Journal of the Association of General Surgeons of Thailand

under the Royal Patronage of HM the King

6 12 2553

..............1
.......2
CME

Review Article..........4
Peripheral vascular injury

Research.................16

1,000
Single Experience of
Consecutive 1,000 Cases
of Elective Groin
Herniorrhaphy under
Local Anesthesia

Surgical Quiz.........23

Vol. 6, No. 12 JanuaryMarch 2010

6 12 2553 Vol. 6, No. 12 JanuaryMarch 2010

.
.
..

(. . )

..

..

..

... .

...

... .

.

.. .

.. ..

..

..

...

..

..

..

..

..

..

.. .

.. .

CME

CME (Continuing Medical

Education)
CME
CME

CME
.
CME
CME
2,000

CME
ACCME
(Accreditation Council for CME)
CME

. 1910 Abraham Flexner

3
1.

(Excessive Commercialization)
2. (Unstandardized Curricula)
3.
Dr. Eric G. Gampbell Dr. Meredith
Rosenthal 100

(JAMA 2009 : 302 :
1807 08)
CME ? CME
(High Profit Margin) 23.5%
(58% )

CME


CME Dr.Eric
CME

CME

CME
CME
CME

CME

. CME

CME

CME

CME

(Maintenance of Certification Processes)

(Electronic Health Record)

CME
(www.iom.edu
NEJM 2009 : 360(21) : 2160-2163)
CME

Review Article

Peripheral vascular injury

. *
.. **

* ,
**

90%
extremities 0.2-2%
blast injury 4%
penetrating injury blunt
injury iatrogenic injury
endovascular procedure
70-90%
20-40 [1,2,4,5,8]
2545-2552 38 upper extremities
26 lower extremities 12
1 2 radial & ulnar artery
popliteal artery

Mechanisms of injury [1,2,4,5,8]

1. Blast injury
2. Blunt injury
3. Penetrating injury
a. high velocity
b. stab wound
4. Iatrogenic injury
blast
injury high velocity
injury

Type of injury

1
signs & symptoms 1

1. Type of injury [8]

Initial evaluation

ATLS
guideline: ABCDE

primary survey
secondary survey [1,5]

[2,4]
Life threatening condition

1. Digital pressure
2. Compression dressing
3. Packing
4. Balloon occlusion

Review Article
1. Type of injury & clinical presentation [2,4]

Type of injury

Clinical presentation

Partial laceration

Decrease pulse, hematoma, hemorrhage

Transection

Absent distal pulse, ischemia

contusion

Initially examination may be normal, may progress to thrombosis

pseudoaneurysm

Initially examination may be normal, bruit or thrill, decrease pulse

AV fistula

Initially examination may be normal, bruit or thrill, decrease pulse

External compression

Decrease pulse, normal pulse when fracture aligned

blind clamping

tourniquets lifesaving procedure occlude
collateral vessels
occlude artery
occlude venous return
venous injury [1,8]

[1]

S. aureus
tetanus prophylaxis [1,4,5,9-11]

Diagnosis

hard signs soft signs ( 2)

Hard signs vascular injury
100%

[5]

( 3)

Investigation

2: balloon occlusion

ABI Imaging
1. Ankle-brachial index arterial pressure index
(ABI or API)
= Systolic pressure in injured limb
Systolic pressure in uninjured arm
ABI < 1.0 vascular injury
sensitivity 95%, specificity 97% NPV 100% [2,4]
shock,
nonaxial arterial injury eg. profunda femoris artery
injury, non-occlusive arterial injury ( AVF, false
aneurysm, intimal flap) atherosclerosis
[1,2,4,5,9-11]

Review Article
2. Clinical manifestation of peripheral vascular injury [2,4,5]

Hard sign
Palsatile bleeding
Expanding hematoma
Palpable thrill
Audible bruit
Distal ischemia : 6Ps
Pain
Pallor
Pulselessness
Piokilothermia
Paresthesia
Paralysis

Soft sign

Unexplained shock
Proximity wound to major vessels
Stable hematoma
History of hemorrhage at scene
Peripheral nerve deficit
Diminished pulse

3. Correlation between orthopedic injury and vascular injury [2]

Orthopedic injury

Arterial injury

Supracondylar Fx of humorus

Brachial artery

Clavicle, 1st rib

Subclavian injury

Shoulder dislocation

Axillary artery

Elbow dislocation

Brachial artery

Distal femur

SFA, popliteal artery

Posterior knee dislocation

Popliteal artery

Proximal tibia

Popliteal artery and distal vessels

2. Duplex ultrasound color flow duplex

ultrasound
non-invasive test

sensitivity 95-100%, specificity 97%
accuracy 98% [6]
dressing soft tissue
injury chest wall, pelvic cavity
operator dependent [1,2,4-6,9-11]
3. Angiography gold standard
sensitivity 95-100%, specificity 98%

invasive study, nephrotoxicity contrast

angiography
hard sign
a. blunt or complex injury
b. missile that parallels the course of an artery
c. multiple potential site of injury
d. chronic vascular injury
soft sign proximity
angiography normal angiogram 90%
angiography 4 [1,2,4-6,9-11]
4. CT angiogram (CTA)
angiography non-invasive

Review Article
4. Indications for angiography [5]

Follow-up of nonoperatively managed

arterial injuries
Intraoperative evaluation
Postoperative evaluation
Thoracic outlet
Shotgun wounds
Confirmation of abnormal noninvasive tests:

ABI <1.0

systolic pressure in the injured limb is
10-20 mm Hg lower than the uninjured
contralateral limb
Any of the following that manifest hard signs:
Blunt or complex injuries
Missile that parallels the course of an artery
Multiple potential sites of injury
(i.e., blast shrapnel)
Chronic vascular insufficiency

angiographic team sensitivity specificity

90% nephroroxic, radiation exposure [1,2,4,5]
5. MRA trauma
contraindication [1,2,4,5]

5
3

Treatment

Medical treatment
Non-operative treatment
Endovascular treatment
Operative treatment

7
Injury extremities
resuscitation
Physical examination

No hard sign

Hard sign
Blunt
mechanism

Severe bone fracture

Chronic / vascular
disease
Soft tissue injury
Short guh wound

Duplex scan /
doppler pressure
abnormal

yes

normal

angiography
Hard sign
develop

Thoracic outlet
location
Missile paralleles
vessele

Nonoperative,
observation

no
Surgical
exploration

Occlusion / extravasation

Negative / Minimal non occlusive arterial injury

(Dotted lines indicate possible alternative modalities that require futher study)

3: Algorithm for evaluation of injured extremities for vascular trauma [5]

Review Article
5. Types of injury, mechanisms of injury, color flow duplex U/S, CTA, DSA role [6]

Mechanical of injury Color flow duplex
CTA role

U/S role
Perivascular
Vascular intervention Focal swelling,
-
hematoma
at puncture site
nonpalsatile

ecchymosis skin
AVF
Vascular intervention High turbulent flow at -

at puncture site,
fistula, low-resistant

postbiopsy, trauma
arterial flow, chaotic

wave form venous

flow, perivascular

color signal
Pseudosneurysm
Vascular intervention Bidirectional swirling Fill-in cavity

at puncture site,
flow in the lumen and Confirm diagnosis

biopsy, trauma
the neck, thrombin

injection under U/S
Thrombosis
Arterial & venous
Partial or complete
Intrathoracic

intervention, trauma echogenic lumen,
thrombosis, difficult

flow devoid
color flow duplex

U/S examination
Dissection
Arterial intervention, Narrow canal,
Confirm diagnosis,

trauma
turbulent flow
difficult color flow

duplex U/S

examination

DSA role
Confirm
diagnosis,
therapy

Confirm
diagnosis,
therapy
Confirm
diagnosis,
therapy
Confirm
diagnosis,
therapy

AVF : arteriovenous fistula CTA : CT angiography DSA : digital subtraction angiography U/S : ultrasonography
Medical treatment
antiplatelet
2 mm. intramural hematoma <50% circumference
pulse deficit systemic anticoagulant
(heparin 100u/kg) microvascular thrombosis, amputation rate limb salvage rate [1]
Non-operative treatment
[2, 4]
1. low velocity injury
2. Minimal arterial wall disruption (< 5 mm)

for intimal defect and pseudoaneurysm
3. Adherent or downstream protrusion of

intimal flap
4. Intact distal circulation

5. No active hemorrhage
Stain
24 non-occlusive vascular injury
non-operation 1-12
21 3
1
acute thrombosis distal embolization
non-operative treatment

develop hard sign
imaging angiography
duplex ultrasound

Endovascular treatment

Review Article
[1,2,4,5,7]
1. Low flow AVF
2. False aneurysm
3. embolized active bleeding from non

critical artery
4. Difficult to surgical access thoracic outlet

Proximal and distal vascular

control surgical repair
5. Patients with medical comorbidity
6. Intra-arterial pharmacotherapy

intra-arterial vasodilator severe vasospasm
7. Remove embolized missiles
8. Vascular stent
Technical success rate endovascular treatment 94% open
repair radiologic intervention team

Operative treatment [1,2,4,5,8,9,10,11]

1. Clinical evaluation / angiography
2. Preoperative ABO
3. Tetanus prophylaxis
4. Systemic heparin
5. Prepare & drape
6. Surgical exposure, Proximal & distal control
7. Debridement, vascular conduit
8. Cover anastomosis with viable tissue
9. Fasciotomy
10. Monitoring
1-3
Systemic heparinization
contraindication heparin multiple injury thrombosis propagation
thrombus limb salvage [1,5]
Dose: 100 u/kg 5000 u IV clamp
5 1-1.5 dose [1,5]
Prepare & drape

pulse, capillary refill

greater saphenous vein
cephalic vein vein graft
Surgical exposure, proximal & distal control

S-shape curvature
proximal & distal control
balloon catheter fogarty
foley catheter control

Debridement, vascular conduit

proximal &
distal control thrombectomy fogarty
catheter proximal distal

back bleeding forward bleeding
heparinized saline heparin : NSS 10:1
proximal & distal debride

synthetic nonabsorbable monofilament suture 5/0 polypropylene

subclavian, axillary,
femoral artery 6/0, 7/0 vein
continuous suture technique
interrupted
pursting constriction stitch
1 mm. 1 mm.
Laceration
50% circumferential
lateral suture
lateral suture
patch angioplasty ( 4)
Contusion
transection
2 end to end anastomosis interposition graft ( 4)

Review Article

10

proximal distal part

condition
vein graft
stable

damage
control
ischemic time
limb salvage
patency 52
systemic
anticoagulant [1,5,9,10,11]
Cover anastomosis
with viable tissue
A : lateral suture
B : patch angioplasty

C : end to end anastomosis
D : interposition graft
vascularized
tissue
4: [3,9]

1-2 cm.
2 conduit autogenous flap extra-anatomical bypass
vein graft prosthesis graft
Fasciotomy prophylaxis fasciotomy
contralateal greater saphenous vein compartment syndrome
short saphenous vein cephalic vein
prosthesis graft autogenous vein
1. Popliteal artery injury
graft
2. Combined arterial and venous injury
long term
3. Prolonged ischemia > 4-6 hr
patency autogenous vein graft
4. Associated with shock
Soft
5. Crush injuries
tissue vascularized tissue
6. Combined skeletal and vascular
extra-anatomical
7. Ligation of a major extremity vein or artery
bypass graft

popliteal vessels
Intraluminal temporary shunt prognosis factor
Monitoring
vascular injury completion angiography arterial runoff
early restore limb missed thrombi
perfusion pulse, Doppler u/s, capillary refill limb
life threatening perfusion
condition complex investigation
vascular injury intraluminal temporary shunt reperfusion syndrome metabolic

Review Article
acidosis, hyperkalemia,
myoglobinuria, renal failure

Complex vascular
injury

Extrimities skeletal injury

OR

yes

Hard sign
no

On table
angiogram
Extravasation,

Negative or

non occlusive
occlusion
injury

4 compartment
Definite

fasciotomy
skeletal
Stable Pt, or

repair
Unstable Pt.
skeleton
or
skeleton
perfusion

Arterial shunt
Completion
Definite vascular
intraluminal
angiogram
repair
External
temporary shunt
fixation


5: Evaluation and treatment of combined arterial and skeletal extremity trauma [5]

5
2. popliteal vein injury collateral
vein [1,5]
Combine venous injury
3. bilateral internal jugular vein injury
cranial venous outflow
brain edema [1,5]
venous
return collateral vein patency Non-salvageable limbs
artery

40-60% 1 vein
distal vein
shock, ongoing hemor- scoring system
rhage, associated life threatening injury Mangles Extremities Severity Score (MESS)
( 5) MESS 7 primary amputation [1,5]
prophylaxis fasciotomy [1,2,4,5]
Compartment syndrome
intraluminal temporary shunt

Stable cell

interstitial fluid fascia
1. combine arteriovenous injury venous capillary
outflow patency compartment
intraluminal shunt 10-12 mmHg compartment

25 mmHg

11

Review Article
dorsiflexion
1st webspace

Criterion
Point
wrist extension

Skeletal/soft tissue injury

Low energy (stab, simple fracture, low energy GSW, etc.)
1

Medium energe (dislocation, open fracture, etc.)
2

High energy (crush, close range shotgun, military GSW, etc.)
3
passive stretching
Very high energy (above plus contamination, avulsion)
4
pulse
Limb ischemia (score double if ischemia > 6 hr)
muscle paralysis
Pulse reduce but perfusion normal
1

Pluseless, paresthesia, decrease capillary refill

2
compartment
Cool, paralyzed, insensate limb
3
pressure
Shock
7
Systolic BP always > 90 mmHg
0
Hypotensive transiently
1
syringe 20 cc.
Persistent hypotension
2
3 way stopcock
Age (yr)
3 way
<30
0
sphygmomanometer
30-50
1
extension
>50
2
tube 18
NSS
pressure
toxic metabolite [1,2,4,5,9,11,13]
st
1 dorsal webspace compartment syringe air
6. Mangled Extremities Severity Score

12

6: Compartment

Review Article

7: compartment pressure

sphygmomanometer NSS

compartment
NSS compartment pressure [11]

1. Remove external device webril

2. Elevate limb to cardiac level
3. Treatment of myoglobinuria volumne
expansion, manitol, loop diuretics, Alkalinized urine
4. Fasciotomy [1,2,4,5,9,10,11,12]

13

8: Fasciotomy incision [12]

Review Article
a. Prophylaxis fasciotomy
b. Compartment pressure > 40-45 mmHg
c. Compartment pressure > 30 mmHg

more than 3-4 hrs
d. Pain on palpation of the swollen compartment
e. Reproduction of symptoms with passive

muscle stretch
f. Sensory deficit in the territory of a nerve

traversing the compartment
g. Muscle weakness
h. Diminished pulses (a very late sign)
fasciotomy skin
fascia local wound care
wound coverage
skin graft
fasciotomy 4- compartment
fasciotomy medial incision

14

2 cm. tibial bone superficial

deep posterior compartment greater
saphenous vein lateral incision 2 cm.
fibula bone anterior lateral compartment
superficial peroneal nerve ( 9)
fasciotomy volar
8 carpal tunnel dorsal
lateral epicondyle mid wrist

Poor prognosis factor

1. 6
2. blunt blast injury
3. Doppler signal
4. ischemia
5. associated life threatening injury
6. popliteal injury
7. underlying chronic vascular insufficiency

Review Article
References
1. ACS surgery : Principle and practice 2007 edition
2. Robert B. Rutherford : Vascular Surgery 6th edition
3. Robert B. Rutherfird : Atlas of vascular surgery : Basic technique and exposure
4. Fred A. Weaver. Vascular trauma. Rutherford Vascular Surgery 6th edition
5. Frygberg ER, Schinco MA. Peripheral vascular injury. : Trauma 6th edition.
6. Gaitini D. et al. Sonographic evaluation of vascular injury. Ultrasound clinic 3(2008) ;33-48
7. CTP Zachary M. et al. Vascular trauma : Endovascular management and technique. Surg Clin N An 87 (2007); 1179-1192
8. Extremity vascular trauma, Vascular Trauma. Surgery 2004, 22(11): 288-93
9. , . Peripheral vascular injury. 30. 2548; 94-127
10. . Pitfall and management of peripheral vascular injury. 20. 2544; 601-621
11. . . . 2545 ; 253-326
12. . Compartment Syndrome, upper and lower extremities. 2548

15

Research

1,000

Single Experience of Consecutive 1,000 Cases of

Elective Groin Herniorrhaphy under Local Anesthesia
. ., FRCST

Phongmanjit P. MD., FRCST.
Division of Surgery, Chiangrai Hospital, Chiangrai Province. Thailand.

Abstract

16

he groin hernia is one of the most common

conditions need surgical intervention. The
surgical procedure has to be attentive in each
step to avoid post operative complications. From
September, 1989 to July 2006, consecutive 1,000-cases of
groin hernia repair were accomplished by an individual
surgeons. The majority is male (93%) and the most
common type is indirect inguinal hernia (88.5%). Every
procedure of anterior approach is obtainable by the
technique of local anesthesia and also allows surgeons
checking completeness of repair by patient straining.
Most of repairing method are tension-free repair
according to modified Lichtenstein technique (38.7%)
and 76.8% of patients were treated as outpatient basis
with great satisfaction. The analysis revealed not only
low short-term complication rate of 2.5% but also very
low recurrence rate of 0.2%. In addition, the medical work
load was minimized by alleviate unnecessary in-patient
burden, thus will this ambulatory service could be
favorable for practice in Thailand.

.. 2532 .. 2549

1,000 (93%) indirect
inguinal hernia (88.5%)

tension free repair
Lichtenstein (38.7) 76.8
(2.5%)
(0.2%)

1-3
4-7

4,8,9
.
.. 2532-2549 1,000

Research


2532

1. Elective surgery
2.

3. 15
4.
5.

6. No uncontrollable hypertension, DM
7.

1. 1% lidocain with
adrenaline 1: 100,000 30 ml. + 0.5%
bupivacain 20 ml.
10-12
2. Syringe 5 ml.
3. Spinal needle No. 25 G

13

A. ilioinguinal nerve
2.5 cm. medial anterior superior iliac spine,
2.5 cm.
1 ml.
external obliges aponeurosis fascia
(lost of resistant)

5-10 ml.
B. Superficial inguinal ring pubic tubercle
pubic tubercle
1 ml.
Pubic tubercle 2-3 ml.
inferior 1 finger breadth
superficial inguinal ring 2-3 ml

C. Incision site

2 finger breadth pubic tubercle
lateral
lateral mid inguinal point


midline

inguinal ligament
superficial ring
inguinal
ligament midline


20-25 ml.
D. Deep inguinal ring
Land mark 1.5 cm. mid inguinal point
external
obliges aponeurosis
(lost of resistant) 1-2 cm.
body mass
5 ml.
syringe

1: 13

17

Research
Sedation

sedation
diazepam 5-10 mg. 30

Indirect
inguinal hernia 885
88.5 ( 2)
Lichtenstein ( 3)
3

.. 2532
.. 2549 1,000
929 71
15 87 46 ( 1)
1.

18

()

()

15-20

65

6.5

21-30

165

16.5

31-40

175

17.5

41-50

155

15.5

51-60

175

17.5

61-70

155

15.5

71-80

90

9.0

>80

20

2.0

()

Tissue repair
Bassini
Marcy
McVey
Femoarl ring repair
Shouldice

600
197
349
18
20
16

60.0
19.7
34.9
1.8
2.0
1.6

Tension Free
Lichtenstein
Plugging

400
387
13

40.0
38.7
1.3

15 100
25 ( 4)
4

()

2.

Type of
hernia

Side
Rt.
Lt.

Total

Indirect

553

332

885

88.5

Direct

58

33

91

9.1

Pantaloon

26

16

42

Bilateral

11

Femoral

10

12

24

2.4

Recurrent

14

22

()

0-15

35

3.5

16-30

440

44.0

31-45

361

36.1

46-60

100

10.0

>60

64

6.4

Research
5

0-8 2.5
.. 2537
( 6)
.. 2537 2

1 92
25 ( 7)

()

Hypertension

25

2.5

COPD, Asthma

20

2.0

DM

15

1.5

BPH

0.9

HIV +Ve

0.4

Thalassemia

0.4

Others

20

2.0

Total

97

9.7

9
10-12,14,15

16-19 Shouldice Clinic
215,000
5

1. 20.21 22

23

24
2. 24
3.
24



24

Hernia Shouldice Clinic
1 3
25
4. 26
5.
10-12

Type of admission ()

Inpatient

232

23.2

Outpatient

768

76.8

Seroma

()
4

Hematoma

11

Ecchymosis

Femoral nerve paresis

Local anesthesia failure

Infection

97 9.7
( 5)
4-5 .. 2532
.. 2537

19

Research

20

Lidocain ( 0.6%)

maximum dose
lidocain Adrenaline 7 mg./Kg.27,28
50 .. 350 mg.
50 ml. Lidocain
300 mg.

Bupivacain
Lidocain
Bupivacain
2-4 27,28

Maximum dose Bupivacain
2.5 mg./Kg. 27,28 50 ..
125 mg.
Bupivacain 100 mg.
Adrenaline

hematoma ecchymosis

1. spinal needle No. 25 G
2. puncture site 4 site
spinal needle No. 25 G
3.
4.


Deep inguinal ring

Syringe

5. 29
4-5

2.5 10


Paracetamol NSAID

10,11





.. 2537

Bassini,
McVey, Shouldice, Marcy

tension free
tension free
.. 2540

Marcy5,30,31 deep inguinal
ring
inguinal floor


Marcy
tissue repair deep
inguinal ring
tissue repair
inguinal floor

Research


tension
free Lichtenstein
direct indirect inguinal hernia deep
inguinal ring
inguinal floor

tissue local responsive mediators
PMN mediator, free radicals
release 32-34
25 2.5
5

1 3

adrenaline
Adrenaline

2 2


sedation

Shouldice Clinic
19
3 Femoral nerve paresis 2


2-4

2
5

Bassini 3
Marcy
4

Marcy


5-20
2 5 4,5

Extern Intern Resident

21

Research

22

1. Wantz GE. Abdominal wall hernia. In: Schwartz SI, Shires TG, Spencer FC, Husser WC, eds. Principle of surgery. 6th ed.
New York : McGraw-Hill Inc. 1994: 1517-44.
2. Rutkow IR, Robbins AW. Demographic, classificatory and socioeconomic aspects of hernia repair in the United States. Surg
Clin North Am 1993; 73:413-26.
3. Lichtenstein IL. Immediate ambulatory and return to work following herniorrhaphy. Industr Med Surg 1996; 35: 3
4. Deysine M, Soroff HS. Must we specialized in herniorrhaphy for better result? Am J Surg 1990; 160: 239.
5. Griffith CA. The marcy repair of indirect inguinal hernia: 1870 to the present. In; Nyhus LM, Cndon RE. eds. Hernia. 4th ed.
Philadelphia: JB Lippicott, 1995: 111-22.
6. Rand Corp. Conceptualization and measurement of physiologic health for adult. Santa Monica, California : Rand Corp.
Publication, 1983; 15:3.
7. Lichtenstein IL, Shulman AG, Amid PK. The cause, prevention, and treatment of recurrent groin hernia. Surg Clin North Am
1993; 73:529-44.
8. Condon RE, Nyhus LM. Complications of groin hernia. In; Nyhus LM, Cndon RE. eds. Hernia. 4TH ed. Philadelphia: JB
Lippicott, 1995: 279-82.
9. Greenburg AG. Revisiting the recurrent groin hernia. Am J Surg 1987; 154: 35. 28. Marcy HO. The cure of hernia. JAMA
1887; 8: 589.
10. . . 1994; 19; 371-5.
11. , . . 1998; 23; 17-21.
12. . . 1999; 24; 545-50.
13. Franagan L Jr, Bascom JU. Repair of groin hernia outpatient patient approach with local anesthesia surgery. Surg Clin North
Am 1984; 64:257-67.
14. . . 1988; 13; 695-8.
15. . . 1990; 15; 364-8.
16. Abdu RA. Ambulatory herniorrhaphy under local anesthesia in a community hospital. Am J Surg 1983; 145:353-6.
17. Bellis CJ. Inguinal herniorrhaphies using local anesthesia with one day hospitalization and under restrict activity. Int Surg
1975; 60:37-9.
18. Berlinner S, Bison L, Katz P. An anterior transversalis fascia repair for adult inguinal hernia. Am J Surg 1978; 135:633-6.
19. Bendavid R. The shouldice repair. In; Nyhus LM, Cndon RE. eds. Hernia. 4TH ed. Philadelphia: JB Lippicott, 1995: 217-31.
20. Abdu RA. Ambulatory herniorrhaphy under local anesthesia in a community hospital. Am J Surg 1983; 145:353-6.
21. Iles J. The management of elective hernia repair. Ann Plant Surg 1979;2:538-42.
22. Amado WJ. Anesthesia for hernia surgery. Surg Clin North Am 1993; 73:427-38.
23. . . : , . .
1. : , 2525:477-87.
24. Bendavid R. The shouldice repair. In; Nyhus LM, Cndon RE. eds. Hernia. 4TH ed. Philadelphia: JB Lippicott, 1995: 217-31.
25. Glassow F. The shouldice repair for inguinal hernia. In; Nyhus LM, Cndon RE. Hernia. 2nd ed. Philadelphia: JB Lippicott,
1978:163-78.
26. Franagan L Jr, Bascom JU. Repair of groin hernia outpatient patient approach with local anesthesia surgery. Surg Clin North
Am 1984; 64:257-67.
27. . Spinal, Epidural Caudal block. : , .
. 1. : , 2525:477-87.
28. . . : , . . 1. :
, 2525:144-60.
29. McKay W, Morris R, Mushlin P. Sodium bicarbonate attenuate pain on skin infiltration wit lidocain, with or without
epinephrine. Anesth Analg 1987; 66:572-4.
30. Marcy HO. The cure of hernia. JAMA 1887; 8: 589.
31. Griffith CA. The marcy repair revisited. Surg Clin North Am 1984; 64:215-27.
32. Hollmann WM, Durieux EM. Local Anesthetics and the Inflammatory Response A New Therapeutic Indication?.
Anesthesiology 2000; 93:858-75.
33. Lee RH, Marzoni FA, Cannon WB, eds: Outpatient adult inguinal hernia repair. West J Med 1984 ; 140:905-906
34. Yifeng D, White EP. Post-herniorrhaphy pain in outpatients after pre- incision ilioinguinal- hypogastric nerve block during
monitored anaesthesia care. CAN J ANAESTH 1995;42:12-15

Surgical Quiz

, .

50 year-old alcoholic cirrhosis with ascites has an umbilical hernia which has never been treated.
On examination, he has massive ascites with a large umbilical hernia, and thin skin at apex.
There is slow oozing of clear, odorless fluid from it. Initial therapy now should be

A. umbilical hernia repair and large volume paracentesis

B. bed rest, diuretics, salt restriction and hernia repair during this admission.

C. umbilical hernia repair with placement of peritoneo-venous shunt

D. observation and the umbilical hernia is unnecessary to treat now

E. paracentesis and abdominal binder application

23

Surgical Quiz
Answer: B

24

Critique:
advanced cirrhosis ascites
caput medusae
umbilical hernia

umbilical hernia ascites

aggressive
medical treatment ascites
low salt diet diuretics potassium
sparing aldactone loop
diuretic Lasix


TIPS, shunt
control ascites

recurrence leak



cirrhosis massive
ascites umbilical hernia
control ascites ...

1. Incarcerated Strangulated umbilical

References
1. Greenfields Surgery 4th ed, 2006: 1201
2. Nyhus LM and Condon RE: Hernia 4th ed, 1989: 354-359.

hernia neck hernia

condition repair hernia
aggressive medical treatment
(large
volume paracentesis)
2. Ruptured hernia ascites
sac hernia
rupture


condition Strangulated umbilical hernia repair
aggressive medical treatment
3. Fluid leakage apex sac
hernia

rupture
condition
admit , bed rest, iv antibiotics
diuretics
preoperative preparation assessment
repair hernia admission
Le Veen shunt peritoneovenous
shunt ascites