inguinal hernia

Types of operations for inguinal hernia
-the goal of all hernia repairs is to eliminate the peritoneal sac (in the case of indirect hernia) and to close the fascial defect in the inguinal floor.
A. Simple high ligation of the sac through an inguinal incision is the key to the repair of indirect hernias in infans and children.
B. Macy repair is combined with a tightening of internal ring.
C. Open Mesh hernia repair
D. Laparoskopik technique, less pain and more rapid return to work, but expensive.
E. Bassini repair, the tradisional autologous tissue repairs. This is conjoined tendon is approximated to pouparts ligament and the spermatic cord remains in its normal anatomic position under the external oblique aponeurosis.
F. Halsted repair, external oblique beneath the cord but otherwise resembles the bassini repair.
G. Lotheissen-mcvay repair, bringing the conjoined tendon farther posteriorly and inferiorly to coopers ligament. Its effective for femoral hernia but always requires a relaxing incision to relieve tension
H. Shouldice repair, more extensive dissection required. The transversalis fascia is first divided and then imbricated to pouparts ligament. Finally, the conjoined tendon and internal oblique muscle are also approximated in layers to the inguinal ligament.

NON SURGICAL MANAGEMENT
Truss, should be fitted to provide adequate external compression over the defect in the abdominal wall. It should be taken off at night and put on in the morning before the patient arises. Its may cause fibrosis of anatomic structure so that subsequent repair may be more difficult.

Prognosis
- recurrence may be triggered by chronic cough, prostatism, constipation, poor tissue quality,infection and poor operative technique.

Obstruction of the large intestine

-constipation-obstipation
-abdominal distention and sometimes tenderness
-abdominal pain
-nausea and vomiting
-characteristic x-ray finding
The wall of the right colon is thinner than that of the left colon and its luminal caliber is larger, so the cecum is at greatest risk of perforation in these circumstances. If the cecum acutely reaches a diameter of 10-12 cm, the risk of perforation is great.
deep, visceral, cramping pain from obstruction of the colon is usually referred to the hypogastrium. Borborygmus may be loud and coincident with cramps.
Feculent vomiting is a late manifestation.
Abdominal distention and tympany, and peristaltic waves may be seen if the abdominal wall is thin. High-pitched, metallic tinkles associated with rushes and gurgles may be heard on auscultation. Localized tenderness or a tender , palpable mass may indicate a strangulated closed loop. Fresh blood may be found in the rectum in Intussusception and in carcinoma of the rectum or colon. Colonoscopy may be diagnostic and perhaps therapeutic in some patients with strictures or Neoplasms.
Imaging
The distended colon frequently creates a picture frame. Water-soluble contrast medium should be used if strangulation or perforation is suspected.
Treatment
The primary goals of treatment are resection of all necrotic bowel and decompression of the obstructed segment to prevent prevent perforation .

Obstruction of the small intestines

Complete proximal obstruction
-vomiting
-abdominal discomfort
-abnormal oral contrast x-rays or CT scan
Complete mid or distal obstruction
-colicky abdominal pain
-vomiting
-abdominal distention
-constipation-obstipation
-peristaltic rushes
-dilated small bowel on x-ray
-transition point on CT scan

Mechanical obstruction may be complete or partial. Simple obstruction occludes the lumen only. Strangulation obstruction impairs the blood also and leads to necrosis of the intestinal wall. Paralytic ileus / adynamic ileus, a disorder in which there is neurogenic failure of peristalsis to propel intestinal contents but no mechanical obstruction.
Etiology
1. Adhesions- from abdominal operations or inflammation, congenital bands
2. Neoplasms-particularly near the ileocecal valve
3. Hernia
4. Intussusception- invagination of one loop of intestine into another is rarely encountered in adults and is usually caused by a polyp or other intraluminal lesion .
5. Volvulus- results from rotation of bowel loops about a fixed point.
6. Foreign bodies
7. Gallstone ileus
8. Inflammatory bowel disease
9. Stricture
10. Cystic fibrosis
11. Hematoma

Swallowed air is the major source of gaseous distention because nitrogen is not well absorbed by mucosa. Bacterial fermentation produces gas too. Fluid fills the lumen proximal to the obstruction, because the bidirectional flux of salt and water is disrupted and net secretion is enhanced.
A. Simple obstruction
- presenting as profuse vomiting that seldom becomes feculent even in prolonged obstruction.
-upper abdominal pain/cramping periumbilical recurs every few minutes.
-vital sign may be normal
-dehydration
-abdominal distention is minimal to absent in proximal obstruction .
-peristalsis may be visible beneath the abdominal wall in thin patients .
-peristaltic rushes ,gurgles, and high-pitched tinkles are audible in coordination with attacks of cramping pain in distal obstruction.
-rectal examination is usually normal.
Laboratory:
-early stages may be normal
-there are hemoconcentration, leukocytosis, serum amylase, electrolyte abnormalities.
Imaging:
-supine and upright plain abdominal : a ladder like pattern, air-fluid levels. It May be minimal or absent in early obstruction .
-opaque Gallstones and air in the biliary tree should be looked for.
B. Strangulation obstruction
-shock that appears early in the course of obstruction suggests a strangulated closed loop.
-high fever may develop
-cramping abdominal pain become a severe countinuous ache.
-vomitus may contain gross or occult blood
Laboratory :
-Marked leukocytosis
-lactic acidosis does not resolve with volume resuscitation.
Imaging:
-intraperitoneal fluid
-loss of mucosal pattern.
Treatment :
1. Nasogastric suction/tube- to relieve vomiting, avoid aspiration, reduce abdominal distention.
2. Fluid and electrolyte resuscitation
-should begin with isotonic saline solution.
-not undergo operation until hypokalemia has been treated.
3. Antibiotics should be given
4. Required plasma or blood
5. Operation
-the patient has been rehydrated and vital organs are functioning satisfactorily.

Hirschprung's disease

dr. OS " congenital megacolon is caused by malformation in the pelvic parasympathetic system which results in the absence of ganglion cells in auerbachs plexus of a segment of distal colon. Not only is there an absence of ganglion cells, but the nerve fibers are large and excessive in number, indicating that the anomaly may be more extensive than the absence of ganglion cells".
Patient with hirschsprungs disease have an increased frequency of mutation in several genes, including GDNF, its receptor Ret, or its coreceptor Gfra-1. Initial investigations indicate that GDNF promotes the survival, proliferation, and migration of mixed population of neural crest cells in culture.
Clinical presentation: abdominal distention, failure to pass meconium (48 hours), and bilious emesis. Abnormal peristalsis, a functional distal intestinal obstruction. Complication is enterocolitis ( fever, failure to thrive, and lethargy, dehidrated.
The definitive diagnosis is made by rectal biopsy. Samples of mucosa and submucosa are obtained at 1cm, 2cm,3cm from dentate line.
Treatment: rehydration, antibiotics, nasogastric decompression, rectal irrigations. If HD doesnt respond to nonoperative management, a decompressive stoma is required. It is important to ensure that this stoma is placed in ganglion-containing bowel, which must be confirmed by frozen section at the time of stoma creation. HD requires surgery in all cases. This included a colostomy in the newborn period, followed by a definitive pull-through operation after the child weighed over 10kg.

Meckel's diverticulum

A meckels diverticulum is remnant of a portion of the embryonic omphalomesenteric (vitelline) duct. It is located on the antimesenteric border of the ileum, usually within 60 cm of the ileocecal valve. Perforation of meckel's diverticulum may occur if the outpouching becomes impacted with food, leading to distension and necrosis. Diagnosis may be made by technetium pertechnetate scans when the patient with bleeding. Treatment is surgical. If the base is narrow and there is no mass present in the lumen of the diverticulum, a wedge resection of the diverticulum with transverse closure of the ileum can be performed. When a mass of ectopic tissue is palpable, if the base is wide, or when there is inflammation, it is preferable to perform a resection of the involved bowel and end-to-end ileoileostomy.