hernia dua.ppt
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E R N I R N I
AS AS
Presented by
Gunawan Tohir SpB.M
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H E R N I AH E R N I A20102010
dr.Gunawan Tohir SpB.MMdr.Gunawan Tohir SpB.MM
F.K.Muhammadiyah Pa!m"an#F.K.Muhammadiyah Pa!m"an#
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P!ndahuuaP!ndahuua
nn S!rin# pada op!ra$i "!dah ana%S!rin# pada op!ra$i "!dah ana% Tampa% $!d!rhana &api pada "ayi'"ayi Tampa% $!d!rhana &api pada "ayi'"ayi
%!(i &!%ni% op!ra$i "i$a m!nyui&%an%!(i &!%ni% op!ra$i "i$a m!nyui&%an
P!ru dia#no$a ) p!nan#anan y# &!pa& )P!ru dia#no$a ) p!nan#anan y# &!pa& )
(!pa& ' in%ar$!ra&a(!pa& ' in%ar$!ra&a
A"ad 2* Ga!n ''+ a"ad 1,* Am"roi$!A"ad 2* Ga!n ''+ a"ad 1,* Am"roi$!
Par!- &!rapi "!dah ''+ &h 12* Mi&(h!Par!- &!rapi "!dah ''+ &h 12* Mi&(h!Ban%$- i#a$i %an&on# &anpa "u%a (an.in#Ban%$- i#a$i %an&on# &anpa "u%a (an.in#
''+ dipopu!r%an* &h 1//0*Ma( !nnan )''+ dipopu!r%an* &h 1//0*Ma( !nnan )
H!r!dH!r!d
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Batasan
Hernia inguinalis indirek adalah kegagalan obliterasidari processus vaginalis yang terletak antara kavum
abdomen dan kantong vaginal di skrotum.
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E&ioo#i ) In$id!n$iE&ioo#i ) In$id!n$i S!rin# pada op!ra$i "!dah ana%S!rin# pada op!ra$i "!dah ana%
In$id!n 1'345 pr!ma&ur 6 1000 #r 7045In$id!n 1'345 pr!ma&ur 6 1000 #r 7045
%!m"ar5 %!ainan "awaan5 riwaya&%!m"ar5 %!ainan "awaan5 riwaya&
%!uar#a%!uar#a 30',04 %anan5 704 %iri5 10'204 "ia&!ra530',04 %anan5 704 %iri5 10'204 "ia&!ra5
P*8* '10*1P*8* '10*1
Indir!% ' %an&on# %on#!ni&aIndir!% ' %an&on# %on#!ni&a
Mani!$&a$i $!&iap $aa&5 &!ru&ama 2 "uanMani!$&a$i $!&iap $aa&5 &!ru&ama 2 "uan
) 1 &ahun) 1 &ahun
I$i* u$u$ hau$5 &u"a aopiI$i* u$u$ hau$5 &u"a aopi
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HERNIA BIATERA*HERNIA BIATERA*
9 In$id!n$i ma$ih %on&ro:!r$ia5 p!ru %ar!na*In$id!n$i ma$ih %on&ro:!r$ia5 p!ru %ar!na*
1. E%$pora$i %on&raa&!ra n!#a&i adaah op!ra$i y#1. E%$pora$i %on&raa&!ra n!#a&i adaah op!ra$i y#&ida% p!ru.&ida% p!ru.
2. K!$aahan op!ra$i ' &rauma :a$%u!r ) :a$ d!!r!n2. K!$aahan op!ra$i ' &rauma :a$%u!r ) :a$ d!!r!n
9 Pa&!n$i pro(.:a#inai$ %on&raa&!ra 304'/04 'Pa&!n$i pro(.:a#inai$ %on&raa&!ra 304'/04 '
pn!umop!ri&ono#raphy 224'2/4 ' oow uppn!umop!ri&ono#raphy 224'2/4 ' oow up204.204.
9 In$id!n$i dip!n#aruhi* u$ia62 " ,74 ' 2'1, &hIn$id!n$i dip!n#aruhi* u$ia62 " ,74 ' 2'1, &h
;145 $!"ro$i$5 !&a% E%$pora$i "ia&!ra ru&in pada* $!mua a%i'a%i 6 2 &hn$!mua a%i'a%i 6 2 &hn
$!mua wani&a$!mua wani&a
inan ) ana%2 d# pr!di$po$i$i p!nya%i& &!r&!n&uinan ) ana%2 d# pr!di$po$i$i p!nya%i& &!r&!n&u
$!mua pa$i!n yan# di(uri#ai$!mua pa$i!n yan# di(uri#ai
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Embriologi
* Fase desensi interna
---> Proc.Vaginalis berupa penonolan!divertikel dr
peritoneum ke dalam dinding abdomen anterior
dekat cincin interna.
* Fase desensi eksterna
* "ontraksi proc.vaginalis menadi #$ibrous cord%
* Putus hubungan dengan kavum peritoneum sblm&
saat kelahiran s!d usia ' th (otopsi )-+,
* "egagalan ---> hernia& hidrokel
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Ana&omiAna&omi ?in(in in&!rna ' di a$(ia &ran:!r$ai$?in(in in&!rna ' di a$(ia &ran:!r$ai$
(in(in !%$&!rna ' (!ah daam apon!uro$i$(in(in !%$&!rna ' (!ah daam apon!uro$i$
o"i@uu$ !%$&!rnu$o"i@uu$ !%$&!rnu$
'''+ !wa& un.$p!rma&i%u$ ) i#.ro&undum'''+ !wa& un.$p!rma&i%u$ ) i#.ro&undum !wa$a* dindin# in#uina po$& ' "#n a$(ia!wa$a* dindin# in#uina po$& ' "#n a$(ia
!ndoa"dominaa$(ia &ran:!r$ai$ ''+!ndoa"dominaa$(ia &ran:!r$ai$ ''+
h!rniora>h!rniora>
S&ru%&ur C(ordD* :a$ d!!r!n5 ar&!riS&ru%&ur C(ordD* :a$ d!!r!n5 ar&!ria.$p!rma&i%a in&) !%$&5 a.d!!r!n$ia5a.$p!rma&i%a in&) !%$&5 a.d!!r!n$ia5
p!%$u$ pampiniormi$p!%$u$ pampiniormi$
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Biologi / Fisiologi (anak / de0asa* 1sal2 kongenital --> proc.vaginalis --> obliterasi3
$ibrous cord
* 4e0asa2 kombinasi ' $aktor& yaitu3
5. 6uang potensial dalam proc.vaginalis'. "elemahan krura $ascia tranversalis
* 7eori 8kantong 6ussell9 meluas : kelemahan $ascia
* ;ntegritas kanalis inguinalis dipertahankan oleh3
5.
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Fisik .1namnesa dari orang tua penting3 adanya benolan yang
hilang timbul - sering dokter bedah tidak bisamembuktikan. Pemeriksaan $isik berupa asimetri daerah
inguinal - sampai adanya benolan(spontan& nangis -
palpasi3 silk golve sign.
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P!na&aa%$anaP!na&aa%$ana
anan Hampir $!mua %a$u$ dapa& dir!du%$iHampir $!mua %a$u$ dapa& dir!du%$i p!ra$i $!#!ra $!&!ah r!du%$i $ui&p!ra$i $!#!ra $!&!ah r!du%$i $ui&
1'2 am &ida% "!rha$i ''+ op!ra$i1'2 am &ida% "!rha$i ''+ op!ra$i
Prin$ip*Prin$ip*
9 in$i$i &ran:!r$ain$i$i &ran:!r$a
9 i#a$i &in##i %an&on# h!rniai#a$i &in##i %an&on# h!rnia
9 p!nu&upan %ui& d!n#an ahi&anp!nu&upan %ui& d!n#an ahi&an$u"%u&i%u!r$u"%u&i%u!r
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ia#no$aia#no$a
Bandin#Bandin# S!rin# pada op!ra$i "!dah ana%S!rin# pada op!ra$i "!dah ana% In$id!n 1'345 pr!ma&ur 6 1000 #r 7045In$id!n 1'345 pr!ma&ur 6 1000 #r 7045
%!m"ar5 %!ainan "awaan5 riwaya&%!m"ar5 %!ainan "awaan5 riwaya&
%!uar#a%!uar#a 30',04 %anan5 704 %iri5 10'204 "ia&!ra530',04 %anan5 704 %iri5 10'204 "ia&!ra5
P*8* '10*1P*8* '10*1
Indir!% ' %an&on# %on#!ni&aIndir!% ' %an&on# %on#!ni&a
Mani!$&a$i $!&iap $aa&5 &!ru&ama 2 "uanMani!$&a$i $!&iap $aa&5 &!ru&ama 2 "uan
) 1 &ahun) 1 &ahun
I$i* u$u$ hau$5 &u"a aopiI$i* u$u$ hau$5 &u"a aopi
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"omplikasiC ;nkarserata3D 5 tahun - menurun s!d usia tahun
C
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?on#!ni&a iaphra#ma&i(?on#!ni&a iaphra#ma&i(
H!rniaH!rnia
a problem unresolveda problem unresolved
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
Herniation of abdominal viscera into the thorax
Result from failure of the pleuroperitoneal canal
to close at ~ 8th wk of gestation or early
return of midgut to the peritoneal cavity
Most challenging and frustrating of all neonatal
surgical emergencies
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
Classification
• bsent diaphragm ! rare
• "iaphragmatic hernia
8#$ posterolateral % &R
'(ochdalek)
*$ anterior 'Morgagni)
+, - *#$ paraesophageal
• .ventration '+, - *#$)
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
ssociated anomalies '*#-,#$)
cardiovascular +/ - */$
C01 *8$
gastrointestinal *#$
genitourinary +,$
• increase the mortality rate
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Congenital "iaphragmatic Hernia
Classic 2riad
"yspnea
Cyanosis
pparent dextrocardia
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
3hysical .xam
scaphoid abdomen and barrel chest
bowel sounds in the chest
displaced heart sounds
%aboratory 1tudies
C(C (4electrolytes calcium
glucose
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Congenital "iaphragmatic HerniaCongenital "iaphragmatic Hernia
"iagnosis! chest x-ray
• loops of bowel in the
chest
• mediastinal shift
• absent lung markings
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Congenital "iaphragmatic HerniaCongenital "iaphragmatic Hernia
IMMEDIATE
5ntubation
6
1tomach "ecompression
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
"eterminants of 1urvival
• degree of pulmonary hypoplasia
ipsilateral lung > contralateral lung
• development pulmonary
vasculature
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
4oals of Management
• maximi7e arterial oxygenation
mechanical ventilation! use low inflating
pressures
increases pulmonary blood flow
• prevention of pain
fentanyl infusion /-+# mcgkghr
• correction of acidosis
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1tandard Management 1trategy
Reduce pulmonary H20
Moderate alkalosis
pC9* : ;# mmHg
3a9* &+## mmHg
Congenital "iaphragmatic HerniaCongenital "iaphragmatic Hernia
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Recent 1trategy
• 3ermissive hypercapnia and hypoxemia
• 3ressure-limited ventilation ':*, cmH*
9)
• 3ostductal pC9* ;#-?*# or pC9* &
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2he Relationship (etween 3aC9* and entilation
3arameters in 3redicting 1urvival in CH"
• rterial C9* accurately reflects the degree of
lung development
• 3oor survival in the presence of severe
pulmonary hypoplasia
• C9* retention and severe preductal shunting
have =#$ mortality
Bohn, DJ, et al Bohn, DJ, et al
J of Pedia Surg 19: 666-671, 188J of Pedia Surg 19: 666-671, 188
Congenital "iaphragmatic HerniaCongenital "iaphragmatic Hernia
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
nomo#ram*nomo#ram*
&o pr!di(& &h! d!#r!! o pumonary hypopa$ia in&o pr!di(& &h! d!#r!! o pumonary hypopa$ia in
&h! inan&$ and (han(! o $ur:i:a&h! inan&$ and (han(! o $ur:i:a
u$!d &h! pr!op Pa?u$!d &h! pr!op Pa?22 and an ind!< o :!n&ia&ion =iand an ind!< o :!n&ia&ion =i
I Pa?I Pa?22 66 ;0 and =i;0 and =i 66 1000* $ur:i:a amo$& uni:!r$a1000* $ur:i:a amo$& uni:!r$a
I Pa?I Pa?22 ++ ;0 and =i;0 and =i ++ 1000* d!a&h :ir&uay in!:i&a"!1000* d!a&h :ir&uay in!:i&a"!
DD Vi = mean airway pressure x respiratory rateVi = mean airway pressure x respiratory rate
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Congenital "iaphragmatic Hernia
Relationship of lveolar-arterial 9xygen
2ension "ifference in "iaphragmaticHernia in the 0ewborn
-a"9* on +##$ 9*
: ;## mmHg! usually survive
;## - ,## mmHg! intermediate chance
& ,## mmHg! unlikely to survive
!arrington J, et al
"nesthesiolog# $6: 7%-76, 198&
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High Mortality
pH : >?#
pC9* &
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5ndications of 1urgical Repair
• Reversal of ductal shunting
• 9* index of : ;#
• rterial pC9* maintainable under
;# mmHg
• Hemodynamic stability
Congenital "iaphragmatic Hernia
?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
Pr!op!ra&i:! Pr!para&ionPr!op!ra&i:! Pr!para&ion
• %ook for associated anomalies
• %abs! C(CE electrolytesE (4E glucoseE
blood type and crossmatch• ncillary procedures! CFRE .cho
• enous access! upper extremities
preferred
• 3revention of hypothermia
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
In&raop!ra&i:! Mana#!m!n&In&raop!ra&i:! Mana#!m!n&
Monitors!
1 standard
invasive ! arterial line G C3
foley catheter * pulse oximeters! preductal and postductal
precordial stethoscope on the right axilla
042 to decompress the stomach
deIuate 5 access
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
In&raop!ra&i:! Mana#!m!n&In&raop!ra&i:! Mana#!m!n&
5nduction
awake intubation
rapid seIuence 5 induction and
intubation with assisted or controlled
ventilation
a)oid *as+ )entilation or PP efore intuation
1upine positionE left subcostal incision
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
In&raop!ra&i:!In&raop!ra&i:!
Maintenance of anesthesia volatile agents 6 5 narcotics 6 muscle relaxants
25
avoid nitrous oxide
avoid increase in 3R leading to RJ% shunting!
hypoxiaE acidosisE hypothermiaE pain
treat metabolic acidosis
replace significant blood loss
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Congenital "iaphragmatic HerniaCongenital "iaphragmatic Hernia
5ntraoperative5ntraoperative
Mechanical entilation
adKust Li9* to achieve
3a9* 8# -+## mmHg 1p9* =, - =8$
small tidal volume to keep airway pressure
: *#-/# cm H*9
high respiratory rate
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1urgical repair
primary closure
staged procedure
2ransabdominal subcostal incision
2horacoscopic repair has been reported
Congenital "iaphragmatic HerniaCongenital "iaphragmatic Hernia
5ntraoperative5ntraoperative
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?on#!ni&a iaphra#ma&i( H!rnia?on#!ni&a iaphra#ma&i( H!rnia
In&raop!ra&i:!In&raop!ra&i:!
3otential 3roblems
• Hypoxemia
distension of stomach+ pulmonary hypoplasia pulmonary H20
• Contralateral pneumothorax
• Hypotension or 5C compression
• Cardiac arrest
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Congenital "iaphragmatic HerniaCongenital "iaphragmatic Hernia
Management of 33H0
• Minimi7e .22 suctioning
• asodilators ! rarely effective
tola7oline isoproterenol 34.+
nitroglycerin 103
• 5nhaled nitric oxide
endothelium - derived relaxing factor '."RL)
selective pulmonary vasodilation
rapidly metaboli7ed
has not been shown to improve survival
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HERNIA FEMRAISHERNIA FEMRAIS
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In(i$iona H!rnia Tr!a&m!n&In(i$iona H!rnia Tr!a&m!n&
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In(i$iona H!rnia'Tr!a&m!n&In(i$iona H!rnia'Tr!a&m!n&
Tr!a&m!n& i$ $ur#i(a un!$$ Tr!a&m!n& i$ $ur#i(a un!$$
(omor"idi&i!$ pr!(ud! &hi$.(omor"idi&i!$ pr!(ud! &hi$.
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HERNIA MBIIKAIS
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HERNIA MBIIKAISHERNIA MBIIKAIS
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