Case Hernia Inguinalis Lateralis 1y5n4

CASE PRESENTATION HERNIA INGUINALIS LATERALIS REPONIBLE SINISTRA

Pembimbing : Dr. Herry Setya Yudha Utama, SpB, MHKes, FInaCS

Disusun oeh : Nabilah Fajriah Barsah 1102012187

CLINICAL CLERKSHIP OF SURGERY DEPARTEMENT FACULTY OF MEDICINE YARSI UNIVERSITY ARJAWINANGUN DISTRIC GENERAL HOSPITAL 2016

CASE PRESENTATION I.

II.

IDENTITY Date of hospital entry Name Age Gender Occupation Addres Religion Marital status

: May, 17, 2016 : Mr. A : 52 years : Male : Labor : Geyongan : Islam : Married

ANAMNESIS Main complaint Patient complain of a lump in the groin left since 2 months ago. History of disease Mr. A came to RSUD Arjawinangun with complain of a lump in the groin left since 2 months ago. the patient said, when he got up and lift heavy object the lump will arise, and the lump will disappear when he lie down. The patient also experience pain on a lump, but no complain about fever, vomiting, nausea, and bloating. History of past disease Mr. A said he never had experienced the same symptoms before. The patient had no history of surgery. Patient said he had a history of hypertension.

History of family disease Mr. A said, there is no family with the same disease as patient. III.

PHYSICAL EXAMINATION a. Present Status Genereal condition Awareness

: Mild pain : Compos mentis

Blood pressure Pulse Breathing Temperature Head Form Hair Eye Ear

: 150/90 mmHg : 88 x/minute : 20 x/minute : 36,7 oC : Normocephale, symmetrical : Black, no hair fall : Anemic conjungtivas (-/-), icteric schleras (-/-), light relexes (+/+), isochore pupil right = left : Normal form, cerumen (-), thympany

membrane intact Nose : Normal form, septum deviation (-), epitaxis(-/-) Mouth : Normal Neck Enlargement of lymph nodes (-), trachea in the middle, no mass found Thorax Lungs – pulmonary Inspection : the chest is symmetrical both left and right Palpation : fremitus vocale and tactile are symmetrical, crepitation Percussion Auscultation

(-),

tenderness

(-),

tenderness (-) : Resonance sound in both lung fields : Vesicular abd bronchial sound in the entire lung field, ronchi (-/-), wheezing (-/-)

Abdomen Inspection Palpation Percussion Auscultation Extremities Upper Muscle Tone Movement Mass Strenght Oedema Lower Muscle tone Movement Mass Strenght Oedema Genitalia No abnormalities

rebound

: Flat, symmetrical, mass (-) : Tenderness (-), rebound tenderness (-) : Tympanity sound in four quadrants : Intestine sound (+) : normal : active / active :-/:5/5 :-/: normal : active / active :-/:5/5 :-/-

b. Localized Status Regio Inspection

: Inguinalis Sinistra : Mass appears with ± 7x5 cm size, same color as the surrounding skin, and there are no signs of

Palpation Auscultation c. Laboratory Examination

inflammation : Palpable masses with flat surfaces : there is no intestinal peristalsis sound

Test Result Full Blood Hemoglobin 14,8 Hematocrit 43,8 Leukocyte 9,30 Trombocyte 434 Erythrocyte 5,18 Erythrocyte Indexes MCV 84,5 MCH 28,6 MCHC 33,8 RDW 12,9 MPV 7,4 PDW 43,5 Counts (DIFF) Eosinophil 14,2 Basophil 1,0 Segmen 50,1 lymphocytes 27,2 monocytes 4,9 Stab 2,5 LED LED 1 jam 20 Coagulation Clotting time 4 Bleeding time 2 Clinical chemistry Ureum 19,1 Creatinine 0,75 Immunology HBsAg 0,01 Anti HIV non reaktif

IV. V.

DIAGNOSIS Hernia inguinalis lateralis sinistra reponible DIFFERENTIAL DIAGNOSIS

Unit gr/dl % 10e3/μL 10e3/μL mm3 fl pg g/dl fl fl Fl % % % % % % mm/jam menit menit Mg/dL Mg/dL

Hernia inguinalis medialis Limfadenopati inguinal sinistra TREATMENT Operative Hernioraphy Medicamentosa Ketorolac, Ranitidin, Cefuroxim PROGNOSIS Ad vitam : ad bonam Ad sanationam : ad bonam Ad fungsionam : ad bonam

VI.

VII.

I.

LITERATURE REVIEW DEFINITION In general hernia is a bulging (protrusion) fill a cavity through a defect or weak parts of the cavity wall concerned. In abdominal hernia, abdominal contents bulging through a defect or weak parts of the musculo-aponeurotik layers of the abdominal wall. Hernia consists of rings, bags and contents of the hernia.

II.

EIDEMIOLOGY Seventy-five percent of all abdominal hernias occur in the inguinal (groin). Others may occur in the umbilicus (belly button) or other abdominal regions. Inguinal hernias are divided into two, namely the inguinal hernia medial and lateral inguinal hernia. If the lateral inguinal hernia bag reaches the scrotum (testicles), called a hernia hernia scrotalis. The lateral inguinal hernia occurs more frequently than the medial inguinal hernia with a ratio of 2: 1, and it turned out to be a man among 7-fold more frequently affected than women. The more we age, the greater the possibility of a hernia. This is influenced by the strength of the abdominal muscles that had begun to decline. In addition to those mentioned in

front of people who have a great opportunity experience hernia that people - those who experienced the dairy operation. III.

ETIOLOGY Hernia occurs because of the weakened muscle wall or membrane that normally keep the organs in place weakened or loosened. Hernia were mostly suffered by the elderly, because of the elderly muscles begin to weaken and loosening so that chances are very big to occur hernia. In women the most of a hernia caused by obesity (excess weight). Another thing that can lead to hernias include: 1. Lift items too heavy 2. Cough 3. Chronic lung disease – pulmonary 4. A result of frequent straining during intestine movements 5. Metabolic disorders in the connective tissue 6. Ascites (abnormal accumulation of fluid in the abdominal cavity) 7. Diarrhea or abdominal cramps 8. Gestation 9. Excessive physical activity 10. Congenital birth (congenital)

IV.

CLASSIFICATION In general, hernias are divided into two types, namely: 1. Internal hernia A hernia that occurs in the patient's body so that can not be seen with the eye. Examples diaphragmatica hernia. 2. External hernia A hernia can be seen by the eye because the lump of hernia penetrate out, so it can be seen by the eye. Based on the occurrence, hernia divided into: 1. Congenital hernia 2. Perfect congenital hernia Based on its location, hernia are divided into : 1. Diaphragmatic hernia, is the prominence of the abdominal organs into the chest cavity through a hole in the diaphragm (septum which limits the chest cavity and the abdominal cavity).

2. Inguinal hernia 3. Umbilical hernia, is a lump that go through the ring umbilicus (belly button). 4. Femoral hernia, is a lump in the groin through the femoral ring.

By their character, a hernia can be called : 1. Hernia reponibel, when contents of a hernia can exit and enter again. The intestines out when standing or straining, and enter again if lying down or pushed in the stomach, no pain or symptoms of intestinal obstruction. 2. Hernia ireponibel, when the contents of hernia can’t be repositioned back into the abdominal cavity. This is usually caused by the adhesions contents of the bag in peritoneal. This is called a accreta hernia. No complaints of pain or intestinal obstruction signs. 3. Incarcerated hernia or hernia Strangulated, when it squeezed by hernia ring so that the bag is trapped and can’t get back into the abdominal cavity. The result is a age disorder or vascularization. In outline, the division of hernia are divided into three, namely:

1. Femoral hernia, is generally found in older women, the incidence in women about 4 times the male. Complaints are usually be a lump in the groin that appears especially when doing activities that increase intra-abdominal pressures like when lifting or coughing. These lumps disappear when lying down. Often patients come to the doctor or hospital with a hernia Strangulated. On physical examination found a lump in the groin software under the inguinal ligamnetum in v.femoralis medial and lateral to the pubic tubercle. The entrance of the femoral hernia is the femoral ring. Furthermore, contents of the hernia enter into femoral canal and out of the fossa ovalis in the groin. 2. Inguinal hernia, can occur due to congenital anomalies or because acquired. Inguinal hernias arise most frequently in men and is more common on the right than on the left side. In a healthy person, there are three mechanisms that can prevent an inguinal hernia, the inguinal canal which runs obliquely, their structure m. obliqus internus abdominis which closes the internal inguinal annulus when contracted, and their strong transverse fascia which covering Hasselbach triangle which generally almost not muscular. The most causal factor that is the process vaginalis (a bag hernia) are open, elevation of pressure within the abdominal cavity and the abdominal wall muscle weakness due to age. Inguinal hernia subdivided, namely: a. Medial inguinal hernia, direct inguinal hernia is almost always caused by factors of chronic elevation of intra-abdominal pressure and muscular wall weakness in the hesselbach triangle. Therefore, the hernia are common bilateral, especially in older men. This hernia rarely experienced incarceration and strangulation. Sliding hernia may occur, which contains most of the bladder wall. Sometimes found small defects in m.obliqus

internus abdominis, at all ages, with stiff and sharp ring that often cause strangulation. This hernia suffered by the population in Africa. b. Lateral inguinal hernia, hernia is called latelaris because bulging from the abdomen in the lateral inferior epigastric vascular. Called indirect because came out through two doors and channels, namely the annulus and the inguinal canal. Different from the medial hernia which direct protruding through the hesselbach triangle and is called a hernia direct. On examination leteralis hernia, a bulge will appear oval, while the medial hernia will appear round. In infants and children, latelaris hernia caused by congenital abnormalities such as not to cover the processus vaginalis of the peritoneum as a result the process of testicular descent into the scrotum. Sliding hernia may occur on the right or left. Hernia on the right usually contain most of the cecum and ascending colon, while the one on the left contains most of the descending colon.

V.

Pathophysiology Hernia caused by the first two factors are factors congenital failure of closure of the processus vaginalis during pregnancy can lead to the inclusion of the contents of the abdominal cavity through the inguinal canal, second factor is a factor obtained such as pregnancy, chronic cough, work lifting heavy objects and the age factor , the inclusion of abdominal contents through the canal ingunalis, if long enough it will protrude from the external ingunalis annulus. If this hernia bump will continue until the inguinal canal into the scrotum because sperm contains cord in males, so it caused a hernia. There is hernias which may return spontaneously or manual, there is also not able to return spontaneously or manually due to adhesions occur between the contents of the hernia and pouch wall hernia, so that the contents can’t be put back. This situation will lead to difficulties to walk or move so that the activity will be disrupted. If there is pressure on ring hernia, the contents of the hernia will strangle and causing hernia strangulate which would cause symptoms of ileus is the symptoms of intestinal obstruction leading to impaired blood circulation which will cause a lack of oxygen supply can cause ischemia. The contents of this hernia will become necrotic. If the hernia pouch consists of a intestinal can occur perforation which can eventually lead to localized abscess or priority if the relationship with the abdominal cavity. Intestinal obstruction also causes a decrease in intestinal peristalsis which can cause constipation. In the state strangulate will be symptoms of ileus are abdominal bloating, vomiting and obstpation.

VI.

Clinical Manifestations In general complaint in adults such as lump in the groin that arise at the time straining, coughing, or heavy lifting, and disappear when lying. In infants and children, intermittent lump in the groin usually known by parents. If the hernia is intrusive and often restless child or baby, cry a lot, and occasionally flatulence, they must consider the possibility of hernia strangulate. On inspection note the state of asymmetry in both groin, scrotum, or labia standing and lying down. Patients are asked, straining or coughing so any lumps or asymmetry situation can be seen. Palpation performed in a state of a lump hernia, palpable consistency, and tried pushing if the lump can be repositioned.

VII.

Diagnosis 1. Anamnesis Complaints usually a lump in the groin intermittent, appearing especially when doing activities that can increase intra-abdominal pressure such as lifting or coughing, these bumps disappear when lying down or entered by hand (manual). There are factors that contribute to the occurrence of hernia. Intestinal age disorder can occur, especially on incarcerated hernia. Pain in the state of strangulation, often suffer come to the doctor or to the hospital with this condition. 2. Physical examination Found soft lump in the groin under the inguinal ligament in the medial femoral vein and lateral pubic tubercle. Lump is bounded above is unclear, bowel sounds (+), transluminasi (-). Examination Finger Test: 1. Using a finger number 2 or 5. 2. Entered through the scrotum through the external annulus to inguinal canal. 3. Patients were told to cough:



If the impulse at the fingertips means



Inguinal Hernia lateral. If the impulse beside the finger, it means Inguinal Hernia Medial.

Examination Ziemen Test: 1. Lying position, if there is a bump first insert (usually by the patient). 2. Right Hernia checked with the right hand. 3. Patients were told to cough when stimulation at:  Finger number 2: Inguinal Hernia lateral.  Finger number 3: Medial Inguinal 

hernia. Finger number 4: Femoral Hernia.

Examination Thumb Test: 1. Pressure the annulus internus with the thumb and the patient was told to push. 2. If the bumps out, it means inguinal hernia medial. 3. When the bumps not out, it means lateral inguinal hernia.

VIII. ing Investigation Hernia diagnosis based on clinical symptoms. Investigations are rarely done and rarely have value. a. Herniography This technique involves the injection of contrast medium into the peritoneal cavity and do X-ray, this technique is now rarely performed in infants to identify contralateral hernia in the groin. May sometimes be useful to ensure the hernia in patients with chronic pain in the groin. b. USG

Often used to judge the hernia which difficult to see clinically, for example in Spigelian hernia. c. CT and MRI Useful for determining hernia rare (eg, obturator hernia).

IX.

Management Operative treatment is the only rational treatment of inguinal hernia rational. Indication of operation already exists so the diagnosis is made. The basic principle of a hernia operation consist hernioplasty and herniotomy. In herniotomy be released hernia pouch up to his neck, pouch was opened and the contents of the hernia delivered if there is attachment, then repositioned. Hernia pouch sewn and tied up as high as possible and in pieces. In hernioplasty action is taken to minimize annulus ingunalis internus and strengthen the back wall of the inguinal canal. Hernioplasty more important in preventing recurrent compared with herniotomy. Known various methods hernioplasty, as minimize ingunalis annulus internus with interrupted sutures, closing and strengthen the fascia transverse, sewed the meeting of m.transversus internus abdominis and m.obliqus internus abdominis known as the cont tendon to the inguinal ligament according to Bassini method, or sewed transverse fascia, m. transversus abdominis, m.obliqus internus abdominus to Cooper ligament on the method Mc vay. In congenital hernias in infants and children which factor cause is processus vaginalis does not close only done by herniotomy because of the internal inguinal

X.

annulus is sufficiently elastic and the rear wall of the canal is strong enough. Diagnosis Differential Tissue Skin Fat Fascia Muscle

Lump Sebaceous cysts or epidermoid Lipoma Fibroma Tumors hernia through the wrapping

Artery Vein Lymph Gonad XI.

Aneurysm Varicose Lymphadenopathy Ectopic testis / ovary

Prognosis The prognosis usually good enough if the hernia is treated properly. The recurrence rate after surgery is less than 3%.

DAFTAR PUSTAKA Ratnasari, I., G., A., D., 2012. Hernia Inguinalis Lateralis. Utama, H., S., Y., 2010. Hernia Hydrocele At A Glance. [cites 19 May 2016] [Available from : https://herrysetyayudha.wordpress.com/tag/hernia-inguinalis/ ].

Unknown, 2013. Penyebab Hernia. [cites 19 may 2016] [Available from : http://www.e-jurnal.com/2013/04/penyebab-hernia.html ].