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CASE PRESENTATION

HERNIA INGUINALIS LATERALIS REPONIBLE


SINISTRA

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

Disusun oeh :
Nabilah Fajriah Barsah
1102012187

CLINICAL CLERKSHIP OF SURGERY DEPARTEMENT


FACULTY OF MEDICINE YARSI UNIVERSITY
ARJAWINANGUN DISTRIC GENERAL HOSPITAL 2016

CASE PRESENTATION
I.

II.

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

: May, 17, 2016


: Mr. A
: 52 years
: Male
: Labor
: Geyongan
: Islam
: Married

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

History of family disease


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

PHYSICAL EXAMINATION
a. Present Status
Genereal condition
Awareness

: Mild pain
: Compos mentis

Blood pressure
Pulse
Breathing
Temperature
Head
Form
Hair
Eye
Ear

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

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

(-),

tenderness

(-),

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

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

rebound

: Flat, symmetrical, mass (-)


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

b. Localized Status
Regio
Inspection

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

Palpation
Auscultation
c. Laboratory Examination

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

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

IV.
V.

DIAGNOSIS
Hernia inguinalis lateralis sinistra reponible
DIFFERENTIAL DIAGNOSIS

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

Hernia inguinalis medialis


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

VI.

VII.

I.

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

II.

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

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

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

IV.

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

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

By their character, a hernia can be called :


1. Hernia reponibel, when contents of a hernia can exit and enter again. The
intestines out when standing or straining, and enter again if lying down or
pushed in the stomach, no pain or symptoms of intestinal obstruction.
2. Hernia ireponibel, when the contents of hernia cant be repositioned back
into the abdominal cavity. This is usually caused by the adhesions contents of
the bag in peritoneal. This is called a accreta hernia. No complaints of pain or
intestinal obstruction signs.
3. Incarcerated hernia or hernia Strangulated, when it squeezed by hernia
ring so that the bag is trapped and cant get back into the abdominal cavity.
The result is a passage disorder or vascularization.
In outline, the division of hernia are divided into three, namely:

1. Femoral hernia, is generally found in older women, the incidence in women


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

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

V.

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

VI.

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

VII.

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

If the impulse at the fingertips means

Inguinal Hernia lateral.


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

Examination Ziemen Test:


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

hernia.
Finger number 4: Femoral Hernia.

Examination Thumb Test:


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

VIII. Supporting Investigation


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

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

IX.

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

X.

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

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

Artery
Vein
Lymph
Gonad
XI.

Aneurysm
Varicose
Lymphadenopathy
Ectopic testis / ovary

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

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

Unknown, 2013. Penyebab Hernia. [cites 19 may 2016] [Available from :


http://www.e-jurnal.com/2013/04/penyebab-hernia.html ].