ANATOMI ABDOMEN

Abdominal muscle
• Ligamentum inguinale
terbentang Spina iliaca
anterior superior –
Tuberculum pubicum
• Pelebaran ligamen inguinal
membentuk banguna segitiga
(ligamentum lacunare=
gimbernati) – berjalan
horisontal melekat pada
pecten pubis. Pada sisi lateral
menjadi batas dari anulus
femoralis
• Hesselbach’sTriangle -> Hernia
inguinal (direct)
Canalis ingunalis
• Menghubungkan cavitas
abdominopelvicus- cavum
scroti
• Berjalan dari anulus
inguinalis profundus-anulus
inguinalis supericial
Anterior = aponeurosis m.obliqus
eksternus + sebagian m.obliqus internus
Medial =fascia transversalis +inguinal falx
Cranial= m. Obliqus internus+m.
transversus
Caudal = lig. inguinale+ lig. Lacunare
• Anulus inguinalis
profundus- fascia
transversalis -> fascia
spermatica interna-
pembungkus funiculus
spermaticus
Hernia Scrotalis
Definition :
• A hernia is a protrusion of a viscus or a part of viscus through an
abnormal opening in the walls of its containing cavity.
• The external abdominal hernia is the most common form. The most
frequent varieties are the inguinal, femoral and umbilical.
General features common to all hernias :

Aetiology:
• Any condition that increase the intra – abdominal pressure such as a
powerful muscular effort may produce a hernia.
• Whooping cough is a predisposing cause in childhood, whereas a chronic
cough, straining on micturition or straining on defecation may precipitate a
hernia in an adult.
• It should be remembered that appearance of hernia in an adult can be a sign
of intra – abdominal malignancy.
• Obesity is an another factor, fat acts to separate muscle bundles and layers,
weakens apponeurosis and leads to appearance of hernia ( para-umbilical,
direct inguinal and hiatus hernia ).
• Hernia is more common in smokers which is due to acquired collagen
deficiency increasing the risk of hernia
Composition of a hernia:
Hernia consists of three parts : sac, coverings and the contents.

1. Sac :
It is a diverticulum of peritoneum consisting of :
1 – Mouth. 2 – Neck. 3 – Body. 4 - Fundus.
The neck is usually well defined but in some direct inguinal hernias and in
many incisional hernias there is no actual neck. The diameter of the neck is
important because strangulation of bowel is a likely complication when the
neck is narrow as in femoral hernia and para-umbilical hernias.
2. Covering :
Derived from the layers of the abdominal wall through which the sac passes.
3. Contents :
These can be :
– Omentum = omentocele.
– Intestine = interocele ( maily the small bowel but may be the large
bowel ).
– A portion of the circumference of the bowel = Richter’s hernia.
– A portion of the bladder.
– Ovary with or without the corresponding tube.
– A Meckel’s diverticulum = Littre’s hernia.
– Fluid.
Classification :
Irrespective of site, a hernia can be classified into 5 different types :
1 – Reducible. 2 – Irreducible. 3 – Obstructed.
4 – Strangulated. 5 – Inflammed.

Reducible hernia : hernia either reduce itself when the patient lies down
or can be reduced by the patient or the surgeon. Such a hernia (
reducible ) gives an expansible impulse on coughing.

Irreducible hernia : in case the contents cannot be returned to the

abdomen but there is no evidence of other complications. It is usually
due to adhesions between the sac and the contents or overcrowding
within the sac. Any degree of irreducibility predisposes to
strangulation.
Obstructed hernia : It is irreducible hernia containing intestine that is
obstructed from without or within but there is no interference to the
blood supply to the bowel. The symptoms (colicky abdominal pain and
tenderness over the hernia site) but less severe and onset is more
gradual than in strangulated hernias. Usually there is no clear
distinction clinically between obstruction and strangulation and the
safe course is to assume that strangulation is imminent and treat
accordingly.
Incarcerated hernia

The term ‘incarceration’ is often used loosely as an alternative to

obstruction or strangulation but is correctly employed only when
it is considered that the lumen of that portion of the colon
occupying a hernial sac is blocked with faeces. In this case, the
scybalous contents of the bowel should be capable of being
indented with the finger, like putty.
Strangulated hernia :
A hernia becomes strangulated when the blood supply of its content
is seriously impaired, rendering the contents ischaemic. Gangrene may
occur as early as 5-6 hours after the onset of the first symptoms.
Although inguinal hernia is more common than femoral hernia, a
femoral hernia is more likely to strangulate because of the narrowness
of the neck and its rigid surrounds.
Pathology : The intestinal blood supply is impaired. Initially, only the
venous return is impeded, the wall of the intestine becomes
congested and bright red with the transudation of serous fluid into the
sac. As congestion increases the wall of the intestine becomes purple
in color. The intestinal pressure increases, distending the intestinal lop
and impairing venous return further. As venous stasis increases, the
arterial supply becomes more and more impaired. Blood is
extravasataed under the serosa and is effused into the lumen.
• The fluid in the sac becomes blood stained and shining serosa dull
because of a fibrinous, sticky exudate. At this stage the walls of the
intestine have lost their tone and become friable.
• Bacterial transudation occurs secondary to the lowered intestinal
viability and the sac fluid becomes infected.
• Gangrened appears at the rings of constriction, which becomes deeply
indented and grey in color. The gangrene then then develops in the
ant mesenteric border, the color varying from black to green
depending on the decomposition of the blood in the subserosa.
• The mesentery involved by the strangulation also becomes
gangerenous. If the strangulation is unrelieved, perforation of the wall
of the intestine occurs, either at the convexity of the loop or at the
seat of constriction.
• Peritonitis spreads from the sac to the peritoneal cavity.
• Clinical features : Sudden pain at first situated over the hernia, is
followed by generalized abdominal pain, colicky in character and often
located mainly at the umbilicus.
• Nausea and subsequently vomiting. The patient may complain of an
increase in hernia size.
• On examination the hernia is tense, extremely tender and irreducible
and no expansile cough impulse.
• Unless the strangulation is relieved by operation, the spasms of pain
continue until peristaltic contractions cease with the onset of
ischemia, when paralytic ileus ( often the result of peritonitis ) and
septicaemia develops.
• Spontaneous cessation of pain must be viewed with caution, as this
may be a sign of perforation
Strangulated hernia

■ Present with local then general abdominal pain and vomiting

■ A normal hernia can strangulate at any time
■ Most common in hernias with narrow necks such as
femoral hernias
■ Require urgent surgery
• Inflammed hernia : inflammation can occur from inflammation of
the contents of the sac as eg. acute appendicitis or salpingitis.
• Inflammation can happen from external causes eg. Trophic ulcers
that developes in the depending areas of large umbilical or
incisional hernias.
• The hernia is usually tender but not tense and the overlying skin red
and oedematous. Treatment is based on treatment of the inderlying
cause.
Inguinal Hernia

Surgical anatomy :
The superficial inguinal ring is a triangular aperature in the
aponeurosis of the external oblique muscle lies 1.25 cm above the
pubic tubercle.
The deep inguinal ring is a U shaped condesation of the transervalis
fascia and it lies 1.25 cm above the inguinal ligament
 An indirect hernia travels down the canal on the outer side of the
spermatic cord. A direct hernia comes out directly forwards through
the posterior wall of the inguinal canal. Whereas the neck of the
indirect hernia is lateral to the inferior epigastric artery, the neck of
the direct hernia is medial to the artery.
An inguinal hernia can be differentiated from femoral hernia by the
ascertaining the relation of the neck of the sac to the medial end of
the inguinal ligament and the pubic tubercle. In the case of an inguinal
hernia, the neck is above and medial, whereas that of a femoral hernia
is below and lateral
Indirect inguinal hernia
It is the most common type of hernia. It is more common in the
young while the direct type is more common in the old. In the first
decade of life, inguinal hernia is more common on the right side in the
male. This is associated with the later descent of the right testis and a
higher incidence of failure of closure of the process vaginalis.
Clinical features :
We start examining the patient in standing position with asking the
patient to cough and feel the cough impulse. Then examiner should
now :
* Is the hernia is right, left or bilateral.
* Is it inguinal or femoral.
* Is it direct or indirect.
* Is it reducible or not.
* Is it complete or not.
* What are the contents
 The patient complains of pain in the groin or pain referred to the
testicles when performing heavy wok or taking strenuous exercise. In
large hernias there is a sensation of weight and dragging on the
mesentery which may produce epigastric pain.

Differential diagnosis in the male :

1 – Vaginal hydrocele.
2 – Encysted hydrocele of the cord.
3 – Spermatocele.
4 – Femoral hernia.
4 – Incompletely descended testis.
5 – Lipoma of the cord.

Differential diagnosis in the female :

1 – Hydrocele of the canal of Nuck.
2 – Femoral hernia.
Note that examination using finger and thumb across the neck of
the scrotum will help to distinguish between a swelling of inguinal
origin and one that is entirely intrascrotal.
Treatment :
Operation is the treatment of choice. ( Herniotomy +
Herniorrhaphy )
* Herniotomy : means dissecting out and opening the hernial sac,
reducing any content then transfixing the neck of the sac and
removing the remainder. By itself it is sufficient for the treatment of
hernia in children and young adults.
* Herniorrhaphy : consist of :
1 – repair of the stretches internal ring and transversalis fascia.
2 – further reinforcement of the posterior wall of the inguinal
canal.
 * A truss may be used when operation is contraindicated or refused.
In this condition if the truss to be used the hernia should be reducible.

Its use should be mainly historical, as there are very few

contraindications to surgery with today’s variety of anaesthetic
techniques.
Direct inguinal hernia

It is always acquired. The passes through a weakness or a defect of the

transversalis fascia in the posterior wall of the inguinal canal.
Predisposing factors are smoking and occupations that involves
straining or heavy lifting. Damage to the ilioinguinal nerve (previous
appendicectomy) is another cause, because of the resulting weakness
of the conjoined tendon. Direct hernia do not often attain a large size
or reach to the scrotum. In contrast to the indirect hernia, the direct
lies behind the spermatic cord. As the neck is wider than that of
indirect inguinal hernia, direct inguinal hernia do not often
strangulate.

Treatment : the principles of repair of direct hernia are the same as

those of an indirect hernia, with the exception that the hernia sac can
usually be simply inverted after it has been dissected free and the
transversalis fascia reconstructed in front of it. This repair can be done
also by mesh which is also true for indirect hernia repair.
PEMERIKSAAN FISIK ABDOMEN
Abdominal wall
 Important Signs in Patients with Abdominal Pain
Sign Finding Association
Cullen's sign Bluish periumbilical Retroperitoneal haemorrhage
discoloration

Kehr's sign Severe left shoulder pain Splenic rupture

Ectopic pregnancy rupture

McBurney's sign Tenderness located 2/3 distance from Appendicitis

anterior iliac spine to umbilicus on right side

Murphy's sign Abrupt interruption of inspiration on palpation Acute cholecystitis

of right upper quadrant

Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis

Obturator's sign Internal rotation of flexed right hip causing Appendicitis

abdominal pain

Grey-Turner's Discoloration of the flank Retroperitoneal haemorrhage

sign

Chandelier sign Manipulation of cervix causes patient to lift Pelvic inflammatory disease
buttocks off table

Rovsing's sign Right lower quadrant pain with palpation of Appendicitis

the left lower quadrant
TEHNIK OPERASI
Herniorhapy Leichenstein
Garis Insisi Bedah
• Panjang dan arah insisi melihat viscera dibawahnya ditentukan oleh
posisi dan arah saraf abdomen, arah serabut otot, susunan
aponeurosis yang membentuk vagina musculi recti abdominis
• Sejajar dengan garis lipatan kulit
• Insisi melalui vagina m recti abdominis – mempertahankan m. Rectus
abdominis dan persarafannya
PRA OPERASI
• Pemasangan NGT dan kateter urethra
• Rehidrasi cukup
• Antibiotik profilaksis

Sumber : Zollinger’s Atlas of Surgical Operations 9th ed 2011

INTRA OPERASI

• Pasien posisi supine dalam regional anestesi

• Asepsis dan antisepsis
• Insisi dari tuberkulum pubikum hingga 2 cm medial SIAS
• Perdalam hingga tampak aponeurosis OAE, potong secara tajam searah dengan serat

Sumber : Zollinger’s Atlas of Surgical Operations 9th ed 2011

INTRA OPERASI

• Identifikasi funikulus spermatikus, bebaskan dari

jaringan sekitar.
• Preservasi nervus ilioinguinal dan iliohypogastrik
• Buka m.cremaster, identifikasi kantung hernia
Sumber : Zollinger’s Atlas of Surgical Operations 9th ed 2011
INTRA OPERASI

• Evaluasi isi kantong hernia, apabila vital, kembalikan ke dalam cavum

abdomen
• Buat bridging, pisahkan kantong proksimal dan distal
• Jahit kantung proksimal setinggi lemak pre peritoneal
• Jahit m.cremaster

Sumber : Zollinger’s Atlas of Surgical Operations 9th ed 2011

INTRA OPERASI

• Pasang mesh, fiksasi pada tuberkulum pubikum, conjoint

tendon, dan ligamentum inguinal
• Tutup luka operasi lapis demi lapis
• Operasi selesai

Sumber : Zollinger’s Atlas of Surgical Operations 9th ed 2011

POST OPERASI
Membatasi aktivitas berat paling tidak 3 hari

Sumber : Zollinger’s Atlas of Surgical Operations 9th ed 2011