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Monday 13 February 2012

Types of Hernia and Management



Herry Setya Yudha Utama


I.                    INTRODUCTION
Lughat s terms of hernia is the protrusion of the general ecara (protrusion) the contents of a cavity through a defect or weakness of the cavity wall in question. In the generalabdominal hernia adult , bowels protruding through a defect or weakness of the musculo-aponeurotik lining the abdominal wall.
Based on the occurrence, congenital hernia or hernias are divided into congenital and acquired hernia or akuisita. Hernias are named according to its location, eg diaphragm, inguinal, umbilical, 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.

 Many definitions adopted:  A hernia is the protrusion of a structure / shape of the viscus or organ where it should be 1 ; protrusion or protrusion of the contents of a cavity through a defect or a weak part of the cavity wall in question 2 .
Hernias can occur between two adjacent cavities such as the abdomen and thorax or into part of a cavity - the so-called internal hernia. Hernias are most often is that the external wall of the abdomen in the inguinal, femoral, and the umbilicus 3 . On abdominal hernia, abdominal contents protruding through a defect or a weak part of the lining of the abdominal wall aponeurotik musculo- 2 , which normally can not be skipped 4 .

Hernias are six times more in men than in women 1 .
In men, 97% of inguinal hernia occurs in the region, 2% as a femoral hernia and umbilical hernia 1% for 1 . Variations in women is different, namely 50% occurred in the inguinal region, 34% in the femoral canal and 16% in the umbilicus 1

Public places hernia is the groin, umbilicus, linea alba, semilunaris line of Spiegel, diaphragm, and surgical incisions. Herniation other comparable places, but very rarely is the perineum, lumbar triangle of Grynfelt superior, inferior lumbar triangle of Petit, and the obturator foramen of the pelvis and sciatica 5 .

Table 1. Relative frequency of external abdominal hernias 3
Type of Hernia
Incidence (%)
Others (rare)

III. HERNIA Etiology
There are two major predisposing factors that increase pressure intrakavitas hernias and abdominal wall weakness 3 .

Increasing pressure on the abdomen due to 3 :

A. Heavy lifting

2. Cough - COPD

3. Prisoners when micturition - BPH or carcinoma

4. Prisoners at defecation - constipation or bowel obstruction

5. Abdominal distention - which may indicate the presence of intra-abdominal disorders

6. Changes in the abdominal contents, ie, the presence of ascites, benign or malignant tumors, pregnancy,

     body fat.

Abdominal wall weakness due to 3 :

A. Increasing age

2. Malnutrition, both macronutrient (protein, calories) or micronutrients (eg Vit. C)

3. Damage or paralysis of the motor nerve

4. Abnormal collagen metabolism.

Often, the various factors involved. For example, a congenital sac which had been formed previously may not lead to weakness of the abdominal wall hernia or an increase in intra-abdominal pressure akuisita allow the abdominal contents into the bag 3 .


Hernia contents vary, but most often is the internal organs. abdominal contents are highest in small intestine and omentum Magi 3 . Other possibilities include:

A. colon and appendix

2. Meckel's diverticulum

3. Vesica urinary

4. Ovaries - with or without the fallopian tubes

5. Ascites fluid

According to other literature, hernia consists of rings, bags, and the contents of hernia 2 or

hernia and hernia sac orifice 5 . Orifice is a defect of the innermost lining of the abdominal aponeurosis, and the yolk sac is out of the peritoneum. The neck of the hernia sac associated with the orifice. Hernia sac is called external if it stands out in full through the abdominal wall, and internal if the yolk is located in the visceral cavity 5 .

A. Based on the occurrence, the hernia is divided into

A. Congenital hernia congenital or 2.3
     In the congenital hernia, previously formed pouch that occurs as

     order or disorder resulting from intrauterine growth process - patent pros esus
     vaginalis is one such example 3 .
2. Hernia income or akuisita 2.3
      There are two types of hernia akuisita 3 :
     a. Primary hernia: occurs at a weak point that occurs naturally, as in:
         a.1. Structures that penetrate the abdominal wall: such as the femoral vein
                through the femoral canal.
         a.2. Muscle and aponeurosis which failed to normally close to each other, such as
                in the lumbar region
         A.3. Fibrous tissue which normally grow to cover the defect, such as 
               the umbilicus
    b. Secondary hernia: occurs at the site of surgery or trauma to the wall, 
        as in penetrating trauma laparotomy and 3 .

B. Hernias are named according to its location,
     Umamanya diaphragm, inguinal, umbilical, femoral, etc..

C. Hernias according to the natural history and complications that occur:
    Development of the natural history of progressive enlargement of a hernia that is, regression     
    are not spontaneous. Exceptions for congenital umbilical hernia in neonates, 
   where the orifice can be closed a few years after birth. Over 
    time, the hernia enlarges and the propensity for complications that 
    increasing life-threatening. Hernia can reponibel, ireponibel, obstruction,
    strangulation, or of inflammation 3 .

A. Hernia reponibel when the contents of the hernia to go out 2 , but settled the bag 3 .  
    The contents do not necessarily occur spontaneously, but occurs when the supported force
    gravity or increased intraabdominal pressure 3 . Gut out when standing or 
    straining and came back when lying down or pushed into the stomach, no complaints
    pain or symptoms of intestinal obstruction 4 .
    Figure 2. Hernia reponibel 2

2. Hernia Ireponibel : if the contents of the bag can not be repositioned back into the cavity
    stomach. This is usually caused by adhesions in the peritoneal pouch bag
    hernia. This is called a hernia hernia accreta 2 . It can also happen because of the narrow neck 
    with a rigid edge (eg: femoral, umbilical) 3 . No complaints taste  
    pain or bowel obstruction 2 . Hernia ireponibel have a greater risk 
    for obstruction and strangulated hernia reponibel than 3 
    Figure 3. Hernia Ireponibel 2

3 . Obstruction Hernia
    Hernia containing bowel obstruction, which lumennya closed. Obstruction usually occurs  
    hernia in the neck pocket. If obstruction occurs on both sides of the intestine, the fluid
    accumulate in it and there was distension ( closed loop obstruction ). Usually
    blood supply is still good, but strangulation may occur over time 3 .
            The term 'used to describe inkarserata'terkadang hernia
      ireponibel but it did not happen strangulation. Therefore, the hernia ireponibel
     obstruction can also be referred to inkarserata 3 .
     Emergency surgery for a hernia operation inkarserata second largest    
     emergency operation for appendicitis. In addition, inkarserata hernia is a cause 
     bowel obstruction number one in Indonesia 2 
    Figure 4. Inkarserata hernia with intestinal obstruction ileus two

4. Strangulated Hernia
    Blood supply to the hernia contents is lost. Subsequent pathological events are occlusive
    vein and l imfe; accumulation of tissue fluid (edema) causing swelling over
    further, and consequently an increase in venous pressure. Bleeding
    vein, and developed into a vicious circle, with the swelling finally 
    disrupt the flow of the arteries. The tissue had ischemia and necrosis. If the hernia contents
    abdominal rather than the gut, such as the omentum, which happens to be sterile necrosis, but   
    intestinal strangulation are the most common and cause necrosis of the infected
    (Gangrene). Involved in the intestinal mucosa and the intestinal wall becomes permeable to bacteria,
     the bertranslokasi and into the bag and from there to the vessel
    blood. Intestinal infarction and vulnerable, having perforations (usually in the neck at 
    pouch hernia) and lumen fluid containing bacteria out into the cavity 
    peritonial causing peritonitis. Occur with septic shock and circulatory failure 
    death 3 . When the clamp only partially strangulated bowel wall, called hernianya
    Richter hernia. Ileus obstruction may be partial or total, while the hernia lump
    not found and newly diagnosed at laparotomy. Complications of hernia  
    Richter is a disturbance resulting in intestinal perforation, and femoral hernia
   looks like an abscess in the inguinal region 2 .
       Figure 5. Strangulated hernias 2

5. Hernia Inflammation
     Contents of the hernia is inflamed by any process as the cause of the network      
     or organs that are not normally have a hernia, for example 3 :
     A. Acute appendicitis
     2. Meckel's diverticulum
     3. Acute salpingitis
     Almost impossible to distinguish the inflamed hernia with a  
      suffered strangulation 3 .

Some Special Types Hernia
A. Sliding hernia (hernia en glissade)

    This is where the hernia extraperitoneal structure forming part of the wall pocket. 5% of all hernias are sliding hernias, indirect inguinal hernia and is a majority. On the right, caecum and colon ascendens involved, while on the left, and sigmoid colon descendens was found in the yolk. Part of the vesica urinary inguinal hernia can be entered into director. Sliding hernia incidence increases with age and duration of the hernia. Failure to recognize when a sliding hernia surgery can result in damage to structures involved 3 .

Text Box: Figure 6.  Sliding Hernia3

2. Richter Hernia
    On this type of hernia, only a portion of intestine is trapped (usually the intestines  
    fine) 3 . I of the hernia sac consists of only one side of the bowel wall (always 

   antemesenterik) 5 . The danger is a hernia, the intestine may experience ischemia without   

   real development of obstructive symptoms 3 .

3. Hernia-en-W-Maydl's Hernia


Local symptoms include:

- Lumps vary in size, may disappear when lying down, and arise when

   the prisoners 3 .

- Local tenderness but sometimes sharp 3 , discomfort is always worse in  

  improved evening and at night, when the patient is lying down leaning and hernia  

   reduced 5 .

   Typically, a hernia sac with its contents enlarges and transmits impulses   

   may be palpable if the patient is straining or coughing 5 .

Symptoms of any complications is 3 :

- Obstruction of the intestines: colic, vomiting, distention, constipation

- Strangulation: Additional symptoms of obstruction, pain that persists in the hernia,

                       fever, tachycardia.  

B. SIGNS / sign

Patient was first examined in a state of lying, then stood up to all of the external abdominal hernia 3 , may not touch a groin hernia is when the patient lies bereduksi 5 . Area of swelling on palpation to determine exact position and characteristics. Bumps can be restored to or be getting bigger when you cough - is a typical. More evident when the patient stands 3 .

Control of the hernia to prevent it out is by pressing with a finger at the point where the reduction can be done. Patients were asked to cough: if the hernia does not appear, he was controlled and indicate the location of the neck of the yolk is exactly 3 .  

Signs related to complications

Ireponibel: an irreducible lump, no pain 3 .

Obstruction: hernia tense, tender, and irreducible. There may be abdominal distension, and

                    Other symptoms of intestinal obstruction 3

Strangulation: hernia signs of obstruction, but the real tension. Skin 

                     above it can be warm, inflammation, and berindurasi 3 .    

Strangulation in the hernia causing severe pain, followed quickly by tenderness, obstruction, and signs or symptoms of sepsis. Reduction of strangulated hernia is contraindicated if there is sepsis or the content of the yolk which is estimated to have gangrenosa 5 .

VII. Examination support
Hernia was diagnosed based on clinical symptoms. Examination is rarely performed and rarely have value.

a. Imaging 3

    a.1. Herniografi

           This technique, which involves the injection of contrast medium into the peritoneal cavity 

      and carried out X-rays, is now rarely performed on infants to identify  

      contralateral hernia in the groin . May sometimes be useful to ensure

     a hernia in patients with chronic pain in the groin .

  a.2. Ultrasound  
        Often used to assess the hernia is clinically difficult to see, for example 

      on Spigelian hernia.

   A.3. CT and MRI

          Useful to define the rare hernia (eg, obturator hernia)  

b. Laparaskopi

             Unexpected hernia sometimes found when laparaskopi for pain

    stomach that can not be diagnosed.

c. Exploration Operations

    In some infants, with a convincing history of her mother, but was not found

    clinically. Exploratory surgery can be performed.

   Table 2. Another bump to be distinguished from hernia of the abdominal wall

Sebaceous cyst or epidermoid
Tumors that have a hernia through the wrapping
Enlarged lymph nodes
Ectopic testis / ovary


A. Inguinal hernia

Inguinal canal is limited in two :

- Kraniolateral: by the internal inguinal ring, which is part of the open  

                            transversalis fascia and aponeuros is m.transversus abdominis.
- Medial bottom: at the top of the pubic tubercle, canal inguinal ring is bounded by  
                            externus, the open part of m.oblikus externus aponeurosis.
- Roof: m.obliqus externus aponeurosis
- Essentially: the inguinal ligament

Channel contains a string of sperm in men, and the round ligament in women. B

Figure 9. Inguinal canal 3
The groin is the area in the abdominal wall is weak by nature and was the most frequent to herniation. Men's 25 times more often affected by an inguinal hernia 5 .

In healthy individuals, there are three mechanisms that can prevent the occurrence of 
   inguinal hernia, which is 2 :
A. the inguinal canal which runs oblique
2. internus abdominis m.oblikus the structure that covers the inguinal ring
    when the internus contracts.
3. The existence of strong transverse fascia covering the trigone Hasselbach
    generally almost no muscular.
    Disorders of the above mechanisms can cause a hernia.

Are thought to play a causal factor is 2 :
A. The existence of an open processus vaginalis
2. Elevation of pressure within the abdominal cavity
3. Abdominal wall muscle weakness due to age. 

A. The existence of the processus vaginalis remains open
Process following the fall of the processus vaginalis testis. In neonates less than 90% of the processus vaginalis remains open, whereas in infants aged one year about 30% of the processus vaginalis has not been closed, however, the incidence of hernia in this age only a few percent. Less than 10% with a child with a patent processus vaginalis hernia. In more than half the population of children, can be found contralateral patent processus vaginalis, but the incidence of hernia does not exceed 20%. Generally inferred the existence of a patent processus vaginalis is not the sole cause of the hernia, but it takes other factors, such as inguinal ring big enough 2 .
The incidence of inguinal hernia in infants and children between 1 and 2%. There may be a hernia on the right side 60%, 20-25% left side and bilateral 15%. Incidence of bilateral hernia in girls than boys is about the same (10%) although the frequency of which remains open processus vaginalis was higher in women 2 .
Children who had hernia surgery in infancy, has the possibility of 16% had contralateral hernia in adulthood. The incidence of inguinal hernia in adults is approximately 2%. Possibility of bilateral hernia incidence is near 10% 2 .

2. Intra-abdominal pressure elevation
Intra-abdominal pressure is elevated in chronic such as chronic cough, prostatic hypertrophy, constipation, and ascites, often with inguinal hernia 2 .
 Hernia incidence increases with advancing age may be due to increased intra-abdominal disease that elevated pressure and reduced the power of networks supporting 2 . Hernias can occur after an increase in intra-abdominal pressure is a sudden and strong like the very heavy lifting, pushing, coughing, or straining with a strong micturition or defecation at 1 .

3. Abdominal wall muscle weakness due to age.
In case of abdominal wall muscle relaxation, which limits the anulus internus turur slack. In case of intra-abdominal pressure was not high and the inguinal canal runs more vertically. Conversely, if the muscles to contract the abdominal wall, inguinal canal runs over the transverse and the inguinal ring sealed so as to prevent the entry of the intestine into the inguinal canal. Abdominal wall muscle weakness, among other things due to damage to n. ilioinguinalis and n.iliofemoralis after apendektomi2 .

Diagnosis of inguinal hernia
a. Anamnesa
Clinical signs and symptoms of hernia is determined by the state of the hernia contents. In the hernia reponibel only complaint was a lump in the groin that appears at the time standing, coughing, sneezing, or straining, and disappeared after lying down. Pain complaints are rare; if there is usually felt in the epigastrium or paraumbilikal blood 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 2 .
b. Physical examination
Clinical signs on physical examination depends on the contents of the hernia. At the time of inspection the patient straining, it can be seen lateral 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, 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, in children, can be tried pushing the contents of the hernia by pushing the scrotal skin through the external annulus 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, inguinal hernia lateral means, and if the finger is touching the side, meaning the medial inguinal hernia. contents of the hernia, the baby girl, who felt like a solid mass usually consists of the ovary 2 .
Diagnosis is made ​​on the basis of a lump that can be repositioned on the basis of the absence of clear restrictions on the right cranial and a link to cranial through the external annulus 2 .
Hernia should be distinguished from hydrocele or elephantiasis scrotum. Palpable testis can be used as a handle to distinguish 2 .

A. A. Indirect inguinal hernias
Also called the lateral inguinal henia , because out of the peritoneal cavity through the internal inguinal ring is located lateral to the inferior epigastric vessels, and hernia into the inguinal canal and, if sufficiently long, protruding from the external inguinal ring. If this continues hernia, the bulge will be up to the scrotum, is called a hernia skrotalis. Pockets are inside m.kremaster hernia, located anteromedial to the vas deferens and other structures in the sperm rope 2 .

Hernia is referred to as the lateral prominence of the abdomen in the 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 of Hasselbach and called a hernia director 2 .   Indirect inguinal pouch of walking through the deep inguinal ring, lateral inferior epigastric vessels, and finally to the scrotum 5 .

On examination of the lateral hernia, a bulge would appear oval-shaped medial hernia bulge while round 2 .
In infants and children, the lateral hernia is caused by congenital abnormalities of the processus vaginalis does not close the peritoneum as a result of the process of testicular descent into the scrotum. Sliding hernia can occur in sebeblah right or left. Biasany yng hernia on the right contains some of the cecum and colon ascendens, while yng on the left contains some of the descending colon 2 .
Inguinal hernia is a hernia indirecta the most common and believed to be congenital, protruding through the annulus profundus inguinal, inguinal canal and superficial inguinal out through the annulus into the scrotum or labium magi. In accordance with the shape and location, it is called an inguinal hernia is also obliqua / lateral. Indirecta inguinal hernia is more frequent than Directa and twenty times more in men than women, as well as more frequent bilateral third on the right side. In accordance with the mechanism of occurrence, shrouded by a third layer of the ductus deferens.
There are two types of inguinal hernia indirecta, namely the congenitalis and acquisita (acquired). Anatomical difference lies in whether the processus vaginalis has or has not closed. At the processus vaginalis congenitalis not closed so that the abdominal contents (intestines) can fill up the cavity scroti. At the acquisita (acquired) is not related to the hernia pouch cavity processus vaginalis scroti since been closed. Congenitalis inguinal hernia that has occurred since birth is often not known until the age of the child, or even adulthood. Hernianya pockets of peritoneum, processus vaginalis rest have closed (vaginale ligament), the layers of fascia spermatica internal, m.cremaster, and fascia spermatica externa as well as for the processus vaginalis remains open congenitalis 1 .
In women where the processus vaginalis settled (Nucki canal), hernia can lead to wise labium. If the place out indirecta inguinal hernia is located next to the lateral of the artery epigastrica, Directa ingunalis hernia protruding through the inguinal triangle next to the medial than the artery.Inguinal hernia Directa break out through the annulus is dilated superficial inginalis protruding into the abdominal wall, there is also the opinion that the hernia is not through superficial inguinal annulus, but the protruding through the "conjoint tendon" and reach the annulus 1 
Indirect hernia sac is actually a processus vaginalis persistently dilated. Hernia was walking through the deep inguinal ring and follow the sheath into the scrotum. At the deep ring, lateral side of the bag fills cord. Properitoneal fat is often associated with indirect sac and is known as a lipoma of the cord, although the fat is not a tumor 5 .

Retroperitoneal organs such as the sigmoid colon, cecum, and the ureter can be slipped into the indirect sac. In the bag, these organs become part of the pouch wall and are susceptible to injury during repair. Sliding hernia is often large and some irreducible 5 .

Indirect inguinal hernias Clinical
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 hernia Strangulated 2 .
Circumstances noted on the inspection of asymmetry on both sides of the groin, scrotum, or labia in standing and lying positions. Straining or coughing patient is asked to state a lump or asymmetry can be seen. Palpation performed in a state of lumps 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 palpable hernia ring of the inguinal ring dilated 2 .
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 with the sperm rope membendingkan palpation of the left and the right; sometimes get the silk glove sign 2 .  

If the bag reaches the lateral inguinal scrotal hernia, hernia hernia skrotalis called. 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 2 .
Hernia should be distinguished from hydrocele or elephantiasis scrotum. Palpable testis can be used as a handle to distinguish 2 .

Labial hernia
Labial hernia inguinal hernia is lateral labium reaching mayus. Clinically visible bumps on labium mayus clear at the time standing and straining, and lost at the time lying down. Differential diagnosis is a hernia femoral hernia labialis and Nuck canal cyst in a prominent caudal inguinal ligament and lateral to the pubic tubercle. Nuck canal cyst is palpable as a cyst with clear boundaries in the next kraniolateral contrast to the indirect hernia and can not be repositioned 2 .

A.2 the Director inguinal hernia
Also called the medial inguinal hernia , prominent straight ahead through the Hasselbach triangle , the area bounded by the inguinal ligament at the inferior part, inferior epigastric vessels at the edge of the lateral and medial rectus muscles in the section. Hasselbach triangle base is formed by the transverse fascia reinforced by fibers m.transversus abdominis aponeurosis which is sometimes not perfect so this area is the potential to become weak. Medial hernia, because it does not come out through the inguinal canal and into the scrotum, usually not accompanied by strangulation because the hernia ring loose 2 .
Ilioinguinalis nerve supplies the muscles and n.iliofemoralis inguinal region, around the inguinal canal, and the rope of sperm, as well as skin sensibility inguinal region, scrotum, and a small leather upper limbs proksimomedial part 2 .
Directa hernia hernia is not so frequent as indirecta; approximately 15% of all inguinal hernias and are usually bilateral. Usually occurs in men over the age of 40 years, rarely occurs in women and occurs as a result of weakness of the muscles of the front of the abdomen, accompanied by elevation of intraabdominal pressure. Hernia pouch consisting of peritoneum and transversalis fascia 1 .  
Director of the inguinal sac protruding directly through the base of the inguinal canal, to the inferior epigastric vessels, and rarely descend into the scrotum 5 .

Inguinal hernia director is almost always caused chronic elevation of intra-abdominal pressure and muscle weakness in the wall trigoum Hasselbach. Therefore, bilateral hernias are common, especially in older men. Hernia is rare, indeed almost never, experienced incarceration and strangulation. May occur sliding hernia containing a portion of the bladder wall. Sometimes a small defect was found in m. The oblique abdominis internus, at all ages, with a rigid ring and sharp that often causes strangulation. This hernia suffered by many African population 2 .
Inguinal hernia sac directors come from the bottom of the inguinal canal, the Hesselbach triangle; stand directly; and hernia sac contains no muscle aponeurosis obliqus ekstemus. 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 sliding hernia sac directors 5 .

Table 3. Difference between Indirect inguinal hernia and inguinal hernia director

Age of the patient
Ages, especially young
Can be congenital
Be obtained
Protrusion when coughing
Appears when standing
Not immediately reach its largest size
Achieve the greatest measure of immediate
Reduction of the time lying down
Can not be reduced
Reduced immediately
Decrease in the scrotum
Occlusion of the internal ring
Not controlled
Neck pouch
Not uncommon
Relationship with the inferior epigastric vessels

Inguinal Hernia Procedure
Conservative treatment is limited to actions to reposition and support the use of buffer or separately to maintain the contents of the hernia that has been repositioned. Repositioning is carried out on Strangulated inguinal hernia, except in pediatric patients. Bimanual reposition done. The left hand holds the contents of the hernia to form a funnel while the right hand leading to a hernia ring 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 to adults. This is caused by a hernia ring which 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 not successful repositioning of the hernia, within 6 hours of operation should be done immediately 2 .
            Buffer usage is only intended to hold pads that have been repositioned and the hernia never healed and should be worn for life. However, the way that has more than 4000 years old is still active today. Better way is not recommended because of complications, including 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 2 .
            Operative treatment is the only rational treatment of inguinal hernia. Indication of existing operations so the diagnosis is established. The basic principle consists of hernia surgery and herniotomy hernioplastik 2 .
            Herniotomy performed on the release of the hernia bag up to his neck, the bag is opened and the contents of the hernia was released when there is attachment, then repositioned. pouch sewn hernia belt high as possible and then cut 2 .  
            Hernioplastik carried out on the action and strengthen the internal inguinal ring back wall of the inguinal canal. Hernioplastik more important in preventing residif than herniotomy. Hernioplastik known methods, such as minimize the internal inguinal ring with interrupted sutures, closing and strengthen the transverse fascia, and sewed m.transversus meeting internus abdominis internus abdominis and m.obliqus obliqus known as the conjoint tendon to the inguinal ligament Poupart by Bassini method, or sewed the transverse fascia, m.transversus abdominis, m. obliqus internus abdominis into Cooper's ligament on the McVay method 2 .
            Herniorafi Bassini method is a technique first published in 1887. After dissection of the inguinal canal, made ​​the basic reconstruction of the groin by muscular mengaproksimasi obliqus internus, transverse abdominis muscular and fascia transversalis with iliopubik tract and inguinal ligament. The technique can be applied, either the director or indirect hernia 2 .
            Weaknesses Bassini technique and other techniques in the form of variations herniotomy Bassini technique is the presence of excessive strain of the muscles are sewn. To overcome this problem, popularized in the eighties approaches the 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 muscles to the inguinal 2 .
            At the Congenital hernias in infants and children is a contributing factor is the processus vaginalis does not close herniotomy only because the internal inguinal ring is quite elastic and the back wall of the canal is strong enough 2 .
            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 inguinal hernia sisnistra. bilateral hernias in adults, dinajurkan perform the operation in one stage, unless there are contraindications 2 .
            Insufficiency is sometimes found behind the wall of the inguinal canal with 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 will happen residif. The important note is to prevent the voltage at the seams and damage to the tissues. Generally dibutukan plastic mesh prosthesis with a material such as 2 
            Residif occurrence is more influenced by repair technique compared with the lateral inguinal hernia konstitusi.Pada factor resididf most frequent cause is the closure of the internal inguinal ring is not sufficient, because the dissection of these bags 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 2 .
            At a laparoscopic hernia surgery mesh prosthesis placed under the peritoneum of the abdominal wall 2 .

B. Femoral Hernia

Femoral canal
Femoral canal is located medial of the v. vasorum lacunae in the femoral, dorsal of the inguinal ligament, where v. saphenous empties into the v. femoralis. foramen is narrow and limited by a hard and sharp edges. Kranioventral boundary formed by the inguinal ligament, by the edge of the os pubis kaudodorsal of iliopektineale ligament (ligament of Cooper), the lateral (sarong) v.femoralis, and medial to the ligament lakunare Gimbernati. Out through a femoral hernia lacunae caudal vasorum of the inguinal ligament. This resulted in a state of anatomical femoral hernia incarceration. B

Femoral hernias are commonly found in older women, the incidence in women is approximately 4 times the man 2 .
            Complaints usually b erupa lump in the groin that appears mainly on the time to do activities that increase intra-abdominal pressure such as lifting or coughing. These lumps are gone at the time lying down. Often the patient to the doctor or hospital with Strangulated hernia. On physical examination found a lump in the groin software under the inguinal ligament in the medial v. Femoral and lateral pubic tubercle. Not infrequently the more obvious are the signs of bowel obstruction, whereas in the groin lump is found, because the small, or because people with fat 2 .
            The entrance is a femoral hernia femoral annulus. Furthermore, the hernia contents into the funnel-shaped femoral canal parallel to the v.Femoralis along approximately 2 cm and exit at the fossa ovalis in the groin 2 .
            Femoral hernia is almost always seen as an irreducible mass, although the bag may be empty, because fat and lymph nodes of the canal around the bag. Single, enlarged lymph nodes can mimic femoral hernia with a very precise 5 .

Femoral hernia sac from the femoral canal through a defect on the medial side of the femoral sheath (femoral sheath). Femoral canal contains one or two lymph nodes, the largest is called the Cloquet. Lymph-nodes are pushed out of the femoral canal by a protrusion peritoenal and often form a palpable mass 2 .

In men, the passage of the testicles through the abdominal wall during the embryonic stage, weaken and enlarge the orifice miopektineal above the inguinal ligament and a predisposition toward Indirect inguinal hernia and director. In women, the enlarged diameter of the true pelvis, when compared with men, proportionally increase the femoral canal and may be a predisposition of femoral hernia 2 .

Pathophysiology Femoral Hernia
            In the pathophysiology of elevated intra-abdominal pressure will push the preperitoneal fat into the femoral canal which will be opening the way the hernia. Another causative factor is multiparous pregnancy, obesity, and connective tissue degeneration due to age. Femoral hernias can occur as a complication secondary to the hernia inguinallis herniorafi, especially those using Bassini or Shouldice technique that causes the transverse fascia and the inguinal ligament that slipped into the femoral canal ventrokranial wider 2 .
            The most frequent complication was strangulation with all its consequences.
            Femoral Hernia out next to the fossa ovalis ligamntum inginale. Femoral hernia sometimes is palpable from the outside, especially when a Richter hernia.

Diagnosis of Femoral Hernia Appeal
Differential diagnosis of femoral hernia, lymphadenitis, accompanied, among others, local inflammatory signs common with the source of infection in the lower limbs, perineum, anus, or skin of the body caudal of the umbilicus level 2 .
            Lipoma is sometimes indistinguishable from the preperitoneal fatty tissue lumps on femoral hernia 2 .
            Another differential diagnosis was single at the mouth v.safena variks magna with or without varicose veins in the legs. Consistency in the fossa ovalis variks soft sole. When coughing or straining lump variks enlarged with a "wave" and easily removed with a pressure of 2 .  
            Cold abscess originating from thoracolumbar spondylitis can stand out in the fossa ovalis.Richter hernia is not uncommon to have strangulated hernia contents impaired vitality, gives an overview such as abscesses. After incision of action, it turns out the contents of the gut, not pus 2 .  
            To distinguish it, please note that the appearance of a hernia is closely connected with the activity, such as straining, coughing, and other motion which is accompanied by elevation of intra-abdominal pressure, whereas other diseases, such as testicular torsion or femoral limfedenitis, not associated with such activity 2 .

Femoral Hernia governance
 Operations consist of herniotomy followed by hernioplastik with the aim of clamping annulus femoralis 2 .
            Femoral hernia can be approached from krural, inguinal, or a combination of both. Krural approach chosen without opening the inguinal canal in women. Inguinal approach with the opening of the inguinal canal while inspecting the posterior wall is usually performed on men because of femoral hernia in men is more often accompanied by medial inguinal hernia. Combination of approaches can be selected on inkarserata femoral hernia, hernia residif, or a combination with inguinal hernia 2 .
            Krural approaches, hernioplastik can be done by sewing the inguinal ligament to Cooper's ligament 2 .
            In the Bassini technique through the inguinal region, sewn to the inguinal ligament ligament lakunare Gimbernati 2 .

How To Distinguish inguinal hernia and femoral hernia
To distinguish between inguinal hernia and femoral hernia inguinal ligament is used as a benchmark. Above the ligament is the inguinal hernia and femoral hernia is below 1 . hernias that occur in the folds of the inguinal hernia and abdominokrural arising under the folds of the femoral hernia 5 .  


C.1. Umbilical hernia
            Congenital umbilical hernia is the only closed peritoneum and skin. hernia is present in approximately 20% of infants and this figure is even higher in  
premature infants. There was no difference in event rates between male and female infants 2 .    
            Hemiasi umbilical is a public place. Umbilical hernia occurs more often in women. Overweight with repeated pregnancy is a common precursor. Ascites is always exacerbate this problem.Strangulation of the colon and omentum are common. Asitik rupture occurs in chronic cirrhosis, a case which required immediate decompression of the portal or peritoneal nevus shortcuts in an emergency.


Clinical symptoms of umbilical hernia
 Umbilical hernia is the protrusion of the abdominal cavity that contains the contents of the  

enter through the umbilical ring due to elevation of intra-abdominal pressure, usually when the baby cries. Hernias are generally not painful and very rare incarceration 2 .

Figure 11. Umbilical hernia 3

Administration of umbilical hernia
If the hernia ring is less than 2 cm; generally spontaneous regression will occur before the baby is 6 months old, sometimes new ring is closed after one year. Effort to accelerate the closure can be done by approaching the edge of the left and right, then memancangnya with adhesive tape (plaster) for 2-3 weeks. Can also be used coin placed on the umbilicus to prevent protrusion of the contents of the abdominal cavity. When it comes to the age of one and a half years of hernias are still prominent, is generally required surgical correction. In the ring hernia greater than 2 cm are rare and spontaneous regression is more difficult to obtain pentupan with conservative measures. B
            Umbilical hernias are common in infants and close spontaneously without specific therapy if the aponeurosis defect measuring 1.5 cm or less. Repair is indicated in infants with a hernia defect diameter greater than 2.0 cm, and in all children with umbilical hernia is still present at age 3 or 4 years.

            Classic for umbilical hernia repair is hernioplasti Mayo. Operation consists of imbrikasi vest-over-pants of the superior and inferior aponeurosis segment. Large umbilical hernia, rather dealt with a similar prosthesis prosthesis for incisional hernia repair. C

Umbilical hernia in adults is an advanced umbilical hernia in children. Pressure elevation due to pregnancy, obesity, or ascites is a predisposing factor. Comparison between men and women is approximately 1:3. Diagnosis is made easier as well as in children. Incarceration is more common than the children. Umbilkalis hernia therapy in adults is only operative. B

C.2. Para-umbilical hernia
    Para-umbilical hernia is a hernia through a slit in the midline on the edge  
    cranial umbilicus, on the edge kaudalnya rare. Spontaneous closure seldom
    occurred so that corrective surgery is generally required. B


  Figure 12. Para-umbilical hernia

C.3. Epigastric hernia
Raphe of the linea alba is formed by wrapping the connection rectus and their fibers cross through the midline; extends from symphysis pubis to the processus xiphoideus. At the top center, 1-3 cm wide and fibrous, but under umbilkus he has narrowed part 3 .
               Alba hernia epigastric hernia is a hernia or an exit through a defect in  
    between the umbilicus and the linea alba xiphoideus processus. Protrusion of the hernia contents consisted of
    preperitoneal fatty tissue with or without pockets peritoneum 2 .
             These hernias are usually small and occurs mostly in the wide part of the linea alba between the processus xiphoideus and umbilicus. These hernias are usually small and occurs mostly in middle aged manual workers 1 .
            Linea alba is formed by woven fibers of the aponeurosis and the anterior lamina   
    m.rektus posterior sheath. Matting is often only one layer. In addition, the linea alba in  
right cranial umbilicus is wider than the side that predisposes to caudal epigastric hernia.Epigastric hernia appears as a soft bulge at the linea alba is a "lipoma" preperitoneal. If the defect of linea alba widened, and then out the peritoneal pouch which can be empty or contains omentum.Rarely, small intestine or large intestine in the epigastric hernia. Hernia is covered by skin, subcutaneous fat, preperitoneal fat, and peritoneum. Often found multiple hernia.

Clinical Overview
Patients often complain of not feeling well and sick stomach, similar complaints in the gall bladder disorders, peptic ulcer, or esophageal hiatus hernia. A vague complaint is especially true when small and difficult palpable hernia.
¾ was asymptomatic and found incidentally on physical examination.
When the symptoms, there are two types:
- Local pain - often triggered by excessive physical activity
- Which can be defined pain located in epigestrium, often worse after eating (the voltage at the stomach contents can menstrangulasi), and the clinical picture may mimic peptic ulcer disease 3 .

Hernias can be seen if the patient is placed in a slightly oblique position. Pembengakakan palpable in the midline and is usually soft and ireponibel.
Patients who present with symptoms in the upper abdomen and epigastric hernia patients who were found to be scrutinized for likely suffering from peptic ulcer, gallbladder disease or pancreatic disease before symptoms set in hernia 3 .
   Pathological picture
         Linea may be attenuated, due to a congenital weakness in the structure Latticenya. The presence of small neurovascular bundles penetrate also the point of loss of custody. Herniation of extraperitoneal fat through the linea this usually occurs in the upper half of the linea. Found in 7% of the adult population and over. men are three times more often than women, and the protrusion are multiple in 20% of cases.
Initially there extraperitoneal fat protrusion, which can be followed by the formation of peritoneal sac, and omentum can enter it (rarely contain intestine). Extraperitoneal fat or omentum can often face incarceration and strangulation 3 .
Patients with symptomatic hernia are offered for repair. Excised fatty hernia. If there is a bag, the contents are reduced and sakusnya in excision. The defect was closed with sutures of fasianya 3 .Surgical therapy is the repositioning of the contents of the hernia and closure of the defect in the linea alba.

C.4. Ventral hernia
    Ventral hernia is a common name for all abdominal wall hernias
    anterolateral such as hernia sikatriks 2 .

C.5. Lumbar hernia
    These hernias can be 3 :
    A. Congenital
    2. Primary acquired
    3. Secondary acquired - from the surgical incision.
 Obtained through an incision hernia in the lumbar approach to the kidney is not uncommon; however, with a reduction in renal surgery is open, it is to be reduced 3 . hernia, which occurs through a weak anatomical point on the lumbar region - the superior and inferior lumbar triangle - is rare.
Lumbar hernias are rare and stand out through the trigonum lubale Petiti. A. In the lumbar region between the XII rib and the iliac crest, there are two triangular pieces each kostolumbalis superior trigone (Grijnfelt) inverted triangle and triangle or trigonum iliolumbalis kostolumbalis inferior(Petit) triangle. Grijnfelt triangle bounded on the ribs cranial XII, in the anterior free edge m.oblikus internus abdominis, in the posterior by the free edge m.sakrospinalis. Is essentially m.transversus abdominis aponeurosis, while the lid m.latissimus dorsi. Petit triangle bounded on the caudal by the iliac crest anteriorly by the free edge m.oblikus externus abdominis, and the posterior by the free edge m.latissimus dorsi. This is the basic triangle m.oblikus internus abdominis and the superficial fascia cover 2 .
            Hernia in both trigone is rare. On physical examination looks and palpable lump in the waist and bottom hem rib XII (Grijnfelt) or on the edge of the dorsal cranial pelvis 2 .
            Lumbar hernia occupies the lateral abdominal wall, for example hernia surgery scar sikatriks the kidney, hernia in the trigonum lumbale Petit inferior and superior lumbale Grijnfelt trigonum.hernias are rarely found in the trigone lumbale 3 .
Clinical Overview
Diagnosis is made ​​by checking the door hernia. Differential diagnosis is a hematoma, abscess cold, or soft tissue tumors. The management consists of herniotomy and hernioplastik.Hernioplastik performed well on the closure of defect 2 .
Most come with a swelling or lump in the lumbar region, which is associated with painful and uncomfortable. Usually there rangasangan of cough and reponibel mass. Contents, which most often is the colon and small intestine - a very rare kidney. Some - about 20% to 10% to incarceration and strangulation.
            Irreponibel lumbar hernia should be distinguished by 3 :  
A. Lipoma
2. Soft-tissue tumor
3. Hematoma
4. Tuberculosis cold abscess
5. Kidney tumors
Primary hernia treated with direct closure of the existing defects. Require a large incisional herniamesh made ​​3 .  

C.6. Littre hernia
Littre hernia is a hernia of Meckel's diverticulum contents. hernias are very rare this is a hernia containing Meckel's diverticulum. Until familiar Meckel's diverticulum, hernia Littre hernia is considered as part of the intestinal wall which was not then known as Littre hernia 2 .

C.7. HERNIA Spieghel 2 / hernia LINEA semilunaris 1
Ventral hernia hernia spigelian is occurring along the semilunaris line Spieghel subumbilikal from and through the fascia Spieghel 5 . Spieghel hernias arise through weak places in between the lateral edge of m. rectus abdominis linea semicircular with 2 . Spieghel interstitial hernia is a hernia with or without its contents through the fascia Spieghel 2 . This is in line interparietal hernia linea semilunaris (lateral border of the rectus muscle wrap, running from the tip-ninth costal cartilage to the pubic crest). Hernias are usually as high as the arcuate line, under which all layers of the anterior aponeurotik reflect on the rectus muscle. The cause is related to the composition of aponeurotic, which produces a weak area in which the fibers of the transversus aponeurosis fuses with fibers of the external oblique 3 .

 Spigelian hernia is rare and, unless a large, difficult to diagnose because its location interparietal and overwhelmed by external obliqus muscular aponeurosis. Sonogram and computed tomography scan of spigelian often find that asymptomatic hernia, which is too small to be detected clinically 5 .

 Spigelian a large hernia can be confused with a sarcoma of the abdominal wall. Spieghel fascia consists of fusion of the muscular aponeurosis muscular obliqus internus and transversus abdominalis between Venter of these muscles on the lateral and medial rectus muscular. Below the umbilicus fibers may be more or less parallel and separate, allowing properitoneal peritoneum and fat protruding through a defect like cracks, but it is actually a muscular aponeurosis above obliqus externus abdominus 5 .

Spigelian most common hernia in the area between the umbilicus and the line connecting the anterior superior iliac spine under the linea arcuate and inferior epigastric vessels arc 5 . This hernia protrudes through aponeuresis m. transversus abdominis just lateral to the lateral edge of the vagina m. recti abdominis. Typically located just below the umbilicus 2 . Usually found at the age of 40-70 years, with no difference between men and women, usually occurs on the right, and rarely bilateral.No one factor is spesisfik pathogenesis 2 .

Clinical Overview
Symptoms 3
- Localized pain that worsens with defense
- Blob
- Discomfort in the lower quadrant is not peculiar to ditelitilagi
- Signs of obstruction or strangulation

Signs 3 :
- Sense of place soft pad hernia orifice
- Lumps that may be difficult or even impossible to be felt.

Diagnosis depends on detecting a lump in the upper right or left McBurney point, the lateral edge m.rektus abdominis. Hernia contents can be made ​​from the intestines, omentum, or the ovary 2 .Incarceration is rare 2 .

Investigation and Management

As the investigation can be carried out ultrasonography 2 . More recently, ultrasound has proven useful to demonstrate hernia in patients with a history of clinical symptoms, but less convincing.Repair is an easy thing is to close the defect mengeksisi yolk and 3 . Hernia small spigelian can be closed in a simple, but great spigelian hernia in the muscle, requiring a prosthesis 5 . Management consists of herniotomy and hernioplastik to close the defect in m.transversus abdominis and m.abdominis internus abdominis 2 .

C.8. Obturator hernia
Obturator hernia is a hernia hernia through the obturator foramen 2 .
            The obturator canal is a channel that runs oblique to the caudal limit on the cranial and lateral by the obturator groove os pubis, in the caudal free edge of the obturator membrane, m.obturatorius internus and externus. In the obturator canal run nerve, artery, and obturator vein 2 .          In this condition, herniation occurs along the obturator canal, which brings obturaorium nerves and blood vessels out of the pelvis. This most often occurs in older women who Frail. Hernia began as stoppers pre-peritoneum and gradually memebesar, brings with him peritonium yolk. Bowel loop can be entered into the peritoneum with yolk. Simultaneously the knuckle failed to spontaneously reduced.More loops can participate. Strangulated Richter often occur 3   
            Obturator hernia can take place in four stages. At first the retroperitoneal fat protrusion into the obturator canal (stage I), followed by a bulge of peritoneum parietale (stage 2). Hernia pouch may be limited by the curve of the intestine (stage 3) that can undergo partial incarceration, often for Richter or a total of 2 .

Figure 14. Obturator hernia 3

Clinical Overview
Located in the pektineus, is mostly asymptomatic till hernia complications due to intestinal obstruction or strangulation. Often there is a history of symptoms of intermittent obstruction.Approximately 50% of complaints there may be pain along the medial side of the thigh that extends down to the knee, caused by pressure on the obturator nerve. While there, most of the complaints is not the case 3 .  
Rarely there are signs, except in the obstruction or strangulation. Diagnosis is mostly made ​​at laparotomy for small bowel obstruction of unknown cause. With the pressure on the obturator nerve, the patient holds the foot in a flexed position in order to reduce the pain. At 20% of patients, the medial yolk hernia out around pektineus and appears as a palpable swelling in the femoral triangle. Examination of the rectum and the vagina may resemble the swelling of the obturator foramen region 3 .
Diagnosis can be established on the basis of complaints of pain such as tingling and paresthesias in the pelvic area, knee, thigh and medial part due to the emphasis on n.obturatorius (Howship-Romberg sign) are pathognomonic. On digital rectal or vaginal examination found a painful hernia protrusion of a Howship-Romberg sign 2 .
Performed with the surgical management of transperitoneal and preperitoneal approach 2 .
If it is found at laparotomy, intestinal smooth in the reduction, sakusnya Withdrawn and the defect closed. If the diagnosis is made ​​clinically, elective procedure with retropubic approach, pre-peritoneum can be done 3 .
C.9. Perineal hernia
    These hernias can be 3 :
    - Congenital
    - Learned primary
    - Incisional 
     Primary acquired hernias occur in multiparous women, middle age. Pelvic area and the effects of muscle weakness due to give birth to a child caused by herniation of the pelvic floor. Perineal hernia incisional following 1% combined abdominoperineal excision of the rectum 3 .
            Perineal hernia perineal hernia is a protrusion through a defect of the pelvic floor that can occur primarily in multiparous women, or through the perineum secondary to surgery such as prostatectomy or abdominoperineal resection of the rectum. Hernia out through the pelvic floor is composed of the anus and m.sakrokoksigeus m.levator its fasianya and can occur in all regions of the pelvic floor. hernia perineal hernia is usually divided into anterior and posterior hernia. Labial hernia inguinal hernia that is not a lateral, pudendalis hernia, and hernia vaginolabialis, including the anterior perineal hernias, while hernias and hernia isiorektalis retrorektalis including posterior perineal hernia 2.  

Clinical Overview
            Usually there is swelling of the perineum and discomfort when sitting. Soft mass was found on the perineum, which is usually reponibel. Hernia neck edge having wide elastic. These hernias rarely have dangerous complications 3 
            Diagnosis is by history and examination. Looks and tera ba bump on the perineum easily in and out and rarely experienced incarceration. The door can be palpated by bimanual hernia with a rectovaginal examination. In the state hesitated to do an ultrasound 2 .

Figure 15. Perineal hernia 3    

Operative management is usually recommended by the transperitoneal approach, perineal, or a combination of abdominal and perinea 2 l.
            Improvement is a combination of abdominal and pelvic approach. Through this approach the hernia from the bottom, the bag was released and reduced into the abdominal cavity. Performed laparotomy and pelvic floor repair of the bottom 3 .   

C.10. Pantaloon hernia
Pantaloon hernia inguinal hernia is a combination of lateral and media lis on one side. Both bags are separated by vasa hernia inferior epigastric so shaped as a pair. This situation is found to be approximately 15% of cases of inguinal hernia 3 .  
            Diagnosis is generally made ​​by clinical examination difficult, and usually only discovered during the operation. Management as usual in the inguinal hernia and hernioplastik 3 . 

C.11. hernia PARASTOMAL
            Hernia through the same hole fascia, a colostomy or ileostomy is formed by known as parastomal hernia. These hernias occur more commonly in people who are obese and at the kolostominya located lateral to the rectus muscular incision or through the initial surgery. In discussing the prevention of hernia, then the ideal place for a colostomy is through muscular rectus.Indications for repair parastomal include 4 :

A. Stoma is not satisfactory, which requires placement on the other side

2. Stricture or stoma prolapse

3. Large hernia

4. The existence of a small fascial defect around the hernia

5. Hernia incarceration or strangulation

6. Cosmetic repairs

Parastomal colostomy hernia and adhesions interfere with the irrigation of the stoma.Parakolostomi hernias are more common than hernia paraileostomi and both are more likely to occur if the stoma emerged through the semilunaris line rather than through the rectus sheath. Therefore, parastomal hernia is usually lateral to the ostomy. Move the stoma to a new location is preferred over local improvements. Local improvements often fail because of the lateral muscular ostomy belt, lack of sufficient aponeurosis. Mechanical prosthesis implantation in the subcutaneous tissue around the stoma and the abdominal wall, is the subject of septic complications. Repair defect of the abdominal fascia with a prosthesis, is selected if the hernia parastoma way in need of repair and can not be moved to a new location, because it does not interfere with the stoma and without the danger of septic contamination 5 .

C.12. Incisional hernia
Incisional hernia is a serious surgical problem. Obesity and infection are two major causes of this situation. The weight of the lateral panikuli, signaling and infection complicate the surgical incision wound healing. A large incisional hernia cause paradoxical abdominal breathing movements as long as flail chest. Diaphragm function becomes less efficient. The diaphragm is no longer contracting against the abdominal viscera and otherwise encouraged him to enter the hernia sac.Need to assess respiratory function and blood gases. Viscera lose its right place in the abdomen in the long incisional hernia. In this case, the reduction of viscera during surgery can cause death due to compression of the inferior vena cava and forced respiratory failure due to elevation and immobilization of the diaphragm 5 .

      Insisonal hernias occur through a wound in the previous operation. These hernias have the same appearance with the hernia is not caused by surgical trauma in the abdominal wall 3 .

            It is realistic to estimate that 1% of abdominal incisional hernia transparietal followed. Hernia covers 10% of total hernia 3 .

    Postoperative incisional hernia occurs because of the need to cut a segmental nerve which supply the muscles of the abdominal wall or jiga as a result of infection and necrosis (dead tissue) 1 .

Dehisensi partial of part or all of the deeper layers of fascia, but the skin is intact or can eventually heal. Incisional hernia is postoperative complications and, like all the complications, the cause may be considered from three factors: preoperative, operative, postopeartive 3 .

Pre-operative factors 3
A. Age

    Network of older people experience the healing is not as good at a young age.

2. Malnutrition-protein energy malnutrition, vitamin deficiency (Vitamin C is important for the maturation of collagen) and metal deficiency (Zinc contributes to epithelialization)

3. Sepsis

    Exacerbate malnutrition and delays anabolism

4. Uremia

      Inhibit cleavage of fibroblasts

5. Jaundice

    impedes maturation of collagen.

6. Obesity

     predisposing to wound infection, seroma, and hematoma.

7. Diabetes Mellitus

    predisposing to wound infection

8. Steroids

     Have the effect of general proteolytic

9. Peritoneal contamination (peritonitis)

    predisposing to wound infection

Operative factors 3
A. Type of incision

     Vertical incisions tend to be more prone to hernias than the transverse incision.

2. Techniques and materials

     The voltage at the closing impedes the blood supply to the wound; poor bonding;  

     closure of the thread material is absorbed quickly fail to    

    support the abdominal wall to allow sufficient time for integration  

    is good.

3. Type of Operation

    Operations involving the bowel or urinary tract are prone to occur


4. Drains

    drain through the wound is often a hernia.

Postoperative factors 3
A. Wound infection

    As important as the selection of the wrong thread: there is destruction

    Enzymatic against tissue healing.

2. Abdominal distension

    ileus posoperative increase the voltage on the wound. Stitches can be open.

3. Cough

    cause tension on the wound.

Pathological picture
Most of the incisional hernia was found in the first year after surgery, and an uncommon hernia after three years of operation if the previous closing of both 3 .

            Incisional hernia varies widely. They can have a wide or narrow neck; often due to the accumulation of the contents of the hernia, adhesions occur in the yolk, and on the neck, so that the hernia becomes ireponibel. Inkareserasi and strangulation to be a very dangerous thing. Yolk can involve large proportions, eventually involving multiple intraperitoneal contents 3 .

Clinical Overview
Complaint is penonojolan the scar. When the hernia enlarges, symptoms of subacute intestinal obstruction are common. Hernia can give a sense of discomfort in the area. Skin covering it can be thin and atrophic; eventually ulcers and even rupture may occur. Strangulation is the severity of surgical 3 .
Examination usually ireponibel, hernia cough with stimulation at a place that has a long scar.If the hernia complicated, many fibrous bonds that can be felt through between the edges of the defect. When the patient is lying down, it looks small hernia, but any maneuver that increases intra-abdominal pressure to the hernia 3 .
            Even a small hernia with symptoms should be corrected early. In the hernia is asymptomatic, the risk of intestinal obstruction, strangulation, and ulcers on the skin as well as repairs, even in older patients, is also recommended. Observation alone can make a hernia the size becomes larger, and further improvements and become more dangerous dulit. Surgical technique that does is the same as for the para-umbilical hernia, but larger hernias may require artificial mesh for abdominal wall reconstruction at 3 .
            Progressive pneumoperitoneum is a useful technique in preparing patients for hernioplasti mem incisional because it overcomes some of the problems of disease due to spending in the tools (eventration). Pneu moperitoneum pull the abdominal wall and attachment intrabdomen, mempcrcepat return the viscera to the abdomen, and improve the function of the diaphragm. Keba nyakan small incisional hernias treated by simple closure of the defect of the aponeurosis. However, a large incisional hernia with aponeurosis defects larger than 10 cm, has a recurrence rate of 50%.As a result, most of incisional hernia, and all recurrent incisional hernia, requiring prosthesis to the success of therapy. Stoppa Hernioplasti preferably in performing incisional hernioplasti. Can be used on all types of incisional hernia in the abdomen, including herniated lumbar pascanefrektomi 5 .

Stoppa Hernioplasti Mersilene prosthesis consists of a very large is implanted into the muscular wall of the abdomen at the top of the posterior rectus sheath or peritoneum. Prosthesis extends far below the defect mioaponeurosis and firmly fixed in place by intra-abdominal pressure and later by fibrous tissue that grows. Prosthesis to prevent eventrasi visceral peritoneum to make the bag can not be berdistensi and by bringing together a solid and consolidating the abdominal wall 5 .

Aponeurosis closure of the parietal defect is important. Closure of the center line can withstand greater stress due to the prosthesis, rather than stitching line, finally united with the abdomen. If necessary, the voltage can be reduced by vertical relaxation incision in the rectus sheath. Aponeurosis approach usually attainable, but if not, the second prostheses that can or can not be absorbed, which is placed on the defect aponeurotik, will ensure the stability of the abdominal wall during the healing process. This usually occurs in the region of the xiphoid or symphysis. Dead space formed by the major prosthesis always require a closed suction drainage to prevent seroma and hematoma and to allow the rapid incorporation of the fibrous prostheses in the abdominal wall 5 .

The results of hernia surgery is not as good as the primer. Small incisional hernia recurrence has a value of 2-5%, while for large by 10-20% 3 .

C.13. Sciatica HERNIA
      Sciatica is a bulging hernia sac peritoneum of the pelvis through the foramen of sciatica major or minor third .

 Clinical Overview
Patients present with discomfort and swelling of the buttocks, and there may be symptoms of suppression N. sciatica. If the hernia width, there will be a reponibel mass in the gluteus region, which progressively increase in size when standing. Herniation of the ureter can cause urinary symptoms. The possibility of strangulation can occur 3 .


Treatment is by excision of the yolk and the closure of the defect with the transabdominal approach or transgluteal 3 .

C.14. Hernia Interparietal
     At this hernia hernia yolk sandwiched between the layers of the abdominal wall. Can cause congenital abnormalities related to testicular descent, or obtained in a weak area on the lateral aspect of the inguinal ring and inguinal canal (when the yolk is usually associated with indirect inguinal hernia is konkomitan) 3 .

Figure 17. Hernia Interparietal 3

Classification of the hernia is dependent on the anatomical position of the yolk 3 :

A. Properitoneal (20%)

2. Interstitial (60%)

3. Superficial (20%)

Clinical Overview

Properitoneal type of hernia is palpable. Interstitial and superficial types often present with a small swelling above and lateral side of the inguinal canal and the inner ring. Important local sightings, often ignored by patients, and 90% of these hernias present with intestinal obstruction that culminated in the strangulation. The key to early diagnosis is to consider this type of hernia in any patients who present with intestinal obstruction (simple or strangulated) to the mass can be palpated on the side of the ring and the testis is located in an abnormal 3 .


Operation (usually an emergency laparotomy separately strangulation obstruction due to unknown reasons) resembling yolk hernia, which is excised and repair of facial defects 3 .

C.15. Diaphragmatic hernia
     Through the foramen of Bochdalek in the diaphragm.

X. Complications of Hernia
Complications of hernia depend on the circumstances experienced by the contents of the hernia. Hernia contents can be retained in the k antong hernia hernia on ireponibel; This can occur if the contents of the hernia was too large, for example, consists of omentum, extraperitoneal organs (sliding hernia) or a hernia accreta. Here no clinical symptoms except for a bump. Can also occur by the ring of the hernia contents strangled hernia Strangulated hernia that occurs that causes symptoms of intestinal obstruction that 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, partial jaws are more common. Rarely retrograde incarceration, the two bowel segments trapped in the hernia sac and the other segments in the peritoneal cavity like the letter W 2 .
            Hernia ring clamps will cause the contents of the hernia tissue perfusion. At the beginning of the dam occurs, causing venous edema organs or structures inside the hernia and hernia transudation into the bag. Incidence of edema causes hernia clamps on the ring and eventually growing network of compromised blood circulation. Hernia contents into necrosis and hernia bag will contain a fluid transudate serosanguinus. If the hernia contents consist of bowel perforation can occur that can eventually lead to local abscess, fistula, or peritonitis in the event of contact with the abdominal cavity 2 .
            Clinical picture inkarserata hernia containing intestine begins with an overview of intestinal obstruction with impaired fluid balance, electrolyte, and acid-base. When the disturbance has occurred due to vascular disorders, a state of gangrene and toxic due to the clinical picture is complex and very serious. Patients complain of more severe nyri hernia in place. Pain will persist due to peritoneal stimulation 2 .
            On local examination found a lump that can not be put back 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 right away 2 .


Indications of Surgery
In general, all hernias should be repaired, unless there is a local or systemic condition of the patients who did not allow a safe outcome. Possible exception of the general case this is a hernia sac with wide neck and the anticipated shallow enlarges slowly. Bebatan or surgical belts useful in the management of small hernias when surgery is contraindicated, but bebatan is contraindicated for patients with femoral hernia 5 .

General Therapy
            Conservative therapy while waiting for healing through natural processes can be performed on umbilical hernia before a child was two years old. Conservative therapy as the use of shackle can be used as a temporary management, such as the use of a corset on a ventral hernia. Meanwhile, the inguinal hernia is not recommended because the use of corsets but not cure, it can weaken the abdominal wall 2 .
            Generally, operative therapy is the only therapy that rational. Old age is not a contraindication to elective surgery. If patients with hernias have no symptoms of systemic inkarserata can try to do postural repositioning. If the successful repositioning effort, herniorafi elective surgery can be done after 2-3 days after tissue edema disappeared and the patient's general condition is better 2 .
            At inkarserata hernia, especially in Strangulated hernia, the contents of the possibility of recovery should be considered when operating henia. If the hernia contents is necrotic, resection. If during the operation to recover the contents of the hernia is doubtful, given a warm compress and re-evaluated after five minutes the color, peristalsis, and pulsation in a. arcuate in the intestine 2 .
            If it turns on the abdominal wall surgery is less strong, which does occur in hernia director, should be used to strengthen the abdominal wall marleks Local 2 .
            Herniorafi elective in general show a low morbidity and mortality, while acute herniorafi inkarserata or Strangulated hernia demonstrated morbidity and mortality can not be ignored 2 .
            Hernia surgery complications may include injury to V. femoral, N. ilioinguinalis, N.iliofemoralis, ductus deferens, or jar when the sliding hernia entered the two .
            Early complications several days after herniorafi may also occur in the form of hematoma, wound infection, dams V. Femoral, especially in the femoral hernia surgery, urinary or fecal fistula and hernia residif 2 .
            Further complications in the form of atrophy of testes due to lesions or dam A.spermatika pampiniform plexus, and the most important complication is hernia residif 2 .
            The incidence of residif depends on patient age, location of hernia, hernioplastik techniques are selected and how to do it. Indirect inguinal hernia in infants is rare residif. Indirect inguinal hernia residif numbers at any age is lower than an inguinal hernia or femoral hernias director. Ventral hernia showed a relatively higher residif. The first repairman gives the highest success rates, while operating on recurrent residif give very high figures. 2

Fold the base of the Thigh Hernia Repair
Object of the inguinal hernioplasti is to prevent the protrusion of peritoneum through the abdominal wall defect. Integrity of the abdominal wall was restored in one or two ways: (1) closure of the aponeurosis of the hernia defect, if necessary, extended closure, or (2) replacement of the fascia transversalis which have a defect with a large synthetic prosthesis. Two such methods are sometimes combined 5 .

Hernia repaired through an incision of the anterior fold of the posterior thigh or abdomen through the incision. The anterior approach is the most popular incision for inguinal hernioplasti.Hernia repair of posterior called hernioplasti properitoneal 5 .

Voltage is the principle cause of the failure of all the closed orifice hernioplasti miopektineal aponeurosis approach. Prevention of stress on the suture line is important, and the stitches should not be withdrawn or diiikat too tight, because it can cause necrosis. Preferably the sutures with permanent synthetic yarn 5 .

Synthetic prostheses currently plays an important role in the management of inguinal hernia.In general, improvement of the prosthesis is reserved for patients at high risk of recurrence after hernioplasti classic. Even so, the routine use of primary hernia repair remained elevated 5 .

Anterior Thigh Hernioplasti Classic Fold
Three classic anterior hernioplasti used at present are: simple closure of the annulus of Marcy, Bassini operation, and Cooper ligament repair, McVay Lotheissen way. All the same procedure satisfactory results in primary hernia if properly indicated and can be performed easily under local anesthesia in adults. Recurrent inguinal hernia repair were fixed with a classic, but now the prosthetic technique is preferred because the results are clearly better. Hernioplasti classic consists of three parts: a dissection of the inguinal canal, repair miopektineal orifice, and closure of the inguinal canal 5.

I. Marcy Repair of miopektineal orifice consists of tightening the deep ring is enlarged. This is commonly referred to as the ring closure is simple and only indicated in men and women who had indirect hernias with minimal damage of the anulus profundus. Operation to restore the anatomy of the deep ring to attach one or two stitches in the aponeurosis transverse arch and right iliopubika medial tract of the spermatic cord 5 .

II. Bassini-Shouldice Hernioplasti miopektineal orifice repair, superior to the inguinal ligament, ie, the deep ring and Hesselbach triangle, and therefore, is indicated in all direct and indirect inguinal hernia. In North America, Bassini repair consists of high ligation of the sac and the approach of the conjoined tendon and obliqus abdominis muscle to the edge of the internal arrangement of the inguinal ligament and suture cut 5 .

III. McVay Cooper ligament Hernioplasti cars-Lotheissen improve the three areas most vulnerable to disc herniation in miopektineal orifice, namely the deep ring, Hesselbach triangle, and femoral canal. In McVayLotheissen repair, transverse arch sutured to the aponeurosis Cooper ligament medially and the lateral femoral saroug. A relaxation incision keharusaa because if not made, there will be a large voltage on the line of stitching terlalul 5 .

Femoral hernia with a small orifice in women, only from below the inguinal ligament repaired with a few stitches or clogged with cylindrical plugs of Marlex, because the hernia is rarely associated with a hernia over the inguinal ligament. Femoral hernia is greater in women, and all femoral hernia in men, however, improved by McVay Cooper ligament repair-Lotheissen. Strangulated femoral hernia in properitoneal dadekati better, because it provides a direct path to the orifice which constrict the femoral hernia, the intestine is trapped easily removed by incision and ligament lakunaris iliopubik tract, and provided ample room for bowel resection 5 .

The baby girl, fallopian tubes and ovaries may be present in the hernia sac. Testicular feminization was found in 1% of women with a hernia, especially in the case of bilateral hernia. These patients should undergo buccal smear test for chromatin. In the female gonad which is found in the hernia sac with no fallopian tubes, should undergo a biopsy for identification of 5 .

The prosthesis material for Hernioplasti
Prostesis.sintetik for hernia repair is Marlex, Prolene, Surgipro, Mersilene, and Gore-Tex.Marlex and Prolene monofilament composed of fibers woven from polypropylene and are similar to each other. Both porous and somewhat stiff, containing plastic memory, when it is bent and curved in two directions at the same time. Surgipro prosthesis consists of knitted yarn woven polypropylene.Mersilene is a knitted prosthesis consisting of an open woven Dacron polyester fiber. More porous and weak, has a grainy texture to prevent derailment, and only have a minimal tendency to curve if it is bent in two directions at once 5 .

Free-Voltage Hernioplasti
Pieces of soft tissue prosthetics have been used for years to make improvements to the classic, but the results did not improve significantly. If the prosthesis is implanted without formal improvement, will eliminate stress, resulting in a dramatic improvement of the results. Lichenstein is an expert in stress-free hernioplasti and reported excellent results in a significant number of patients.Tension-free repair piece prostheses is not recommended for recurrent hernia, karenaa piece prosthesis will not be able to prevent the protrusion of the peritoneum with fibrosis of the underlying defect and because remobilisasi of the spermatic cord can cause testicular atrophy. The technique does not require remobilisasi blockage of the spermatic cord and only requires a small incision in the anterior groin, directly above the aponeurosis defects. A large hernia and recurrent hernia with multiple defects aponeurosis is not appropriate for the blockage and techniques are best treated with a permanent repair properitoneal prosthesis 5 .

Fold Hernioplasti Thigh Properitoneal
Properitoneal room is an alternative place for the implantation of the prosthesis. Prosthesis is fitted in place through intrabdomen pressure. Hernia defect can be patched or capped and hernioplasti done through pcndekatan posterior prosthesis, such as the interior approach. Properitoneal prosthesis innovative techniques, introduced by R. Stoppa in 1969. He offers treatment of inguinal hernia with a prosthesis that can not be absorbed, which serves to replace the fascia transversalis.Prosthesis is attached to the visceral sac and the peritoneum can not make out through the orifice miopektineal or other weak areas nearby; repair defects in the abdominal wall is not necessary. This operation is technically known as a sentence that describes the 'giant prosthesis fitting on visceral sac "(giant prosthetic reinforcement of the visceral sac = GPRVS), but generally referred to as the Stoppa procedure. GPRVS an efficient repair, anatomic, and stress-free. This is probably the best hernioplasti. If done correctly, can cure all inguinal hernia, femoral hernia even pravaskular. Recovery is very fast and only cause a little discomfort 5 .

Laparoscopic repair

Posterior repair of the hernia with a laparoscope, is currently in great demand. Almost all laparoscopic techniques implant a synthetic prosthesis. Laparoscopic approach for inguinal hernia repair can be performed by transperitoneal or extraperitoneal. Properitoneal space of groin hernia orifice and exposed. Indirect hernia sacs separated on his neck and distal pouch allowed to remain in situ. Prosthesis implanted to close hernia ori fisium. In practice, the surgeon can perform laparos hernioplasti kopik without assistance in an amount equal to the time required to perform the conventional procedure. More experience is needed before a clear evaluation possible. Important disadvantage is the cost of laparoscopic hernioplati more expensive than conventional hernioplasti because this procedure requires general anesthesia and expensive equipment. The advantage atunya acceptable is that the procedure causes minimal discomfort of the incision; whether the patient recovers segeraa or not, is uncertain. At this time conventional hernioplasti performed under local anesthesia in surgery on the same day, remains the best option for the majority of patients with primary hernia 5 .


Complications Hernioplasti Thigh Fold

Ischemic orchitis, with the remaining symptoms, testicular atrophy, and residual neuralgia is a complication unique two important, though not common, of hernioplasti groin. Occur more frequently after anterior groin hernioplasti because the nerves and the spermatic cord should didiseksi and mobilized. Recurrence is also part of hernioplasti groin complications, although the surgeons do not traditionally categorized as such 5 .

Classic improvements to the recurrence rate of about 1% -3% in 
10 years later. Recurrence is caused by excessive voltage at the time of repair, the less tissue, hernioplasti is not adequate, and the hernia is neglected. Recurrence, which was expected, more common in patients with hernia directors, especially directors of bilateral inguinal hernia. Indirect recurrence is usually due to inadequate excision of the proximal end of the bag. Recurrence is the most direct and usually in the region of the pubic tubercle, where the voltage is the largest line of stitching 5 .

Relaxation incisions are always helpful. Bilateral inguinal hernia repair at the same time not increasing the voltage and the stitching is not the cause of recurrence, as previously believed.Recurrent hernia repairs needed for a successful prosthesis. Recurrence after anterior protesis hernioplasti best done with the anterior approach with properitoneal or plug prosthesis 5 .

Endoscopic Hernioplasti
            Hernioplastik endoscopic approach with the patient lying in the Trendelenburg position 40 degrees. Used three trokar, the first in the midline near the umbilicus, and two others in the lateral 2 .
            Usually the hernia contents tereposisi own after the abdominal cavity filled with CO2 gas because the intestines will fall into the cranial direction. Abdominal wall of the pelvis and inguinal look good. Parietal peritoneum is opened and released in the vicinity of the hernia; hernia bag left in place2 .
            Annulus area internus, Hasselbach triangle, and the lacunae vasorum, meaning entrance indirect hernia, hernia director, and femoral hernia, as well as displayed. The area is covered with a sheet of synthetic material which is placed behind prolen inferior epigastric vessels with clips that dipancang next caudal ligament Cooper. Peritoneum was closed with a clip back and dipancang 2 .
            The advantage of this method is mild morbidity, the patient feels less pain, and general state operations are less disturbed than the outside. Patients can go home after work one day and again after one week. Hernia of the approach is certainly more rational. Complications consisted of hemorrhage atu infection. Generally, bleeding easily overcome during endoscopic surgery by placing a clip. Injury to the bladder or bowel are rare. This method is highly recommended for bilateral hernia hernia residif and 2 .

Indirect inguinal hernia Hernioplasti for large and hernia director; a. Cut off the weak posterior inguinal wall in a large indirect inguinal hernia; b. Posterior inguinal wall is weak will be eliminated in inguinal hernia director; c to f. The next stage in sequence on the reconstruction of the posterior inguinal wall. Indirect inguinal hernia Hernioplasti for large and director. (From McVay, CB: At Davis, L (Ed): Christopher's Text - Book of Surgery, 9 th ed. Philadelphia, WB Saunders Company, 1968).


A. Widjaja, H, Anatomy of the abdomen, Jakarta, EGC, 2007, Page: 21-25.
2. Sjamsuhidayat R, Wim de Jong, 2005, Textbook of Surgery, Issue 2, Jakarta, EGC,   
     Page: 523-537
3. Henry MM, Thompson JN, 2005, Principles of Surgery, 2 nd edition, Elsevier  
    Saunders, page 431-445. 

4. Sabiston, Textbook of Surgery, part I, the second mold, EGC,Jakarta, 1995. It:   
     228, 243.

5. Schwartz, Shires, Spencer, Digest Principles of Surgery, Issue 6, EGC, Jakarta,
    It: 509-517. 

6. McVay, CB: At Davis, L (Ed): Christopher's Text - Book of Surgery, 9 th ed.                 Philadelphia, WB Saunders Company, 1968.


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