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CLINICAL SCIENCE SESSIONHERNIA
Preseptor :
dr. Liza Nursanti, Sp. B., M.Kes.
Disusun Oleh :
Meylani Ardianty 12111!"#
Pe$y Astrie Pratista 12111!%!
BA&'AN 'LM( B)DA*
P+O&+AM P)ND'D'KAN P+O)S' DOK-)+ P#D/
AK(L-AS K)DOK-)+AN
(N'0)+S'-AS 'SLAM BAND(N&
+S( AL'SLAM
21
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Anatomy abdominal
wall skin
fatty (Campers fascia)
membranous (Scarpas fascia)
deep fascia
external oblique muscle
deep fascia
internal oblique muscle
deep fascia
transverse abdominal muscle
transversalis fascia
endoabdominal (extraperitoneal) fat
parietal peritoneum
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There are fve (bilaterally paired) muscles inthe anterolateral abdominal wall three !atmuscles and two vertical muscles"
The three at muscles are the external obliqueinternal oblique and transversus abdominis"
The t! vertical muscles of the anterolateralabdominal wall contained within the rectussheath are the lar#e rectus abdominis and thesmall pyramidalis"
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Nerves !" the A#ter!lateral Abd!mi#al $all
$ulit dan otot di anterolateral abdominal wall disuplai
oleh % Thoracoabdominal (yan# membentuk inferior
intercostal) nerves yaitu anterior abdominal(cutaneous) caban# dari ventral primary rami of the
inferior six thoracic nerves (T& sampai T'') Subcostal nerves (T')
liohypo#astric * ilioin#uinal nerves (+')
T& sampai T, mensuplai kulit superior dari umbilicus
T'- men#inervasi kulit di sekelilin# umbilicus T'' dan cutaneous caban# subcostal (T')
iliohypo#astric dan ilioin#uinal (+') mensuplai kulitinferior dari umbilicus
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The primary bl!!d vessels (arteries a#d vei#s)
of the anterolateral abdominal wall are the Superior epi#astric vessels and branches of the
musculophrenic vessels from the internal thoracicvessels"
nferior epi#astric and deep circum!ex iliacvessels from the external iliac vessels"
Super.cial circum!ex iliac and super.cialepi#astric vessels from the femoral artery and
#reater saphenous vein respectively" /osterior intercostal vessels of the ''th
intercostal space and the anterior branches ofsubcostal vessels"
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Lymphatic %rai#a&e !" the A#ter!lateralAbd!mi#al $all
Superfcial lymphatic vessels bersama den#ansubcutaneous vein" Terba#i men0adi dua yaitusuper.cial lymphatic vessels yan# superiorterhadap umbilicus yan# akan men1drainase
axillary lymph nodes dan beberapa ke parasternallymph nodes2 serta super.cial lymphatic vesselsyan# inferior terhadap umbilicus yan# akan men1drainase ke super.cial in#uinal lymph nodes"
%eep lymphatic vessels bersama den#an deepveins * men1drainase ke external iliac commoniliac dan lumbar (lateral aortic) lymph nodes"
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Lymphatic drai#a&e of the anterolateralabdominal wall %
Superfcial lymphatic vessels accompany thesubcutaneous veins2 those superior to thetransumbilical plane drain mainly to the axillarylymph nodes2 however a few drain to the
parasternal lymph nodes" Super.cial lymphaticvessels inferior to the transumbilical plane drainto the super.cial in#uinal lymph nodes"
%eep lymphatic vessels accompany the deep
veins of the abdominal wall and drain to theexternal iliac common iliac and ri#ht and leftlumbar (caval and aortic) lymph nodes"
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n#uinal 3e#ion
The in#uinal re#ion or #roin extends betweenthe ASS and pubic tubercle" t is an important
area anatomically and clinically% anatomicallybecause it is a re#ion where structures exitand enter the abdominal cavity and clinicallybecause the pathways of exit and entrance
are potential sites of herniation"
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n#uinal Canal
The in#uinal canal in adults is an oblique passa#eapproximately ' cm lon# directed inferomediallythrou#h the inferior part of the anterolateral abdominalwall" t lies parallel and superior to the medial half ofthe in#uinal li#ament"
The main occupant of the in#uinal canal is thespermatic c!rd i# males and the r!u#d li&ame#t!" the uterus i# "emales" These are functionally anddevelopmentally distinct structures that occur in thesame location" The in#uinal canal also contains bloodand lymphatic vessels and the ilioin#uinal nerve in bothsexes"
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The in#uinal canal has two walls (anterior and posterior)a roof and a !oor %
A#teri!r all% formed by the external obliqueaponeurosis throu#hout the len#th of the canal2 itslateral part is reinforced by muscle .bers of the
internal oblique"
!steri!r all% formed by the transversalis fascia2 itsmedial part is reinforced by pubic attachments of theinternal oblique and transversus abdominis
aponeuroses that frequently mer#e to variable extentsinto a common tendon4the in#uinal falx (con0ointtendon)4and the re!ected in#uinal li#ament"
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R!!"% formed laterally by the transversalis fascia
centrally by musculoaponeurotic arches of theinternal oblique and transversus abdominis andmedially by the medial crus of the externaloblique aponeurosis"
l!!r% formed laterally by the iliopubic tractcentrally by #utter formed by the infoldedin#uinal li#ament and medially by the lacunar
li#ament"
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protusi/penonjolan isirongga melalui defek
atau bagian lemah daridinding rongga yang
bersangkutan
DEFINISI
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5erniareponibel %
irreponibel 6
%'
/ria 7 wanita
8/98:;+;
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Frekuensi relatif Hernia
Tipe Hernia Insidens (%)
Epigastric 1
Umbilical 3
Insisional 10
Inguinal 78
emoral 7
!ain"lain #jarang$ 1
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Eti!l!&i
Tekanan yan# menin#kat pada abdomen ter0adikarena % :en#an#kat beban berat >atuk ? //;$Tahanan saat miksi ? >/5 atau karsinoma
Tahanan saat defekasi ? konstipasi atau obstruksi usus besar 9istensi abdomen ? yan# mun#kin men#indikasikan adanya
#an##uan intraabdomen /erubahan isi abdomen misalnya % adanya asites tumor 0inak
atau #anas kehamilanlemak tubuh"
$elemahan dindin# abdomen ter0adi karena @mur yan# semakin bertambah :alnutrisi?baik makronutrien (protein kalori) atau mikronutrien
(misalnya% it" C) $erusakan atau paralisis dari saraf motorik Abnormal metabolisme kola#en"
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%ernia ba&aan atau congenital
%ernia dapatan atau akuisita
%ernia primer ' terjadi pada titik lemah yang terjadi
alamiah
%ernia (ekunder ' terjadi pada tempat pembedahan
atau trauma pada dinding
BERDASARKAN TERJADI
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BERDASARKAN LETAK
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BERDASARKAN SIFAT
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Her#ia rep!#ibel
bila isi hernia dapat keluar masuktetapi kantun#nya menetap"
sinya tidak serta merta munculsecara spontan namun ter0adi biladisokon# #aya #ravitasi atau tekananintraabdominal yan# menin#kat"
@sus keluar 0ika berdiri ataumen#edan dan masuk la#i 0ikaberbarin# atau didoron# masuk peruttidak ada keluhan nyeri atau #e0ala
obstruksi usus
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Her#ia irep!#ibelbila isi kanton# tidak dapat direposisikembali kedalam ron##a perut" nibiasanya disebabkan oleh perlekatan isikanton# pada peritoneum kanton#hernia" 5ernia ini disebut hernia
akreta" 9apat 0u#a ter0adi karena leheryan# sempit den#an tepi yan# kaku(misalnya pada % femoral umbilical)"
Tidak ada keluhan rasa nyeri ataupunsumbatan usus" 5ernia ireponibelmempunyai resiko yan# lebih besaruntuk ter0adi obstruksi dan stran#ulasidaripada hernia reponibel"
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Her#ia !bstru*si
5ernia obstruksi berisi usus dimana lumennya
tertutup" >iasanya obstruksi ter0adi pada leherkanton# hernia" Bika obstruksi ter0adi padakedua tepi usus cairan berakumulasi di
dalamnya dan ter0adi distensi (closed loop
obstruction)"
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Her#ia Stra#&ulata Suplai darah untuk isi hernia
terputus" $e0adian patolo#isselan0utnya adalah oklusi vena danlimfe2 akumulasi cairan 0arin#an(edema) menyebabkan
pemben#kakan lebih lan0ut 2 danseba#ai konsekuensinyapenin#katan tekanan vena"
Barin#annya men#alami iskemi dannekrosis"
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BENTK LAINN!A
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Her#ia I#amasi
si hernia men#alami in!amasi den#an proses
apapun seba#ai penyebab pada 0arin#an atauor#an yan# secara tidak normal men#alamihernia misalnya %
Apendisitis akut
9ivertikulum :eckel Salpin#itis akut
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Her#ia Richter
/ada hernia tipe ini hanya seba#ian dari ususyan# terperan#kap (biasanya usus halus)"
si dari kantun# hernia terdiri dari hanya satusisi dari dindin# usus (selalu antemesenterik)"
>ahayanya hernia ini adalah usus dapatmen#alami iskemi tanpa perkemban#an nyatadari #e0ala obstruksi"
Siste" Klasifikasi N#$us
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S s e s s N# us
)ipe I %ernia indirek* cincin inguinal interna normal* biasanya pada bayi* anak"
anak dan remaja+
)ipe II %ernia indirek* cincin inguinal membesar tapi tidak menyentuh lantai
canalis inguinalis* tidak meluas ke scrotum
)ipe III , %ernia direk* ukuran tidak diperhitungkan
)ipe III- %ernia indirek* meluas ke dinding inguinal posterior* hernia indirek yang
turun ke scrotum termasuk dalam kategori ini karena biasanya
berhubungan dengan perluasan ruang langsung* juga termasuk hernia
pantalon* dan hernia yang menyebabkan kelemahan dinding inguinalposterior+
)ipe III . %ernia femoralis
)ipe I %ernia rekuren #direk* indirek* femoralis dan kombinasi$
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AT&FISI&L&'I
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9ia#nosis
/hysical examination is the best way todetermine the presence or absence of an
in#uinal hernia" The dia#nosis may be obviousby simple inspection when a visible bul#e ispresent" onvisible hernias require di#italexamination of the in#uinal canal" This is bestdone in both the lyin# and standin# position"
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The examiner should place the tip of the index
.n#er at the most dependent part of thescrotum and direct it into the external in#uinalrin#" The patient is then asked to strain"
The ritual of havin# the patient cou#h is
discoura#ed as it results in the overdia#nosis ofa hernia because of the diDculty ofdiEerentiatin# a normal expansile bul#e ofmuscle from a true hernia especially inasthenic individuals
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Fin#er Test
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Gieman Test
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Thumb Test
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A@H+A3I 9A
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@ltrasono#raphy
Annals of 3oyal Colle#e of Sur#eons 8n#land--J2 KL2 '&K1'K-
'" 5ernia femoralis ('--M)" 5ernia directa (Sensitivitas KNM danspesi.tas ,&M)
J" 5ernia indirecta (Sens" ,&M dan spesf"K&M)
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@S< ima#in#
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+on#itudinal section 3ansversal section
@S< ma#in#
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9iEerential 9ia#nosis
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Treatment
Konservative
operative
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8duardo >assini5erniorhhapy
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Chester > :cay :9 /h9',O- (Coopers li#ament repair)
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S 88 Shouldice ',OL
multilayer repair
recurrence rate P 'M
complicated
extensive dissection
Tension Free 6:esh
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Tension Free 6:esh
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K&LIKASI
>leedin#
>iasanya ter0adi ekimosis pada kulit sekitar insisi
Cedera pada vesika urinaria
>isa ter0adi pada saat melakukan diseksi padakanton# hernia direk ataupun indirek yan# besar
$omplikasi pada testis seperti pemben#kakanorchitis dan atro. testis lebih disebabkan olehterikatnya vena spermatic cord
Cedera pada vas deferens
Cedera pada usus dan saraf nfeksi
Seroma
5ematoma
/ost operative neural#ia
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+ERI,A-ASIH