When a hernia reduces itself as the patient lies down or can be reduced by the patient or by the surgeon, it is called a reducible hernia. One of the 2 most characteristic features of the hernia is its reducibility. The second characteristic feature is impulse on coughing. When the hernia is an enterocele i.e. the content is small intestine, it gurgles on reduction and the first portion is difficult to reduce. Once reduction is commenced it is easily reduced particularly the last portion. In case of omentocele the first portion is easy to reduce but it is difficult to reduce the last portion. An uncomplicated hernia is usually a reducible hernia.
Irreducible hernia.— When the contents of the hernia cannot be returned back to the abdomen it is called an irreducible hernia. There are various causes of irreducibly :— (i) Adhesion of its contents to each other;
(ii) Adhesion of its contents with the sac;
(iii) Adhesion of one part of the sac to the other part;
(iv) Sliding hernia;
(v) Narrowing of the neck of the sac due to fibrosis following continued use of the truss;
(vi) Presence of omentum in the sac often causes irreducibility;
(vii) When the content is the large intestine which becomes obstructed (incarcerated);
(viii) When there is massive hernia inside the scrotum {scrota! abdomen} it often becomes irreducible.
Femoral and umbilical herniae are often irreducible. Irreducible hernia is dangerous and may lead to strangulation.
Obstructed or Incarcerated hernia.— It is irreducibility plus intestinal obstruction. An obstructed hernia means that the hernia is associated with intestinal obstruction due to occlusion of the lumen of the bowel. The term 'incarcerated hernia' is often used as an alternative to obstructed hernia, but to be more precise it indicates that a portion of colon is the content of the sac and is blocked with faeces. It can be ascertained by indenting with the finger like putty.
The features of obstructed hernia are — (i) Expansile coughing impulse is not present;
(ii) The hernia is irreducible;
(iii) Patient does not complain of pain;
(iv) The hernia is lax and not tender,
(v) Features of intestinal obstruction.
One must be very careful to make this diagnosis as against strangulated hernia. It also possesses two of its features i.e. irreducibility and intestinal abstraction. Of course the 3rd and the most important feature of a strangulated hernia is missing in this hernia i.e. interference with the blood supply of the intestine. So it is a dangerous venture to diagnose obstructed hernia when strangulation may be the real state of affairs and thus valuable time will be wasted until it becomes too late to save the patient's life.
Strangulated hernia (irreducibility + obstruction + arrest of blood supply to the contents).— A hernia is said to be strangulated when the blood supply of its contents is seriously impaired. Ultimately the content becomes gangrenous. This condition develops when the neck of the sac is very much constricted. When the intestine is the content, intestinal obstruction obviously takes place, but intestinal obstruction may not be present in case of omentocele, Richter's hernia and Littre's hernia. Although inguinal hernia is 4 times more common than femoral hernia, yet a femoral hernia is more likely to strangulate as the femoral ring is quite tough in comparison to the superficial inguinal ring.
PATHOLOGY.— When the mouth of the sac is very much constricted, intestinal obstruction first ensues and the intestine within the sac starts dilating. In case of enterocele the venous return is first impeded. The intestine becomes congested and bright red. Serous fluid is seen oozing out into the sac. As venous stasis increases, the arterial supply is also impaired. Ecchymoses appear in the serosa. Blood comes out into the lumen of the intestine as also into the fluid of the sac, so the fluid in the sac becomes blood stained. The serous layer loses its shining character and gradually becomes dull and covered with fibrinous exudate.
Gradually the intestine loses its tone and it feels flabby. The vitality of the intestine diminishes and this favours migration of bacteria through the intestinal wall and the fluid within the sac becomes full of bacteria and toxins.
The mesentery within the sac becomes congested and haemorrhagic. Thrombosis of its vessels occurs.
Gangrene first appears at the place of constriction and at the antimesenteric border of the intestine. In the places of gangrene the colour changes from purple to black and ultimately to green. Gangrene may start as early as 5 to 6 hours after the onset of first symptom of strangulation.
Internal strangulation is more dangerous since spreading peritonitis sets in from the sac.
CLINICAL FEATURES.— Patient first complains of pain and vomiting. Pain is particularly located at the hernial site. In case of internal strangulation it is located at the umbilicus. Soon pain spreads all over the abdomen and vomiting becomes forcible and frequent. If the strangulation is not relieved the paroxysm of pain continues. Such pain will only cease with the onset of gangrene and paralytic ileus. So in case of strangulated hemia spontaneous cessation of pain is an ominous symptom.
On examination patient is seriously ill. The hernia is tense and tender. Obviously the hernia is irreducible and there is no impulse on coughing. There are also features of acute intestinal obstruction in case of enterocele.
STRANGULATED OMENTOCELE.— The initial symptoms are more or less similar to those of strangulated enterocele. Vomiting is not so prominent feature, similarly the abdominal pain. The pain is localised to the hernia but recurrent attacks of generalised abdominal pain are absent. Similarly there will be no feature of intestinal obstruction. Omentum can withstand meagre blood supply for quite a long time, so onset of gangrene is usually delayed. It first occurs in the most distal part of the omentum. Once the gangrene sets in the mass gets infected and it becomes an inflamed hernia alongwith strangulation. In case of inguinal hernia such infection may even cause scrotal abscess.
STRANGULATED RICHTER'S HERNIA— When a portion of the circumference of the intestine becomes the content of the sac it is called Richter's hernia. Strangulation of such a hernia often complicates a femoral hernia and rarely obturator hernia.
Clinical features mimic gastroenteritis and diagnosis becomes difficult. Vomiting if present is not that frequent. Unless V, of the circumference of the bowel is involved intestinal obstruction may not be present. Intestinal colic may occur but the bowels are opened normally and there may be even diarrhoea. Absolute constipation may develop when paralytic ileus supervenes and this often is very much delayed.
For the above reasons diagnosis becomes delayed and operation is perfonned late. So during operation the knuckle of bowel in the sac is often gangrenous and peritonitis has set in.
Maydl's hernia (HERNIA-EN-W) or Retrograde strangulation.— In this condition 2 loops of bowel remain in the sac and the connecting loop remains within the abdomen and often becomes strangulated. The loops of intestine look like 'W. The loop within the abdomen becomes first strangulated and can only be suspected when tenderness is elicited above the inguinal ligament and with the presence of intestinal obstruction. The fallacy of this condition is that even on opening the sac the coils of intestine look normal. Only on traction of these loops one can find the strangulated loop inside the abdomen. Since the strangulated loop is inside the abdomen generalised peritonitis may set in early.
Inflamed hernia.— When a hernia becomes inflamed it is called an inflamed hernia. Inflammation can occur from outside i.e. from an abrasion or an ill-fitting truss or can occur/row inside e.g. when its content is an inflamed appendix or Meckel's diverticulum or a salpinx. The diagnosis is made by the presence of constitutional disturbances associated with local signs of inflammation — overlying skin becomes red and oedematous. The hernia becomes painful, swollen and tender. The only differentiating feature from a strangulated hernia is that this hernia is not tense and is not associated with intestinal obstruction.
INGUINAL HERNIA
An inguinal hernia is the protrusion of part of the contents of the abdomen through the inguinal region of the abdominal wall. This inguinal region is a weak part of the abdominal wall by the presence of the inguinal canal, the deep inguinal ring and the superficial inguinal ring.
The inguinal canal.— The inguinal canal is a triangularslit almost horizontal in direction which lies just above the inner half of the inguinal ligament, h commences at the deep inguinal ring and ends at the superficial inguinal ring. In infants the superficial and deep inguinal rings are almost superimposed and the obliquity of this canal is slight. In adults the inguinal canal is about 3.75 cm (1'/- inch) long and is directed downwards and medially from the deep to the superficial inguinal ring. This canal has been developed due to descent of testis in the embryonic life.
The' deep inguinal ring.— It is an opening in the fascia transversalis 1.25 cm above the mid-inguinal point i.e. midpoint between the symphysis pubis and the anterior superior iliac spine. It is of an oval shape, the long axis being vertical. It varies in size in different individuals and is much larger in the male than in the female. At its margins the fascia transversalis is condensed. Medially it is related to the inferior epigastric vessels. It transmits the spermatic cord in the male and the round ligament of the uterus in the female.
The superficial inguinal ring.—It is an interval in the aponeurosis of the external oblique muscle. It is situated just above and lateral to the crest of the pubis. The aperture is somewhat triangular with its long axis oblique corresponding to the course of the fibres of the aponeurosis. It is smaller in the female. Its base is formed by the crest of the pubis and its sides by the margins of the opening of the aponeurosis which are called the crwa of the ring. The lateral crus of the ring is stronger. There are some fibres which course at right angles to the fibres of the aponeurosis. Some of these fibres may arch over the superficial inguinal ring and are called the intercrural fibres. The superficial inguinal ring gives passage to the spermatic cord and ilio-inguinal nerve in the male and to the round ligament of the uterus and the ilio-inguinal nerve in case of females.
Boundaries of the inguinal canal.—
Anteriorly — throughout its whole length there are skin, the superficial fascia and the aponeurosis of the external oblique and in its lateral l/3rd there are the fleshy fibres of the origin of the internal oblique.
Posteriorly — the transversalis fascia along the whole length of the canal separates it from the extraperitoneal connective tissue and the peritoneum. In the medial half there are the conjoined tendon (combination of internal oblique and trans versus muscles) and reflected part of the inguinal ligament.
Above — there are arched fibres of the internal oblique and transversus abdominis before they fuse to form the conjoined tendon.
Below or floor — is formed by the grooved upper surface of the inguinal ligament and its union with the fascia transversalis. At its medial end there is lacunar ligament.
Presence of the canal weakens the lower part of the anterior abdominal wall. But obliquity of the canal to some extent compensates, as increase in intra-abdominal pressure will cause approximation
(ii) Laterally — by the inferior epigastric vessels.
(iii) Below — by the medial part of the inguinal ligament.
The floor of this triangle is formed by fascia transversalis. This triangle is bisected by the medial umbilical fold which is formed by the obliterated umbilical artery. Through this Hesselbach's triangle direct inguinal hernia comes out.
Mechanisms which prevent hernia in the inguinal region.— Though inguinal region is a weak spot in the abdominal musculature, rise in intra-abdominal pressure would have caused inguinal hernia in every individual. So there must be some defensive mechanisms which prevent hernia to occur. These are:—
1. Obliquity of the inguinal canal -— when there is rise in intra-abdominal pressure the posterior wall is apposed to the anterior wall and thus prevents coming out of abdominal content through inguinal canal.
2. Shutter mechanism of the arched fibres of the internal oblique and transversus abdominis will bring down these muscles towards the floor when they are contracted during rise of intra-abdominal pressure.
3. Ball-valve action of the cremaster muscle which pulls up the spermatic cord into the canal and plug it during rise in intra-abdominal pressure. '
4. In front of the deep inguinal ring there are strong fibres of the internal oblique. This prevents entry of any abdominal content through the deep inguinal ring.
5. Strong conjoined tendon is there in front of Hesselbach's triangle to prevent direct inguinal hernia.
INDIRECT OR OBLIQUE INGUINAL HERNIA
In indirect inguinal hernia the contents of the abdomen enter the deep inguinal ring and traverse the whole length of the inguinal canal to come out through the superficial inguinal ring. This is much more common than direct inguinal hernia. This hernia usually occurs when there is apreformed sac of partially or completely patent processus vaginalis. Shortly after birth this processus vaginalis becomes obliterated in normal individuals. Such obliteration occurs first at the deep inguinal ring, then just above the testis and finally the remaining portion between the deep inguinal ring and the upper pole of the testis is obliterated to a fibrous cord.
Indirect inguinal hernia is more commonly seen on the right side, though l/3rd of the cases of the hernia is or will be bilateral. Particularly in children hernia is more common on the right side due to later descent of the right testis.
According to the extent of the hernia, it can be divided into 3 groups :
1. Bubonocele.— In this case the hernia is limited in the inguinal canal and the processus vaginalis is closed at the superficial inguinal ring. This hernia presents as an inguinal swelling. The history is usually short and majority of the victims are young adults.
2. Funicular hernia.— Here the processus vaginalis is closed at its lower end just above the epididymis. So the contents of the hernia can be felt separately from the testis and the testis lies below the hernia. Most of this hernia occurs in adults. A long standing history is usually received in these cases.
3. Complete or vaginal or scrota! hernia.— Here the processus vaginalis is patent throughout. The hernial sac is continuous with the tunica vaginalis of the testis. In this case the hernia descends down to the bottom of the scrotum lying in front and at the sides of the testis. The testis can be felt posterior to the hernial sac with great difficulty. Though it is a congenital hernia and commonly encountered in children, yet may not appear until adolescent or adult life.
COVERINGS OF INDIRECT INGUINAL HERNIA.— From inside outwards the hernial sac is covered by the following structures:
(i) Peritoneum;
(ii) Extraperitoneal fat;
(iii) Internal spermatic fascia (derived from the fascia transversalis at the deep inguinal ring);
(iv) Cremasteric fascia and muscles (derived from internal oblique and transversus abdominis), the muscular fasciculae being separated by areolar tissue;
(v) External spermatic fascia (derived from the intercrural fibres at the superficial inguinal ring);of the posterior wall to the anterior wall of the canal. The posterior wall is strengthened by the conjoined tendon and the reflected part of the inguinal ligament precisely behind the superficial inguinal ring and the fleshy fibres of the internal oblique strengthens the anterior wall of the canal in front of the deep inguinal ring.
Contents of the inguinal canal.—
1. Ilioinguinal nerve in both the sexes and is particularly seen in the medial part of the canal. It pierces the internal oblique muscle distributing filaments to it and then enters the inguinal canal in its midway and lies below the spermatic cord to accompany it through the superficial inguinal ring.
2. In case of male the spermatic cord and its coverings, the vestigial remnant of the processus vaginalis (it is the prolongation of the peritoneum, which accompanies descent of testis into the scrotum).
3. In case of female the round ligament of the uterus and the remnant of processus vaginalis.
COVERINGS OF THE SPERMATIC CORD.— When the testis descends through the abdominal wall into the scrotum it drags its vessels and nerves alongwith its ductus deferens. These structures meet at the deep inguinal ring and form the spermatic cord, which extends from the deep inguinal ring to the posterior border of the testis.
In passing through the inguinal canal the spermatic cord acquires coverings from the different layers of the abdominal wall and these coverings from within outwards are —
(i) The internal spermatic fascia is derived from the fascia transversalis at the deep inguinal ring.
(ii) Cremastericfascia which consists of a number of muscular fasciculi derived from the internal oblique muscle. The muscular fasciculi constitute the Cremaster.
(iii) The external spermatic fascia is a thin fibrous membrane continuous above with the aponeurosis of the obliquus externus abdominis at the superficial ring.
STRUCTURES OF THE SPERMATIC CORD— (i) The main constituent is the vas deferens.
(ii) Arteries of the spermatic cord are — testicular artery, artery of the vas deferens and artery to the cremaster.
(iii) Pampiniform plexus of testicular veins.
(iv) Lymph vessels of the testis.
(v) Nerves — testicular plexus of sympathetic nerves which accompany the testicular artery and the artery of the ductus deferens and the genital branch of the genitofemoral nerve.
Hesselbach's triangle.— It is a weak spot of the anterior abdominal wall through which direct inguinal hemia protrudes.
It is a triangle which is bounded — (i) Medially — by the outer border of the rectus abdominis muscle.
(vi) Superficial fascia. When the hernia is a complete one the dartos muscle of the scrotum comes in this layer;
(vii) The skin.
DIRECT INGUINAL HERNIA
A direct inguinal hernia protrudes through the posterior wall of the inguinal canal medial to the inferior epigastric vessels i.e. through Hesselbach's triangle. Such hernia lies outside the spermatic cord, either behind or above or below the cord. So during operation the most important differentiating feature is that the neck of the direct hernia lies medial to the inferior epigastric vessels, whereas the neck of the indirect hernia lies lateral to the inferior epigastric vessels.
A direct hernia is acquired with the sole exception of a rare type in which there is a small rigid circular orifice in the conjoined tendon just lateral to where it inserts with the rectus sheath (Ogilvie hernia).
Direct hernia is much rare and constitutes 15% of all cases. More than '/2 the cases are bilateral.
Direct hernia is always an acquired type except the Ogilvie hernia and occurs in elderly persons. It occurs in individuals with poor abdominal musculature as shown by presence of elongated Malgaigne's bulges. Direct hernia almost always occurs in men. Women particularly never develop such hernia.
Direct inguinal hernia rarely attains a large size. Even if it comes out through the superficial inguinal ring it never descends into the scrotum. As the neck of a direct hemial sac is wide,;'(rarely gets strangulated.
DIFFERENTIATING FEATURES BETWEEN INDIRECT AND DIRECT INGUINAL HERNIA
Indirect
1. It can occur at any age, but more common in children and young adults. Males are affected 20 times more commonly than females.
2. In 2/3rds of cases it is unilateral, only in l/3rd of cases both the sides are involved.
3. It is commoner on the right side particularly in children due to later descent of the right testis.
4. Frequently, the hernia is complete and in this case it is of pyriform shape. When it is incomplete it is of oval shape
5. This hernia descends obliquely downwards and medially.
6. This hernia has to be reduced by the patient or the doctor and it does not reduce by itself.
7. Impulse on coughing.— Clinician puts his index finger over the deep inguinal ring (l'/) inch above the midinguinal point and the middle finger over the superficial inguinal ring. The patient is asked to cough or to hold the nose and blow (Zieman's technique). If an impulse is felt on the index finger it is an indirect hernia.
8. Imagination test (see the text below).— When the little finger enters the ring if it goes upwards, backwards and outwards it is an indirect hernia and if the impulse is felt on the tip of the finger it is an indirect hernia.
Direct
1. Elderly individuals are usually affected.
2. Females are not affected.
3. More than 1/2 the cases are bilateral. Such hernia is usually caused by poor abdominal musculature, evident by presence of long Malgaigne's bulges.
4. This hernia is always incomplete and it is of spherical shape.
5. This hernia appears as a forward bulge.
6. It automatically reduces when the patient lies down.
7. If an impulse is felt on the middle finger it is a direct hernia.
8. When the little finger goes directly backwards, it is a direct hernia. Moreover when the patient coughs, impulse is felt on the pulp of the finger.
9. Ring occlusion test (see the text below).— hi 9. A direct hernia will show a bulge medial to the this test indirect hernia will not bulge out.
Clinical features.—
HISTORY.—
(i) Age.— Inguinal hernia can occur at any age. Indirect inguinal hernia occurs in children in the first few months of life, in the late teens and young adults. A direct hernia is mostly seen in older subjects.
(ii) Occupation.— Strenuous work is often responsible for development of hernia. Heavy work, especially lifting weights, puts a great strain on the abdominal muscles. If there is an underlying weakness already present, hernia may develop. The patient may be able to relate the onset of the hernia to a particular event e.g. lifting a heavy weight.
SYMPTOMS—-(i) PAIN.— The commonest symptom of hernia is discomfort or pain. Patient complains of a dragging or aching type of pain in the groin which gets worse as the day passes. This is often noticed when there is a 'tendency to hernia'. So pain may appear long before the lump is noticed. Pain. continues so long as the hernia is progressing, but ceases when it is fully formed. In well formed hernia, there is a sense of heaviness or weight. Pull on the mesentery may cause pain in the epigastric region. The patient may complain of pain allover the abdomen due to drag on the mesentery and omentum.
When the hernia becomes very painful and tender, it is probably strangulated.
(ii) LUMP.— Many herniae may cause no pain and he has noticed only a swelling in the groin. But this is rare and some sort of discomfort is almost always present.
(iii) SYSTEMIC SYMPTOMS.— If the hernia is obstructing the lumen of the bowel (incarcerated hernia). cardinal symptoms of intestinal obstruction will appear. These are colicky abdominal pain, vomiting, abdominal distension and absolute constipation. If the patient is vomiting, note the character of the vomitus — whether bilious or faecal. Faecal smelling vomitus heralds ominous sign.
(iv) OTHER COMPLAINTS.— The cause of hernia must be enquired into. Persistent coughing of whooping cough or chronic bronchitis, constipation, dysuria due to benign enlargement of prostate or stricture urethra may show other symptoms which the patient deliberately do not mention considering them to be irrelevant. Leading questions should be asked to find out these symptoms.
(v) PAST HISTORY.— Whether the patient had any operation or not ? During appendicectomy division of subcostal or ilioinguinal nerve may lead to weakness of the abdominal muscles at the inguinal region. This may cause subsequent direct inguinal hernia. Many a patient gives a previous history of hernia repair on the same side (recurrent hernia) or on the opposite side (right sided hernia generally precedes that of the left side).
LOCAL EXAMINATIONS.—The patient should be first examined in the standing position and then in the supine position. Majority of the herniae are better examined in the standing position.
Two classical signs of an uncomplicated hernia are — (i) Impulse on coughing and (ii) reducibility. Sometime must be spent for inspection. Impulse on coughing can be detected by inspection alone.
1. POSITION AND EXTENT.— If the swelling descends into the scrotum or labia majora it is obviously an inguinal hernia. When it is confined to the groin, it should be differentiated from a femoral hernia. Two anatomical structures are to be considered in this respect— (a) the pubic tubercle and (b) the inguinal ligament. An inguinal hernia is positioned above the inguinal ligament and medial to the pubic tubercle, whereas a femoral hernia lies below the inguinal ligament and lateral to the pubic tubercle.
2. TO GET ABOVE THE SWELLING— This examination differentiates a scrotal swelling from an inguinoscrotal swelling. The root of the scrotum is held between the thumb in front and other fingers behind in an attempt to reach above the swelling. In case of inguinal hernia one cannot get above the swelling, whereas in case of pure scrotal swelling e.g. vaginal hydrocele one can get above the swelling.
3. CONSISTENCY.— If the inguinal hernia contains omentum (omentocele or epiplocele) the swelling feels doughy and granular. If it contains intestine (enterocele) it feels elastic. A strangulated hernia feels tense and tender
4. IMPULSE ON COUGHING.—When there is no swelling, a finger is placed on the superficial inguinal ring and the patient is asked to cough. The root of the scrotum can also be held between the index finger and thumb and the patient is asked to cough. An expansile impulse on coughing can be felt as the contents of the hernia will be forced out through the superficial inguinal ring and will separate the thumb from the index finger. When hernia is already present it becomes larger and more tense on coughing. Impulse on coughing will be absent in case of strangulated hernia, irreducible hernia and obstructed hernia.
5. REDUCIBILITY.— The patient is first instructed to lie down on the bed. In many instances the hernia reduces itself when the patient lies down (direct hernia). The patient himself can often reduce the hernia. In the remaining cases the surgeon should try to reduce the hernia. The patient is then asked to flex the thigh of the affected side, to adduct and rotate it internally. This will not only relax the pillars of the superficial ring but also the oblique muscles of the abdomen. The fundus of the sac is gently held with one hand and even pressure is applied to squeeze the contents into the abdomen while the other hand will guide the contents through the superficial inguinal ring. This is known as 'Taxis'.
6. IN VAGI NATION TEST.— After reduction of the hernia one can perform this test to know the gap in the superficial inguinal ring. Little finger should be used. Invaginate the skin from the bottom of the scrotum, the little finger is gradually pushed up and then rotated to enter the superficial inguinal ring. Normally the superficial is a triangular slit which admits only the tipofthe little finger. When thepatentcoughs the examining finger will be squeezed by the approximation of the two pillars. A palpable impulsed/ill confirm the diagnosis. For convenience of the clinician one may use the index finger, but utmost gentleness is expected.
7. RING OCCL USiON TEST.— The hernia m ust be reduced first. A (hum b is pressed on the deep inguinal ring i.e. 1/2 inch above the mid-inguinal point. The patient is asked to cough. A direct hernia will show a bulge medial to the occluding finger but an indirect hernia will not find access, so no bulge. A hernia can be classified into :
1. CONGENITAL — when a preformed sac was present congeni tally i .e. presence of partly or completely unobiliterated processus vaginalis.
2. ACQUIRED — when there was no preformed sac and the sac has acquired later in life.
A hernia is whether congenital or acquired can sometimes be confirmed by the history alone. A congenital hernia becomes complete within a short period of its appearance, whereas an acquired hernia progresses gradually and usually fails to be complete.
All direct herniae are acquired. Many surgeons believe that all indirect herniae are congenital. Though the sac was present since birth, the hernia may not appear until adult life. But other surgeons believe that some of the indirect hernia are acquired.
According to the contents of 'the sac a hernia can be classifiedint6
1. Enterocele — when the sac contains intestine.
2. Omentocele — when the sac contains omentum.
3. Entero-omentocele — when the sac contains both intestine and omentum.
4. Cystocele — when a part of (he urinary bladder is inside the sac, this usually occurs in a direct hernia or in sliding hernia. It is suspected when the patient gives the history that the hernia gets enlarged just before micturition and smaller after the micturition. Moreover pressure on this hernia induces a desire for micturition particularly when it is distended.
Difference between enterocele and omentocele are :
Enterocele | Omentocele |
| 1. On inspection one may see visible peristalsis in this case | 1. Peristalsis is never seen.. |
| 2. Consistency of the hernia is elastic. | 2. Consistency is doughy and granular. |
| 3. Reduction.— (i) This hernia reduces easily Comparatively the first part is more difficult to reduce than the last part | 3. (i) Reduction in general is difficult. Its first part goes in easily burthe last part resents to be , , which slips in easily, reduced. |
| 4. Percussion — may produce a resonant note | 4. Percussion reveals dull note. |
| 5. In auscultation one may hear peristaltic sound ii) While reduction a gurgling sound can be heard. | 5. No peristaltic sound can be heard(ii) No gurgling sound is heard |