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Case Discussion - Hernia

Jul 20 | 3:30 PM

"No disease of the human body, belonging to the province of the surgeon, requires in its treatment a greater combination of accurate anatomic knowledge, with surgical skill, than hernia in all its varieties" - Sir Astley Cooper. This perfectly depicts the level of precision we require for dealing with hernia cases. Let's dissect a case and untangle all the mysteries around evaluation & management of hernia.

let's start with the case presentation a 53 year old male came to the opd with the complaints of swelling over the left coin since 20 years patient was apparently alright 20 years ago when he first noticed the swelling over his left groin region which was of insidious onset appeared on standing and cuffing and disappeared on lying down patient did not seek any medical consultation for the same at that time generally we also like to add the occupation the religion of the patient and uh but if yes sir and something else so what is what is the importance of all this occupation especially occupation is important relevant to this your case yes um so i actually supposed to omit it because it was not relevant the occupation was taylor yeah but if it is not relevant you um so he came to the opd with the complaints of swelling over the left groin since 20 years a patient was apparently alright 20 years back when he first noticed a swelling over his left groin region which was of insidious onset appeared on standing and cuffing and disappeared on lying down a patient did not seek any consultation for the same at that time now since the last three months patient has noticed a gradual increase in the size of the swelling which is to the current extent and this is associated with pain which is mild intermittent and dull aching in nature he has his teeth complaining isn't it the complicated patient has come to you with so based on hernia the first and foremost clinical possibility a classic history of uh having appearing on standing and coughing and disappearing on lying down points to basically inguinal hernia so is there anything that is their diagnosis uh female hernia can also present like this but it's very rare in a male patient and uh the swellings which are there in the inguinal yes which is not changing in its position right from the beginning but is insidiously growing so what will differentiate your diagnosis would you consider so here we are expected to examine your thought process so what differential diagnosis would you consider so it could be a lymph node which is not reducing in size it could be stefano varix which is but it would increase on straining and everything uh it would be if if the onset is really acute it could also be a source abscess or a subcutaneous abscess okay it can be any tumor he's a young patient isn't it at the time of presentation he was young 33 year old he's now 53 and he had symptoms since 20 years ago okay okay go ahead there's history training and maturation there's intermittency and nocturia present since five months what are the causes of straining of maturation could be starting from the meatus any obstruction in the urinary tract could be metal stenosis could be structured at the urethra could be prosthetic hyperplasia or prosthetic cancer could be bladder stone or bladder malignancy going higher up could be urethric uh stenosis and uh stone renal stones european oceans will not be it's it's a basically a lower unitary uh urinary tract symptoms okay classically causes um yes i think it's relevant since it has been increasingly analyze history properly he has all these obstructive urinary symptoms since only five months and hernia has been there since 20 years but the size was increasing since the past three months the hernia onset was 20 years ago but there was no obstacle symptoms has led to the development of hernia they may have reflected of increase in the size of the so they've led to the development of increase in size yeah but so does that mean theology um no sir okay go ahead go ahead proceed he also has history of pulmonary tuberculosis 20 years ago for which six months of akt was taken okay all right there's no history of spaining its tools or chronic calf there was no history of lifting heavy weight there's no history of irreducibility no history of vomiting constipation or abdominal distension no history of acute severe pain over the swelling associated with fever or redness over the skin no past surgical history he's a known case of pulmonary tb i've mentioned that before he's a known diabetic diagnosed a year ago currently on this we are interested in knowledge so uh i if this were hernia i would be more interested in knowing appendisectomy history but this is left side again why have you asked this past surgical history so is there any reason so i just wanted to roll out uh any past uh surgical history in general for completeness of the case okay is there any relevance is uh scar is important appendicitis what is the importance of weakness of the muscles of the anterior abdominal wall is incision or some other incision do you know any other incisions taken from you to me yes sir there's a land sensation and then there's morrison sensations very good out of which which is muscle cutting muscles um the like bernie's just muscles splitting incision and the rest are muscle cutting incisions yes sir it's a it's cosmetically better plants is incision wherein you have to extend your insulin laterally to gain more exposure especially on the retrosequel appendix or emergency appendicitis and that is when you are likely to injure eyeline vinyl knob because what is the landmark of island vinyl now where does it lie it is uh medially and superior to anterior superior iliac spine about one to two centimeters very good so does your macbook incision go in that area uh not really sir exactly so it crosses little laterally so when you place the laterally placed when you take a laterally placed incision and when you cut muscle you are likely to injure this alloying vinyl now not in regular macbook institute yes you have to take for any surgeries on the left side like a 12 grip so that's not where i go now can usually get injured any other lower flank incisions which you can take which can cause injuries any procedures you know i don't know if it's the lateral i'm not sure about the lateral extension of this incision but those which are similar i mean uh wearing the muscle cutting incision it can be a palamos repair for vapicosilectomy high high but nowadays all these are treated endoscopically but if the patient is coming from an area where endoscopic facilities are not available somebody may have operated in for ureteral [Music] he's a known diabetic diagnosed a year ago and is on oral hypoglycemic agents he's a tobacco chewer since 20 years and his sleep and appetite are adequate there's no contributory family history disorders in the family presenting with hernias in any member of the family okay go ahead my patient moving on to examination my patients my patient was examined in a well-lit room with new consent and standing in supine position with adequate light and exposure from nipple to knee he is of average built in well nourished his pulse is 78 beats per minute taken in a right atrial artery and his blood pressure yes yes sir on inspection over the left and vinyl region swelling is not visible on standing but appears on puffering uh it is single well defined globular swelling about four by three centimeter noted over the left vinyl region which appears smooth with no visible pulsations of peristalsis and the skin over the swelling is normal there is no visible swelling over the right angle region even after coughing no evidence of malgachness bulging is same external genitalia appear normal and other hernia orifices appear normal okay uh the female orifice and the umbilical area the epigastric region and the lumbar region regional number so there are two triangles the upper and the lower uh lumbar triangle which are uh which are not as strong as the rest of the area and i've checked those why have you not seen so because it's more it's very rare it's more common females more common in females so what is that only yes um so if there's any redness or if there's any inflamed area i would like to rule that out what does it suggest uh it suggests that the underlying content is either strangulated or inflamed okay what about the previous car suppose this patient had scar of hernia some scar over the inguinal region but he doesn't know whether he's underwent some hernia repair what is the importance of this uh it would mean that he has a recurrent hernia or a incisional hernia incisional hernia see as a conventional hernia canal [Music] is uh moving on to palpation the inspectory findings are confirmed there's no local warmth or tenderness uh swelling is above and medial to the pubic tubercle it is about four by three centimeters regular doughy in consistency and it's reducible on doing the siemens test the impulse was felt on the middle finger and on doing the superficial ring imagination test the finger goes directly backwards and the cuff impulse was felt on the pulp of the finger and on doing the ring occlusion test the culture scene medial to the occluding finger he has good abdomen if it's wider or if it's narrow yes sir i would ask the patient to lie down and i would uh after lying down i'll ask i'll keep my hand over the rectus muscle and i'll ask the patient to uh raise his head or his legs and i'll feel for the contraction of the rectal muscle and i'll try to imaginate my finger if there's no like if there's good contraction then the tone is good and i'll also see for evidence of mild action malcolm x bulges which were defined uh so what is power uh the tone is the muscles uh status at rest and power is when uh when the muscles are put into action yes sir so what you described is actually your power [Music] the external genitalia are unremarkable and testers are bilaterally palpable okay on percussion over the swelling dull muscles present and oscillation of the swelling no peristaltic sounds were heard systemic examination was within normal limits and on political examination there's great one prosthetic normal anal tone was present and no other abnormality was present what is how did you create what is great so on uh per rectal or digital rectal examination when you uh feel the prostate uh that is great one if you uh can pass your finger above what do you mean by grade one when you feel it otherwise normally you don't feel it uh so normally we feel the posterior loop of the prostate posterior lobe of prostate how many lobes does the prostate have so five what again anterior to plateau and the posterior four four lobes of the fibers confused yes this is the anterior of the by two lateral lobes and one posterior lobe how many zones does it have three zones the posterior zone the transition zone and the central zone so what is what is normal finding like normally kidney is not palpable kidney will get pulsable only if it is enlarged normally screen is not pulsable normally liver is not pulsable so normally proximate is also not palpable on pr so how have you played it how many grades of plastic omega they exist uh there are four grades of prosthetic and they are basically radiological grades but in some you're [Music] some literature has mentioned correlation between radiological and clinical grading based on the invacination of your finger in the rectal canal are various findings like where whether your finger is able to reach above the prostate whether you are able to feel the medium surface of the prostate and weather and the lateral which you feel on the aspect of the cascade how deep is it i mean as the grade go on increasing that the lateral groove goes on whitening the median sulcus goes on becoming shadow and your finger cannot reach above so at least you should be able to know what are the criteria clinical criteria is used to grade the prostaglandin when you are pushing your foot reading the prosthetic uh to summarize my patient has left sided direct uncomplicated inguinal hernia with content being momentum and with good abdominal muscle tone with probable ideology being benign prosthetic hyperplasia so why are you saying is behind property hyperplasia what is the evidence you know on examination he has only great one prostate omega-3 which can be visualized uh obstruction that urinary obstacle you're saying since last five months uh whichever way then why are you putting benign prostatitis hyperplasia [Music] [Music] [Music] chronic cuff might have caused the swelling in the first place uh the first instant and after which it was cured so like there was no gradual there's no increase in the size of the swelling up until three to four or five months ago when there was another precipitating factor which was probably bph which then again led to increase in symptoms so uh if i tell you the patient has history of screening and urination then can you differentiate on history whether the patient has training because of pph or because of your electron structure uh yes sir when a patient says that he's training and after straining if the stream improves yes in vp um so in bph because there's a hybrid placey of the lobes while straining they will sort of compress on the internal sprinter which will increase more pressure and that will lead to even more poor stream than to begin with in the first place go ahead so i yes sir to diagnose the cause of the urinary symptoms lower urinary tract uh symptoms is there any clinical symptoms score that you know off which will pollute to a severity of obstruction uh so there are obstructive symptoms and then there are irritative symptoms first the irritative symptoms will start irritating symptoms or what are they all also called as symptoms irritative symptoms are storage symptoms symptoms and obstructive symptoms um so it's a prosthetic scoring system which is basically a symptomatic grading of the patient's symptom and it's divided into mild moderate and severe and it refers to the affection of pph over the quality of life of the patient okay and it may not necessarily be the size of the casket medically surgically or you address it before surgery during surgery so that depends on the level or degree of obstruction so that is somewhat clinical grading system of mild moderation okay and one more thing about urethral structure what are the causes of common consciousness structure in a young patient uh the most common cause before was uh cornorial urethritis leading to structure why bulba uh so because the bacteria has more affinity not sure why [Music] glands which secrete the secretions so there are secretions which are stagnant there and infection infected secretions are stagnant there so that makes it more prone to getting classical history of trauma uh the patient uh it he could have a pelvic fracture or pelvic injury and he could while walking have a gymnastic injury or a manhole falling injury which includes his uh cbcs and lfts and rfps i would also like to do a sonography kub uh kidney urinary bladder to check for trusted size and pre and post void and if any residual volume is present in this patient i would also like to do a uroflometry to check for uh the severity of or the obstructive symptom all we have to do is make the patient drink uh so what is the normal ufr it is more than 15 ml per minute so if i ask you this question is it common is it same for males and females yes sir if it's less than 12 then that's abnormal is uf same for males and females you need to check values normal values are different from means and females just like hemoglobin with different marbles okay so we'll check [Music] so what is the threshold of uh urinary flow rate at which you you can hold out urinary obstruction 10 ml you said post called residue what is normal residue less than uh ten percent of the additional volume to begin with less than ten percent volume to begin with okay or around 50 ml is expected to be normal okay i would like to know i'd like to do a pressure measurement of the bladder yes sir why so um so to differentiate our neurogenic bladder because his symptoms are similar but like i would not suspect that in this patient so he does not have any symptoms why do you want to hold out in his blood [Music] which is critically indicated no sir like in this case i can start i would like to start him on medical management first which would include uh alpha blockers score will guide you yes sir if it's less than 7 that is mild objective method of comparing the improvement also okay so if it's less than seven that is mild i would like to start him on uh ultra blockers and um [Music] like i was just naming the alpha blockers what will you give him why why you would have to give him selective alpha no because it's selective yes and uh if uh that's not happy this would help with the immediate action and i will also like to start him on five alpha reductase inhibitors which will take time to act about one month to act uh other than that i would uh monitor this patient for uh reduction of symptoms and uh uh i would also like to do serum psa just to rule out uh did you find any hard modules yeah [Music] then i'd like to do that open surgical repair in this patient and why have we selected why not laparoscopic repair laptop endoscopic repair is advised for any uh unilateral or bilateral case of hernia but if the surgeon but if there are no available setups in so you should be able to give him pros and cons of open surgery versus laparoscopic surgery so tell me that and amongst open there are various other options amongst laparoscopic there are two approaches so which one will you choose and why that you should be able to compare and tell me and counsel patient about it so that the patient would decide what surgery he wants to understand [Music] yes sir um so the advantages of laparoscopic surgeries are less chances of pain so i didn't get that question what would you advise him you can do about the surgery so you are going to put them put him as a cafeteria approach so there are two options and you choose is that what you are going to tell him uh so if i can if this could set up enough i can do the laparoscopic surgery i would want him to choose the labrador endoscopic approach no here this is case presentation so i'm asking you so you can say don't be afraid or don't be ashamed of saying that i am not expert i am not experienced or trained in laparoscopic repair so i would go ahead with lichtenstein's mesoplasty okay the advantage is why the engine sends meshvac so because the open approach is without the mesh in this space a case case will like it's not attention free repair if without mesh approaches are used and the recurrence rates are higher in those cases but when a mesh is used the recurrence rates are lower it's uh it's a good approach and it's a tension-free repo repair 18 year old boy what surgery would you do erlichtenstein smash blasty 15 year old 12 year old if a 12 year old is there chances are he'll have an indirect hernia more than the direct hernia but the patient processes vaginalis so if he's less than 12 years older herniatomy would suffice okay go ahead yeah so the advantages of laparoscopic surgery over the open surgery are less chances of recurrence less chronic uh post-operative pain for surgery and early uh mobilization less chances of breakup do you have any daca to suggest that there are less chances so the advantage is that you can uh see both the sides of the yes that is advantage but that is but that doesn't mean that recurrence rate is like when you are talking of recurrence recurrence at the operating side i mean if you operated on the right side recurrence on the right side that is not nothing to do with me on the left side so if the patient has undergone hernia on the right are you getting it yes sir sorry i don't think recurrence rates are better laparoscopic what is the ideal recurrence rate that you should be accepted except accepting or aiming at less than one percent sorry so what kind of mesh would you use a non-absorbable protein [Music] uh it should provoke minimal tissue reaction it should be uh it should not shrink too much it should it should provoke minimal tissue reaction so adequate tissue reaction like it should not be too less or too much properly it should know here you are aiming towards a good tissue reaction because what gives strength after hernia repair the mesh which will not have any tissue reaction if they don't have any tissue reaction there would be no scar form okay yes because pretty early mesh will not have any start formation that's why ptfe is used for vascular prosthesis what are other properties of ideal mesh minimal risk of infection should be easy to handle okay should not uh should not be should not lead to too much shrinkage [Applause] that means the mesh which was 10 centimeter in size will get reduced to 2 centimeter no like the 80 percent of the original mesh 20 shrinkage [Music] any other properties absorbable mesh a lightweight mesh is preferred with a microporous poly filament mesh so which measures poly filament the vicryl white materials but we you said macro porous meshes um so i'm not sure because the size of the pulse is bigger than the macrophages a macrophage is around 90 microns the size of the pore is bigger so that the macrophage can go through the force and cause phagocytosis and kill the bacteria so the chance of infection is lesser okay what are the important steps of surgery 8 by 15 centimeter of polypropylene mesh and you will uh put the mesh uh pair uh above like video to the pubic tubercle and uh you'll take the master stitch over the rectus sheet and you will uh like you will uh cut the mesh laterally and you will make the fish mounting of the mesh laterally so that uh the deep ring is uh secured special preference that you will take while suturing the mesh to record part of inguinal ligament below inferiorly you fix the mesh to record part of inventive ligament right inferior yes yes sir suppose you are assisting your junior [Music] but that's not the question i was expecting um because if you take the suture at the same level the entire external record part of invincibility the fibers are likely to tear and come away with the mesh okay the suturing of the mesh to the record part of inguinal measurement is always done in a staggered manner who discriminate attention okay um have to be done so what kind of posterior wall repair will you do uh the simple one where i'll approximate the fascia transversal is to facial transversals with a non-absorbable suture does that repair has an engine what you're saying approximation of fascia transfer is it is more than an approximation it is called glycation glycation of facial transphosis is to form the floor of the posterior wall suppose this patient has ring which is spatulas i'll take a little stitch to make the ring where would you take that little medium so any technique will differ what would be the difference in technique uh for a reduced hernia i'd like to do first uh sand dissection and uh after the sac has been dissected and it is not getting reduced then what would you do again i would like to say but i'm not sure i'll have to read you've never encountered this situation you're right this time because immediately there are lessons so you cannot cut cutting lessons okay yes sir [Music] clinic where the rates are really the recurrence rates are really low if you get a patient in emergencies theater after doing basic preliminary emergency investigations and um so then i'll have to proceed with exploratory laboratory and depending on the segment of the gangrenous uh and you do uh procedure how would you deal with hermia in this patient uh so after the reduction and everything is done i would like to do a hernia rafi and i would avoid uh placing a mesh since uh yes today's day and age [Music] modified massiveness repair where the posterior wall will be yes sir yes what is modified repair uh the posterior wall is repaired the fascia transversalis and fascia transfers so what is that suture too conjoined tendon is after the um suppose this patient has wound infection so how would you manage that uh so i would first like to remove one or two sutures and i'll like check the depth of the wound infection if it's just superficial i'd like to manage the patient on daily dressing if it's deeper and uh if the patient uh mesh it's below the level of external oblique upon your losses and i'm suspecting mesh infection then i would like to remove the mesh and do a hernia raffi or like proceed according to the maybe you will drain it everything you would wash deep drink or [Music] history of surgery in the past water management so if the patient has had an open surgery and has presented with a recurrence then i would like to go for a copic approach yes sir if the recurrence occurred while doing the anterior repair then i would like to prepare uh proceed with the posterior approach in this case and if um yes um the uh like how much is uh in a regular opening repair how many uh doses of antibiotic do you give so in a low risk environment no need of antibiotic doses the ot is modular and there's no uh cross infection and the sterile technique has been maintained and the counts and gloves have of surgeries based on the risk of infection yes sir the clean surgery is the clean contaminated surgeries the contaminated and the dirty [Music] for cleaning surgery yes external prosthesis which is at more risk of infection so many many times people would give three dozens of antibiotics or up to 24 hours so antibiotics not more than 24 hours or a single dose of antibiotic if you would have said but just no antibiotics is something which is very radical i don't think anybody practices it according okay

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dr. Gayatri Muley

Dr. Gayatri Muley

Resident Doctor | Grant Medical College & Sir JJ Hospital, Mumbai

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dr. Suchin Dhamnaskar

Dr. Suchin Dhamnaskar

Associate Professor & Head of Unit, Seth GSMC & KEM Hospital, Mumbai

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dr. Gayatri Muley

Dr. Gayatri Muley

Resident Doctor | Grant Medical College & Sir...

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dr. Suchin Dhamnaskar

Dr. Suchin Dhamnaskar

Associate Professor & Head of Unit, Seth GSMC...

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