hernia dua.ppt

8/19/2019 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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Classification

• bsent diaphragm ! rare

• "iaphragmatic hernia

8#$ posterolateral % &R

'(ochdalek)

*$ anterior 'Morgagni)

+, - *#$ paraesophageal

• .ventration '+, - *#$)


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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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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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IMMEDIATE

5ntubation

6

1tomach "ecompression


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"eterminants of 1urvival

• degree of pulmonary hypoplasia

ipsilateral lung > contralateral lung

• development pulmonary

vasculature


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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



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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



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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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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




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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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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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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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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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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


5ntraoperative5ntraoperative


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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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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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hernia dua.ppt

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