Hydrocele and hernia at a Glance (etiology,sign, symptoms,diagnosis and management)

A.      ANATOMY

Generally hernia is a protussion the content of the cavity through  defect or the weakness of the cavity wall in question. On abdominal hernia, abdomenal content protunding  through a defect or weakness of the musculo-aponeurotik layer of the abdominal wall. Based on the occurance, congenital hernia or hernia are divided into congenital and acquired hernia. Hernia are named according to its location, eg diaphragm, inguinal, umbilical and femoral

By their very nature, can be called a hernia hernia when the hernia contents can reponibel jeluar entry. Out when standing or straining, and came back when sleeping or pushed into the stomach. When the contents of the bag can not be repositioned back into the abdominal cavity, called a hernia hernia ireponibel. This is usually caused by adhesions in the peritoneal pouch bag hernia. This is called a hernia hernia accreta. There is no pain or signs of intestinal obstruction.

Inkarserata called hernia or hernia strangulate when it squashed by the hernia ring so that the bag can not be caught and returned to the abdominal cavity. As a result, frequent passage or vascular disorders. Inkarserata hernia clinically more intended for hernia ireponibel with passage disturbance, whereas vascular disorder known as Strangulated hernia.

External hernia is an abnormal protrusion of intra-abdominal organs through the abdominal wall defect in the fascia. Hernia which often happens is inguinal, femoral, umbilical, and paraumbilikal.

Inguinal hernia is the protrusion viscus (organ) from the peritoneal cavity into the inguinal canal.

All hernia occurs through slit weak or potential weakness in the abdominal wall that is triggered by an increase in intra-abdominal pressure that repeated or continuous.

Seventy-five percent of all abdominal hernias occur in the inguinal (groin). Others may occur in the umbilicus (navel) or other abdominal area. Inguinal hernias are divided into two, namely the medial inguinal hernia and inguinal hernia lateralis. If the bag reaches the lateral inguinal hernia scrotum (testicles), called a hernia hernia skrotalis. Lateral inguinal hernia occurs more frequently than the medial inguinal hernia with a ratio of 2:1, and among men it was 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 abdominal muscles that have been weakening.

Hernias that arise in the crease and the inguinal hernia abdominokrural is arising below the fold is a femoral hernia. Inguinal canal is an oblique line passing through the lower anterior abdominal wall. This channel allows the structures to pass to and from the testis to the abdomen in the male. In women, the channel is crossed by ligaments rotundum uteri, magi from the uterus to the labium. In addition, the channel is bypassed Ilioinguinalis nerve in both sexes.

            The length of the inguinal canal in adults is approximately 4 cm, formed from the profundus inguinal annulus / annulus inguinali internal to the superficial / external. Inguinal canal is located parallel to and just above the inguinal ligament. In neonates, the internal inguinal annulus is located almost directly posterior to the external inguinal annulus so that the inguinal canal is very short at this age. Then, the internal annulus moves toward the lateral growth effect.

            Internal inguinal annulus is an oval hole in the fascia transversalis, located about 3 cm above the inguinal ligament, midway between the Messiah and symphisis pubis.Medial to the internal annulus there is av. inferior epigastric. Edge of the annulus is the origin of the internal spermatica fascia in the male or the inner wrapper rotundum uteri rotundum ligaments in women.

            Externa is an annular shaped defect in the inguinal triangle (Hesselbach's triangle) on the aponeurosis. Obliquus externus abdominis and essentially formed by the crista pubica. Edge of the annulus is the origin of the fascia spermatica externa. Lateral boundary is the inferior epigastric artery, the medial border of the m. rectus abdominis lateral part, and the inferior border of the inguinal ligament.

            Inguinal canal is formed on the wall of the anterior, posterior, superior, and inferior.Anterior wall formed by the aponeurosis m. Obliquus externus abdominis is amplified at 1/3 by the lateral fibers of m. Obliquus internus abdominis. The entire length of the posterior wall of the inguinal canal is formed by the fascia transversalis tendon reinforced cojoint in 1/3 medial. Cojoint tendon is the tendon insertion combined m. Obliquus internus abdominis and m. transversus abdominis is attached to the crista pubica and linea pectinea. Basic or inferior wall of the inguinal canal is formed by the inguinal ligament, while the roof is formed by m. Obliquus abdominis internus abdominis and m.transversus.

Figure 1. Hesselbach's triangle

Inguinal hernias can be directly (direct) and can also indirectly (indirect). Indirect inguinal hernia bag of walking through the deep inguinal ring, lateral to the inferior epigastric vessels, and finally towards the scrotum. Pockets of directors inguinal hernia protruding directly through the base of the inguinal canal, medial to the inferior epigastric vessels, and rarely go down towards the scrotum. Femoral hernia is almost always seen as a mass irredusibel, although pockets more kososng, because fat dam of femoral canal lymph nodes around the bag. Single, enlarged lymph nodes can mimic femoral hernia very quickly.

Indirect hernia bag is actually a process vaginalis persistently dilated. Hernia was walking through the deep inguinal ring and follow the sheath into the scrotum. At the deep ring, bag filling anterolateral side of the cord. Properitoneal fat pockets often associated with indirect and is known as a lipoma of the cord, although the fat is not a tumor.

Retroperitoneal organs such as the sigmoid colon, cecum and ureter can be slipped into a pocket indirect. In the bag, these organs become part of the pouch wall and are susceptible to injury during repair.

Inguinal hernia pouch directors come from the bottom of the inguinal canal, the Hesselbach triangle; protruding hernia bag directly and does not contain obliqus externus muscle aponeurosis. Only in rare circumstances, the hernia is so intense that it pushes out through the annulus superficial and descend into the scrotum. The bladder is often a component of the bag is empty hernia director.

Bags from the femoral hernia femoral canal through a defect on the medial side of the femoral sheath (femoral sheath). Femoral canal contains one or two lymph nodes, which are scattered called Cloquet. Lymph-nodes are pushed out of the femoral canal by a protrusion of peritoneal and often form a palpable mass.

                                    Figure 2. Inguinal canal

 It had been mentioned in the definition of Hernia is a protrusion protusi or contents of a cavity through a defect or weakness of the cavity wall in question. Derived from the Latin herniae, the prominence of the contents of a cavity through a thin connective tissue weakness in the wall cavity. Weak cavity walls that form a pocket with a door in the form of a ring. This disorder often occurs in the abdominal area with the exit of the contents of the intestine. On abdominal hernia, abdominal contents protruding through a defect or weakness of the musculo-aponeurotik layers of the abdominal wall.

Hernia consists of:

ring

bag

hernia contents

Figure 3. Hernia sac

3. Epidemiology

            Seventy-five percent of all abdominal hernias occur in the inguinal (groin). Others may occur in the umbilicus (navel) or other abdominal area. Inguinal hernias are divided into two, namely the medial inguinal hernia and inguinal hernia lateralis. If the bag reaches the lateral inguinal hernia scrotum (testicles), called a hernia hernia skrotalis. Lateral inguinal hernia occurs more frequently than the medial inguinal hernia with a ratio of 2:1, and among men it was 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 abdominal muscles that have been weakening. In addition to the front of the people who have a great opportunity menggalami hernia is people - people who have dairy operations.

4. Etiology (Causes)

Hernia occurs due to the weakened muscle wall or membrane that normally keep the organs in place weaken or relax. Diterita hernias were mostly by older people, because in the elderly muscles - the muscles begin to weaken and sag so chances are very likely to happen hernia. In women the majority of hernia is caused by obesity (excess weight).Another thing that can lead to hernias include:

Too heavy to lift items

Cough

Chronic lung disease - pulmonary

Due to frequent straining during bowel movements

Metabolism in connective tissue disorders

Ascites (abnormal accumulation of fluid in the abdominal cavity)

Diarrhea or stomach cramps

Gestation

Excessive physical activity

Congenital birth (congenital)

This - the above are some examples of the cause of the hernia to watch

5. CLASSIFICATION

In general, the hernia is divided into two types, namely:

Internal Hernia

A hernia that occurs in the patient's body so it can not be seen with the eye. For example diaphragmatica hernia.

External Hernia

Hernias can be seen by the eye due to hernia through the bumps out so it can be seen by the eye.

      Based on the occurrence, hernias are divided into:

A. Congenital hernia (congenital)

a. Perfect congenital hernia

Due to a defect in certain places.

b. Congenital hernias are not perfect

Babies are born normal (not visible abnormalities) but he has a defect in certain places (predisposition) and a few months after the birth will occur due to hernia through a defect is influenced by the increase in intra-abdominal pressure.

2. Acquired hernias (akuisita)

            Based on its location, the hernia is divided into:

a. Diaphragmatic hernia is the prominence of the abdominal organs into the chest cavity through a hole in the diaphragm (the partition that limits the chest cavity and abdominal cavity).

b. Inguinal hernia

c. Umbilical hernia is a lump that goes through the ring of the umbilicus (navel)

d. Femoral hernia is a lump in the groin through the femoral annulus.

By their very nature, a hernia can be called:

a. Hernia reponibel; when the contents of the hernia to go out. Gut out when standing or straining and go again if lying down or pushed into the stomach, no pain or symptoms of intestinal obstruction.

b. Hernia ireponibel; when the hernia contents of the bag can not be repositioned back into the abdominal cavity. This is usually caused by adhesions in the peritoneal pouch bag hernia. This is called a hernia hernia accreta. No complaints of pain or signs of intestinal obstruction.

c. Strangulated hernia or hernia inkarserata; when the content trapped by a hernia ring so that the bag trapped and can not return into the abdominal cavity. The result is a passage or vascular disorders.

According to the location, form of hernia inguinal hernia, femoral hernia, and that rarely includes spieghelian, obsturator, umbilical and diaphragmatic.

          

Broadly speaking, the division of hernia is divided into three, namely:

A. Femoral hernia

Femoral hernias are commonly found in older permepuan, permepuan events at approximately 4 times the men. Complaints will usually be a lump in the groin that appears mainly on the time to do activities that increase intra-abdominal pressures such as lifting or coughing. These lumps are gone at the time lying down. Pernderita often come to the doctor or hospital with Strangulated hernia. On physical examination found a lump in the groin in the soft bottom in the medial inguinal ligamnetum v.femoralis and lateral pubic tubercle. Not infrequently more unclear is a sign of intestinal blockage, while a lump in the groin can be found, karen akecilanya or obese patients.

The entrance is a femoral hernia femoral annulus. Furthermore, the hernia contents into the funnel-shaped femoral canal parallel dena v.femoralis sepaanjang approximately 2cm and come out at the fossa ovalis in the groin.

Pathophysiology

In the pathophysiology pennggian intrabdomen pressure will push into the preperitoneal fat that will be kalalis femoral hernia pacesetter. Another causative factor dalah multiparous pregnancy, obesity, and the generation of connective tissue due to old age. Secondary femoral hernia can occur as a complication of inguinal herna herniorafi on, especially the Bassini and Shouldice memakaiteknik causing tranversa fascia and ligamnetum ventrokranialb ingunale more shifted to the more widely so that the femoral canal.

The most frequent complication was strangulation with all its consequences. Femoral hernia ligamnetum out underneath the inguinal fossa ovalis. Femoral hernia sometimes is palpable from the outside, especially Biala is a hernia Ritcher.

Management (treatment)

Can with conservative management, as well as the definitive action of the operation.Limited to conservative measures and actions to reposition the use of a brace or support to retain the hernia contents have been repositioned. Reduction in non-operative hernia can be performed by lying, elevated waist position, and given an analgesic (pain reliever) and sedatives (tranquilizers) are sufficient to provide muscle relaxation. Repair of hernia occurs when a lump is reduced and there are no clinical signs of strangulation.

The use of buffer pads only intended to hold a hernia that has been repositioned and never heal so it should be worn for life. This is usually done dpilih if the patient refuses surgical repair or there are contraindications to surgery. This method is not recommended because of complications, among others, damage the skin and abdominal wall muscle tone in distressed areas, while still threatening strangulation. In children this can lead to atrophy (shrinkage) testicular sperm due to pressure on the string that contains the blood vessels of the testes.

Surgery is the rational management of inguinal hernia, especially the type that strangulation. Indication of existing operations so the diagnosis is established. If repositioning does not work, within 6 hours of operation should be done immediately. The basic principle consists of a hernia operation and hernioplastik herniotomy.

Herniotomy performed on the release of the hernia bag up to his neck, the bag is opened, and the hernia contents were released if there is attachment, then repositioned. Hernia belt pouch sewn as high as possible and then cut.

Hernioplastik carried out the action on the annulus inginalis internus and strengthen the back wall of the inguinal canal. Hernioplastik known methods, such as minimize the internal inguinal ring with interrupted sutures, closing, and strengthen the transverse fascia, and sewed with a gathering m.transversus internus abdominis internus abdominis m.oblikus known as the conjoint tendon to the inguinal ligament Poupart by Bassini method. This method of fixing orifice miopektineal, superior to the inguinal ligament, namely the deep ring and Hesselbach triangle, so it can be applied to either director or indirect hernia.

Another method is to sew the transverse fascia, m.transversus abdominis, m.oblikus internus abdominis into Cooper's ligament on the method of Mc vay. These methods improve the three areas most vulnerable to disc herniation in miopektineal orifice, ie the annulus prounda, Hesselbach triangle, and femoral canal. Incision of relaxation is a must because if not made, there will be considerable strain on the suture line.

Complication

Complications of hernia depend on the circumstances experienced by the contents of the hernia. Hernia contents can be retained in the pockets of the hernia ireponible hernia can occur if the hernia contents are too large, for example, consists of the omentum, or an organ extraperitoneal hernia accreta. Here can not arise except in the form of a lump of clinical symptoms. Can also occur by the ring of the hernia contents strangled hernia Strangulated hernia causing the symptoms of bowel obstruction menimbiulkan simple. Or total blockage that occurs as the hernia pasrisal Richer. If the hernia cincicn narrow, less elastic, or more rigid as in femoral hernia and obturator hernia, partial jaws are more common. Rarely inkaserasi retrograde, ie two bowel segments trapped in the hernia bag and one other segment-chested in the peritoneal cavity.

Cincicn hernia clamps will cause the contents of the hernia tissue perfusion. Veins occur at the beginning of the dam, causing edema organ or structure within the hernia and hernia transudation into the bag so that eventually peredarah increasingly disturbed tissue blood. Hernia contents into necrosis and hernia bag will contain a fluid transudate beruapa serosanguinis. If the hernia consists of isis intestinal perforation may occur which could eventually lead to local abscess, fistula, or peritonitis if there hubungn the abdominal cavity.

                               

Figure 4. Femoral Hernia

2. Inguinal hernia

Inguinal hernias can occur due to congenital or due to causes anamoli obtained. Inguinal hernias occur most frequently in men and more often on the right side than on the left side.In healthy individuals, there are three mechanisms that can prevent the occurrence of inguinal hernia, the inguinal canal that runs side, the structure that covers the m.oblikus internus obdominis the internal inguinal annulus when bekontraksi, and the presence of strong transverse fascia covering the Hasselbach triangle which generally scarcelymuscular. The causal factor is the existence of the process vaginalis (hernia bags) are open, raising the pressure within the abdominal cavity and abdominal wall muscle weakness due to age.

Figure 5. Inguinal hernia

Diagnosis

Symptoms (symptoms) and signs (sign) is determined by the state hernia hernia contents.In the hernia reponibel only complaint was a lump in the groin that appears on standing, coughing, sneezing, or straining, and disappeared after lying down. pain complaints are rare; if there is usually felt in the epigastrium or paraumbilikal of visceral pain due to strain in the mesentery during one segment of the small intestine into the pockets of the hernia.Pain accompanied by nausea or vomiting that occurs incarceration emerging as ileus or strangulation due to necrosis or gangrene.

Clinical signs on physical examination depends on the contents of the hernia. At the time of inspection the patient straining, it can be seen latelaris inguinal hernia appears as a protrusion in the inguinal region that runs from lateral to medial on the bottom. Hernia is an empty bag can sometimes be palpated on funikulus spermatikus as the friction of two layers of bags that give the sensation of friction of two surfaces of silk. This sign is called the silk glove sign, but this sign is generally difficult to be determined. If the hernia bag containing organs, depending on its content, may be felt on palpation of the bowel, omentum (like rubber), or ovary. With the index finger or little finger, the child can be tried pushing the hernia contents push through the annulus, the external skin of the scrotum so that it can be determined whether the contents of the hernia can be repositioned or not. In the case of hernia can be repositioned, when the finger is still in the external annulus, patients were asked to straining. When the fingertips touch the hernia, hernia ingunalis letelaris means, and if the finger is touching the side, meaning the medial inguinal hernia.Contents of the hernia in baby girl, who felt like a solid mass usually consists of the ovary.

Diagnosis is made on the basis of a lump that can be repositioned, or, if it can not be repositioned, on the basis of the absence of clear restrictions on the right cranial and a link to cranial through the external annulus.

Hernia should be distinguished from hydrocele or elephantiasis scrotum. Palpable testis can be used as handles to distinguish them.

Inguinal hernia in for more, namely:

A. Medial inguinal hernia

Inguinal hernia director is almost always caused by a factor of chronic elevation of intra-abdominal pressure and muscle weakness in the wall of Hesselbach triangle. Therefore, bilateral hernias are common, especially in men tua.Hernia rarely, almost never, suffered incarceration and strangulation. May occur sliding hernia containing a portion of the bladder wall. Sometimes a small defect in m.oblikus dtemukan internus abdominis, at all ages, with a rigid ring and sharp that often lead to strangulation. This hernia suffered by many people in Africa.

                                          

                                                        Figure 6. inguinal hernia director

2. Lateral inguinal hernia

Hernia is referred to as protruding from the stomach latelaris in lateral inferior epigastric vessels. Called indirect because the door and exit through two channels, namely the annulus and the inguinal canal; different from a direct hernia protrudes through the medial triangle and dsebut Hessebach as hernia direk.Pada leteralis herna examination, will appear while the hernia bulge is elliptical-shaped medial rounded bulge. In infants and children, latelaris hernia is caused by a congenital abnormality of the processus vaginalis does not close the peritoneum as a result of the process of testicular descent into the scrotum. Sliding hernias may occur on the right or left. That the right hernia usually contains most of the cecum and ascending colon, while the one on the left contains some of the descending colon.

                  

                             Figure 7. Indirect inguinal hernia.

Clinical Overview

In general, the complaints in adults in the form of a lump in the groin that arise during straining, coughing or lifting heavy loads, rest periods and rest disappear. In infants and children, an intermittent lump in the groin are usually known by the parents. If the hernia interfere and children or infants are often restless, cries a lot, and sometimes abdominal bloating, should consider the possibility of a hernia strangulate.

On inspection of the state observed asymmetry in the groin, scrotum, or labia in standing and lying positions. Patients in'm straining or coughing so that a lump or a state of asymmetry can be seen. Palpation performed in any state benjlan hernia, palpable consistency, and tried pushing if the lump can be repositioned. After the bump tereposisi with the index finger or little finger in children, sometimes a palpable hernia ring ingunalis wide annulus.

At insipien hernia bulge can be felt only touches the tip of the finger in the inguinal canal and not stand out. In infants and children are sometimes not seen any bumps on the crying, coughing, or straining. It needs to be done by comparing the sperm rope palpation of the left and the right, sometimes you get silk gloves.

Management

Conservative treatment is limited to measures put through repositioning and the use of a brace or support to retain the hernia contents have been repositioned.

Repositioning is not silakukan in inguinal hernia strangulate, except in pediatric patients.Bimanual reposition done. The left hand holds the contents of the hernia to form a funnel while pushing it toward the right-hand ring of the hernia with a little pressure to remain slow until there is repositioned.

Incarceration on children is more common in under two years of age. Spontaneous repositioning more often and otherwise impaired the vitality of the contents of the hernia is rare compared with adults. It is caused by a ring ni hernia is more elastic in children.Repositioning is done by a child to sleep by administering a sedative and an ice pack over the hernia. When the repositioning effort is successful, the child is prepared for surgery the next day. If repositioning the hernia does not work, within six hours of surgery to be done immediately.

The use of buffer pads are only intended to hold the hernia has been repositioned and never an ever heal so it must be for a lifetime. However, the way that has more than 4000 years old is still active today. We recommend that this method is not recommended because it creates komplkasi, among others, damage the skin and abdominal wall muscle tone in distressed areas, while still threatening strangulation. In children this can cause testicular atrophy due to pressure on the rope of sperm-containing testis blood vessels.

Operative treatment is the only rational treatment of inguinal hernia is rational. Indication of existing operations so the diagnosis is established. The basic principle consists of a hernia operation and hernioplastik herniotomy.

Herniotomy performed on the release of the hernia bag up to his neck, the bag is opened and the contents of the hernia dbebaskan if there is attachment, then repositioned. Hernia pouch sewn-in belt high as possible and then cut.

Hernioplastik carried out on the action and strengthen the internal annulus dnding ingunalis behind the inguinal canal. Hernioplastik more important in preventing residif than herniotomy. Known brbagai hernioplastik methods, such as to minimize the annulus ingunalis internus jahitn disconnected, shut down and strengthen the transverse fascia, menjahtkan m.transversus meeting internus abdominis internus abdominis and m.oblikus known as the conjoint tendon to the inguinal ligament Poupart by Bassini method, or sew the fascia transverse, m.tranversus abdominis. M.oblikus internus abdominus to the ligament of Cooper on the method of Mc vay.

Herniorafi Bassini method is a technique first published, performed the basic reconstruction of the groin by muscular mengaproksimasi transversus abdominis and transversalis fascia with iliopubik tract and inguinal ligament. The technique can be applied to either director or indirect hernia.

Herniotomy and Bassini Herniorafi by

A. Patients sleep in the supine position. Antisepsis performed on the area around the groin hernia sesisi.

2. Perform local anesthetic according to Brown with novokain 1% in the following places:

a. Injections intrakutan membenjol in place until approximately the medial two fingers Messiah.

b. Anesthetics block the ilioinguinal n menusukan way syringe SIAs in the medial region, perpendicular to the ileum bone deep to the bone and then touch the tip of the needle is pulled slightly and moved to right and left as he sprayed a substance anestesik taste.

c. Without unplugging the needle, anesthesia continued along the longitudinal direction of the femoral subcutaneous injections of 5 cm with infiltration by 5 ml.

d. Direction of the needle and then transferred to the median horizontal, injection subcutaneously as far as 5 cm.

e. Subcutaneous injection into the symphysis pubis infiltration as much as 5-10 ml.

f. Injection under the fascia as much as 5-10 ml and the needle removed from the skin.

g. Infrakutan injections until membenjol above the pubic tubercle.

h. Then an injection of subcutaneous infiltration in the area of ​​the pubic tubercle to the lateral direction to meet the injection site to the femoral.

i. Moving toward the cranial and subcutaneous infiltration injections to meet the injection is done at point d.

3. Once believed to successful anesthesia, an incision made along the bottom of 10 cm between the two lumps (points a and point g) cut kutis and subcutis.

4. Fascia cleaned and sliced, immediately visible aponeurosis. The oblique abdominis externus with medial and lateral krural which is the outer ring of the inguinal canal. Cut the aponeurosis m. Abdominis externus oblique inguinal ring to join apart.

5. Then covered with funikulus spermatikus m. Kremaster searched and released. Exempt are the inguinal ligament is thick and shiny on the lateral and the conjoined area (as conjoined tendon there is only 5% of the population) in the medial.

6. Funikulus spermatikus dipreparasikan then withdrawn with a sterile gauze wrapped around the lateral direction. Nervous ileoinguinal who has released also secured to the lateral. Hernia bags searched with the help of two anatomical tweezers dicubitkan enveloped in layers of tissue, then carefully cut and released layer by layer until finally tammpak layer of blue-gray and strong. This means we have reached the processus vaginalis peritonei is a hernia pouch packaging.

7. Hernia pouch was then opened 3-4 cm to view its contents. Then release the hernia bag full circle with the direction transverse to the axis of the surrounding tissue, ie m.Kremaster and all connective tissue and vascular enveloped. SCARA this action must be done carefully to avoid bleeding. Then inserted a finger into the bag hernia and held by means of a sterile gauze, then with the other hand dibebasan tissue layers are enveloped with sterile gauze. Fingers holding the bag shifted little by little fingers to follow the direction of freeing the bag from the outside. Direction should be such that the release from medial to lateral can be met within the shortest distance. Once successful, then the pouch wall hernia is held by some clamps, and then the wall of the bag is released again enveloped the network as far as possible to be found proximal to the preperitoneal fat layer. Hernia pouch clipped to this limit, and distal transverse cut with scissors. Then do herniorafi by Bassini (Bassini plasty) as follows: after the fascia tranversa split:

a. Bassini I: Sew a big and strong thread and a needle tip as a nail, to the pubic tubercle trasversa fascia and transverse fascia and the conjoined tendon again on the edge of the nearest m. The rectus abdominis.

b. Bassini II: Sew with a needle and thread as usual, inguinal ligament, the transverse fascia and conjoined tendon suture between points I and III Bassini.

c. Bassini III: As above in the lateral position of the Bassini II when it was still able to proceed dilonggar IV, V and so on.

8. Bassini bond prepared all first, then concluded with a close one by one.

9. Bassini III bond shall be such close but still loose enough for funikulus spermatikus, that is, when at your fingertips can still be inserted easily between the internal inguinal ring with sutures Bassini III. Then funikulus spermatikus n. Illioinguinal and others dikembalikkan into place.

10. Treated bleeding and abdominal wall was closed layer by layer.

11. Fascia is sutured with silk, subkuts with Catgut, and kutis with silk.

12. Surgical wound cleaned and covered with sterile gauze.

Figure 8. Herniorafi

Weaknesses Bassini technique and other techniques in the form of variations herniotomy Bassini technique is the presence of excessive strain of the muscles in jait. To overcome this problem, popularized in the '80s approach strain-free operation. On the technique used mesh prosthesis to reinforce the fascia transversalis which form the basis of the inguinal canal without sewing on the groin muscles.

At the Congenital hernias in infants and children are factors that cause is prosesis vaginalis do not cover only the internal inguinal herniotomy because the annulus is quite elastic and the back wall of the canal is quite strong.

Operative therapy of bilateral hernia in infants and children is done in one stage. Given the relatively high incidence of bilateral hernia in children, is sometimes recommended as a routine contralateral exploration, especially in the left inguinal hernia. Bilateral hernia in an adult, are encouraged to do the operation in one stage, unless there are contraindications.

Sometimes ditemuakan insufficiency back wall of the inguinal canal with inguinal hernia with a large medial inguinal hernia is usually bilateral. In this case, it is necessary hernioplastik done carefully and thoroughly. None of the techniques that can guarantee that nothing happens residif akn. The important note is to prevent the voltage at the seams and damage to the tissues. Generally it takes plastic material such as mesh prosthesis.

Residif occurrence is more influenced by repair technique compared with constitutional factors. On the lateral hernia causes residif ingunalis most serng internus inguinal ring closure is inadequate, such as dissection of the bag is less than perfect, the preperitoneal lipoma or hernia sac was not found. On the medial inguinal hernia cause residif generally due to excessive tension on the sutures of plastic or other deficiencies in technique.

At a laparoscopic hernia surgery mesh prosthesis placed under the dnding abdominal peritoneum.

Complication

Complications of hernia depend on the circumstances experienced by the hernia is.Hernia contents can be retained in the pockets of the hernia reponibel hernia can occur if the contents of the hernia was too large, for example, consists of omentum, extraperitoneal organs (sliding hernia)

Here does not arise except clinical kejala bumps. Can also occur by strangulation of hernia contents, causing the ring Strangulated hernia that causes intestinal symptoms obtruksi simple. Blockages can occur as the total or partial Richter hernia. If the hernia ring is narrow, less elastic, or more rigid as the hernia femoral and obturator hernia, is more common retrograde incarceration, the two bowel segments trapped in the hernia bag and one other segment in the peritoneal cavity

Hernia ring clamps will cause the contents of the hernia tissue perfusion. Veins occur at the beginning of the dam, causing edema in the organ or structure and transsudasi hernia hernia into the bag. Incidence of edema causes hernia ring clamps on growing and eventually circulatory jaringn disturbed. Hernia contents into necrosis and hernia bag will contain a fluid transudate serosanguinus. If the hernia contents consisted of the intestine, can occur perporasi which ultimately can lead to local abscess, fistula, or peritonitis if there is a relationship with rogga stomach.

Clinical picture inkarserata hernia containing intestine begins with an overview of intestinal obstruction with impaired fluid balance, electrolyte, and acid-base. In the event of disruption stranggulasi because vascularization, a state of gangrene and toxic due to the clinical picture is complex and very serious. Patients complain of pain is more severe in the hernia. Pain will persist due to peritoneal stimulation.

On local examination found a lump that can not be entered again with tenderness and, depending on the state of the hernia contents, can be found signs of peritonitis or local abscess. Strangulated hernia is an emergency. Therefore, the need to get help immediately.

3. Other hernia - other

Included in this hernia hernia is a rare:

A. Richter Hernia

· In femoral hernia or obturator hernia

· Most of strangulated bowel wall (usually the ante mesenterial)

· Passage could be disrupted, or may not be disturbed

· Rarely

· Usually found during surgery

· Complications: strangulation, intestinal perforation

2. Hernia Interna

· Protrusions (not bags), within the abdomen through a hole (foramen Winslowi)

· For example, the hernia diaphragmatica

3. Hernia Insipiens

· Including the lateral inguinal hernia à only just entered the inguinal canal, but the content does not come out (through the inguinal ring ext)

4. Sliding hernia (sliding hernia)

· Most of the bag wall hernia consists of retroperitoneal organs (caecum - the sigmoid colon - vesica urinary)

5. Hernia Spieghel

· Locus minor resist: dg abdominis linea m.recti lateral semicircular

· It is interstitiel hernia / hernia interparietalis

· Rarely

· Age 40-70 years

· Clinical: a bump on the left and right McBurney point

· Pockets entrance slit of the abdominal wall hernia

· À hernia contents consisted of intestine, omentum, ovary

· Supporting the ultrasound diagnosis

· Rarely experienced incarceration

· Therapy: herniotomy and hernioplastik

· Sew m.transversus abdominis and m.internus abdominis

6. Littre hernia

· It is very rare

· Fill diverticulum = contains Meckeli

· Hernia partial bowel hernia Richter à ~

7. Obturator hernia

· Through the obturator canal

· Limit the cranial / lateral = os pubis obturator sulcus

· Limit = caudal edge of the obturator membrane, m.obturator ext int et

· Fill canal and AV = obturator nerve runs

Figure 9. Meckel's diverticulum Typical located on the antimesenteric border.

Stages of hernia

Phase I consisted of protrusion of fat content

Phase II bulge parietal peritoneum peritoneum contents

Phase III bag filled with indentations intestinal hernia

Phase IV Richter Hernia

Diagnosis

The signs = HOWSHIP-Romberg (such as tingling, paresthesias in the pelvic area to the knee and medial thigh)

This happens due to the emphasis the obturator nerve

Sign patognomonis performed vaginal or rectal toucher toucher ó the pain palpable hernia bulge (Howship-Romberg Patognomonis)

Therapy

Herniotomy with the approach (approach) of the transperitoneal or preperitoneal

8. Labial hernia

· Usually the child is a à lateral inguinal hernia into labium mayus

· Pd physical development labium mayus à lump, bump while standing, lying down is lost when the lump

· DD /: femoral hernia, cyst of the canal nuck

9. Bilateral Hernia

· Left Right there

· In an inguinal hernia

· Common in children (incidens 1-2%)

· At least a lot happening on the right (60%), left (20-25%) and the remainder occurred in both

· The operation is usually performed once the child left and right

· In adults also operating at the same time unless there are contraindications

10. Perineal hernia

· In the perineal region (bulge)

· Ordinary in multiparous women and women who have had surgery the perineal area

· Female perineal post op can also be affected (eg, prostatectomy) or surgical "resection of the rectum through the perineal

· It could happen to all of the pelvic floor

· Ultrasound (Diagnosis)

11. Hernia Pantalon

· Combination indirekta hernia (inguinal hernia lateralis) with direkta hernia (inguinal hernia Medial) on one side

· Lateral and medial artery separated by the inferior vena epigastrica

· Shaped like a pair of

· Usually found during surgery

Hydrocele

Hydrocele is a buildup of excess fluid between the parietal and visceral layers of the tunica vaginalis. Under normal circumstances, the fluid inside the cavity exists and is in the balance between production and reabsorption by the lymphatic system in the vicinity.

Figure 10. Hydrocele

A. Etiology

Hydrocele that occurs in newborns can be caused by: (1) incomplete closure of processus vaginalis resulting in peritoneal fluid flow into the processus vaginalis (communicating hydrocele) or (2) incomplete lymphatic system in the scrotum in doing hydrocele fluid reabsorption.

In adults, hydrocele may occur in idiopathic (primary) and secondary. Due to secondary causes of acquired abnormalities of the testis or epididymis that causes disruption of secretion or reabsorption of fluid systems in the bag hydrocele. Abnormalities in the testis may be a tumor, infection, or trauma to the testis / epididymis.

2. The clinical

Patients complain of a lump in the scrotum pouches are not painful. Examination found a lump in the scrotum pouch with Christ and the consistency penerawangan examination showed transillumination. On an infected hydrocele or scrotal skin is very thick, it is sometimes difficult to do these checks, so it must be assisted by ultrasound. According to the location of hydrocele of the testicle bag, clinically distinguished several kinds of hydrocele, namely (1) hydrocele testis, (2) funikulus hydrocele, and (3) hydrocele communicant. This division is important because it deals with the methods of operation to be performed at the time of hydrocele correction.

In the hydrocele testis, hydrocele pocket as if to surround the testis testis can not be touched. In the anamnesis, the amount of bags hydrocele does not change throughout the day.

At funikulus hydrocele, hydrocele bags are funikulus is located next to the cranial of the testis, so that on palpation, palpable testis and hydrocele are out of pocket. In the anamnesis bag hydrocele fixed amount throughout the day.

In the hydrocele communicant there is a relationship between the processus vaginalis with the peritoneal cavity can be filled so that the processus vaginalis fluid peritoneum. In the anamnesis, hydrocele pocket size can change the increase in size when the child cries.On palpation, the bag separate from the testis and hydrocele can be inserted into the abdominal cavity.

3. Therapy

Hydrocele in infants usually wait until the child reaches the age of 1 year in the hope after the processus vaginalis, hydrocele will heal itself, but if the hydrocele is still present or grow lot of rethinking to do necessary corrections.

Action to address the aspiration of fluid and hydrocele is surgery. Hydrocele fluid aspiration is not recommended because in addition to the high recurrence rate, can sometimes cause complications of the infection.

Some indications to perform surgery on a hydrocele are: (1) a large hydrocele that reduce blood vessel, (2) an indication of cosmetics, and (3) hydrocele permagna which were deemed too heavy and disturbing the patient in performing daily activities.

At the Congenital hydrocele is often done because a hydrocele inguinal approach is accompanied by an inguinal hernia that at the time of hydrocele surgery, as well as doing herniorafi. In the adult testis hydrocele done skrotal approach by conducting excision and marsupialisasi bag according to Winkelman hydrocele or hydrocele pplication bag according to Lord. In the hydrocele hydrocele ekstirpasi funikulus do it in toto

4. Complication

If left unchecked, the hydrocele is large enough and easily traumatized permagna hydrocele can suppress the blood vessels leading to the testicle, causing testicular atrophy.

REFERENCES

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4. Mansjoer A, Suprohaita, Wardhini WI, Setiowulan W. Selekta capita Medicine. Ed. III vol 2. New York: Media Aescupalis. Of 2000. h313-317

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6. Suwardi, ref hernia surgery and workarounds, cirebon, 2010.

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8. http://www.pubmed.com/