HERNIASURGERY

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HERNIA

• PROTRUSION OF A VISCUS OR A PART OF VISCUS THROUGH A NORMAL OR ABNORMAL OPENING IN THE WALLS OF ITS CONTAINING CAVITY

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HERNIA COMMONINGUINAL

INCISIONAL

FEMORAL

UMBILICAL

EPIGASTRIC

RAREOBTURATOR

SPIGELIAN

GLUTEAL

LUMBAR

DIAPHRAGMATIC

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HISTORY

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HISTORY

• AGE :

YOUNG

• INDIRECT

OLD AGE (weak musculature)

•DIRECT

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HISTORY

• OCCUPATION =STRENOUS

STRENOUS WORK

PERSISTENT PROCESSUS VAGINALIS

WEAK ABDOMINAL

WALL

HERNIATION

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• SEX

• MOST COMMON HERNIA (BOTH IN MALES & FEMALES) INDIRECT

• FEMORAL HERNIA IS COMMON IN FEMALES

• DIRECT HERNIA IS ABSENT IN FEMALES & CHILDREN

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IN FEMALES

PELVIS IS TILTED ANTERIORLY APEX & BASE OF HSSELBACH TRIANGLE AT THE SAME LEVEL

OBLITERATEDLESS CHANCE

PRESENTING COMPLAINTS

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• ABOUT LUMP

• COMPLICATIONS

• ETIOLOGY (PRECIPITATING FACTORS)

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LUMP

• 1. Duration

• 2. Onset: Suddenly/gradually

• 3. Site of start: • From groin to scrotum (hernia) • From scrotum to groin (hydrocele and varicocele)

• 4. Aggravating factors:• – On straining• – On standing• – On coughing

• 5. Relieving factors:• – By lying down• – Manuallybyhimself

• 6. Associated with pain: Usually painless

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PRESENTING COMPLAINTS

LUMP

• Onset : coughing

lifting weight

• Site: groin scrotum} inguinal hernia

below groin crease & ascends above it} femoral hernia

• Size and extent:

congenital: reaches bottom of scrotum at its first

appearance itselfTHOUGH

CONGENITAL

CAN APPEAR AT

ANY AGE due to

preformed sac

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PAIN

• PAIN= DRAGGING & ACHING TYPE

Appears b4 the swelling

Increase with time

Subsides when it is

fully formed

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PAIN

Acute pain around

umbilicustenderness strangulation

Due to drag

on mesentry

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PAIN

• In strangulation due to drag on mesentrypain all over the abdomen

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HISTORY SUGGESTIVE OF COMPLICATIONS:

• Irreducibility,

• severe pain in the groin over the swelling and also

• colicky abdominal pain, abdominal distension, vomiting,

• constipation

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acquired } small initially ↑ size gradually

• REDUCIBILITY

Reduces on lying down DIRECT

Does not reduce on lying down

INDIRECT

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• SYMPTOMS OF OBSTRUCTION

COLICKY ABDOMINAL PAIN

VOMITING

•BILIOUS

•FAECAL (USUALLY)

ABDOMINAL DISTENSION

ABSOLUTE CONSTIPATION

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PRECIPITATING FACTORS

• C/C COUGH=TB ,BA,C/C BRONCHITIS

• STRAINING IN

• CONSTIPATION

• FREQUENCY OF MICTURITION

• URGENCY OF BENIGN ENLARGEMENT OF PROSTATE

• PHIMOSIS

• PINHOLE MEATUS

• PENILE STRICTURES

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OBSTRUCTION

PAST HISTORY

• TB BA

• PREVIOUS SURGERY

• Damage to ilioinguinal nerve weak abdominal wallDIRECT hernia

APPENDICECTOMY

• Same side

• Opposite sideRECURRENT HERNIA

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FAMILY HISTORY

• CONNECTIVE TISSUE DISORDERS

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PERSONAL HISTORY

• History of Smoking:

• Smoking leads to chronic bronchitis

• Collagen deficiency occurs in smokers.

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LOCAL EXAMINATION

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INSPECTION

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INSPECTION

• Patient in standing position

• 1. Site

• 2. Size

• 3. Shape

• 4. Extent

• 5. Surface

• 6. Skin over the swelling

• 7. Visible peristalsis

• 8. Cough impulse

• 9. Draining lymph nodes

• 10. Penis

• 11. Urethral meatus

• 12. Opposite scrotum

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INSPECTION

• EXPOSE 4M UMBILICUSMID THIGH

POSITION OF PATIENT

STANDING

Inguinal, lumbar, femoral,

epigastric, obturator, gluteal,

spigelian

SUPINE

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SWELLING

shape spherical femoral

direct

pyriform indirect

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POSITION & EXTENT

• Inguinal hernia above the inner part of inguinal ligament

Inguinal hernia

Congenital

(complete)

Extend in to scrotum

acquired

(funicular)

Stops above testis

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POSITION & EXTENT

• Femoral hernia starts below the inginal ligament and ascend over it

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VISIBLE PERISTALSIS

• Invisible = femoral hernia

• Visible in case of inguinal hernia when skin is thin as in case of recurrent hernia

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SKIN OVER THE SWELLING

• Uncomplicated=normal

• Strangulated=reddened

• Truss 4 long time=discolouration, due to deposition of hemosiderin

streaks,

• Scar=recurrence

• Wide irregular puckered=wound infectionrecurrence

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IMPULSE ON COUGHING

• Characteristic of hernia

Impulse on coughing

present

Expansile impulse on coughing

(increase in size with coughing)

Momentary bulge synchronous with

coughing

absent obstructed

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POSITION OF PENIS

• Deviation of penis to opposite side= in large complete inguinal hernia

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PALPATION

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PALPATION

• 1. Temperature

• 2. Tenderness

• 3. Site

• 4. Size

• 5. Shape

• 6. Extent

• 7. Surface

• 8. Skin over the swelling

• 9. Consistency

• 10. Reducibility

• 11. Get above the swelling

• 12. Cough impulse

• 13. Invagination test

• 14. Ring occlusion test

• 15. Zieman's technique.

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POSITION & EXTENT

• SWELLING REACHING SCROTUM/LABIA MAJORA}INGUINAL HERNIA

Swelling in the groin

Above inguinal ligament

Medial to pubic tubercle

INGUINAL

Below inguinal ligament

Lateral to pubic tubercle

FEMORAL

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HOW TO IDENTIFY PUBIC TUBERCLE

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GET ABOVE THE SWELLING

• DISTINGUISH B/W INGUINAL & INGUINOSCROTAL SWELLING

• NO USE IN FEMORAL HERNIA

ROOT OF SCROTUM IS HELD B/W THUMB IN FRONT &

OTHER FINGERS BEHIND THE SWELLING IN AN ATTEMPT

TO GET ABOVE THE SWELLING

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GET ABOVE THE SWELLING

INGUINAL HERNIA

• NOT ABLE TO GET ABOVE THE SWELLING

SCROTAL SWELLING

• ABLE TO GET SBOVE THE SWELLING

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CONSISTENCY

• DOUGHY & GRANULAR} OMENTUM=OMENTOCELE

• ELASTIC} INTESTINE=ENTEROCELE

• TENSE & TENDER} STRANGULATED HERNIA

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RELATION OF THE SWELLING TO THE TESTIS & SPERMATIC CORD

INGUINAL HERNIA

•Remains in front & sides of spermatc cord and testes which remains incorporated in front and sides

FUNICULAR

•Stops just above the testis

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CLASSICAL SIGNS OF AN UNCOMPLICATED HERNIA

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EXPANSILE IMPULSE ON COUGHING

• STANDING POSITION

• ABSENT IN CASE OF STRANGULATED & INCARCERATED HERNIA

1. MOMENTARY BULGE IN SUPERFICIAL RING ON COUGHUING

2. ROOT OF SCROTUM B/W INDEX FINGER & THUMB IS SEPARATED ON COUGHING

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EXPANSILE IMPULSE IS ALSO PRESENT IN

• Meningocele

• Laryngocele

• Empyema necessitans

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ZEIMANN’S TECHNIQUE

• Distinguish b/w direct, indirect or femoral hernia

• Can be used only when the swelling is completely reduce

when there is no visible swelling

Index finger deep inguinal ring (1/2 “ above mid inguinal point)

Middle fingersuperficial inguinal ring (superomedial to pubic tubercle)

Ring finger saphenous opening (4cm blw & lateral 2 pubic tubercle)

Hold the nose & blow or cough

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ZEIMANN’S TECHNIQUE

Imp

uls

e o

n

Index finger

Middle finger

Ring finger

Direct inguinal hernia

Indirect inguinal hernia

Femoral hernia

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ZEIMANN’S TECHNIQUE

• In presence of swelling coughing expansile impulse on coughing

Movement of swelling is not a criterion

bcz as these swellings move with

coughing

Encysted hydrocele of

cord : localized swelling

of spermatic cord

Undescended testis

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HOW TO IDENTIFY DEEP RING

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HOW TO IDENTIFY DEEP RING

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REDUCIBILITY

• Reduces on lying down direct hernia

• Using TAXIS

• Flexes the thigh

• Adduct the thigh

• Rotate internally

• Reduces with gurgling=>ENTEROCELE Difficult to reduce initially but last

part slips of easily

• First part reduces easily last part difficultomentocele

Relaxes

superficial

inguinal ring +

oblique muscles

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REDUCIBILITY

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INVAGINATION TEST

• After reduction of hernia in recumbent position

• Using little finger rt. Hand side for rt. Side

lt. hand side for lt. side

• Invaginate skin 4m the bottom of scrotum & the little finger is pushed to palpate pubic tubercle

• Finger is then rotated & pushed further up in to superficial inguinal ring

• Nail will be against spermatic cord pulp will feel walls of ring

• Normal ring transmits only tip of finger ,>1 finger}abnormally large

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INVAGINATION TEST

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INVAGINATION TEST

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INVAGINATION TEST

Finger goes

directly

backward=direct

hernia

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INVAGINATION TEST

Finger goes upwards,

backwards,

outwards= indirect

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INVAGINATION TEST

Impulse on coughing

Pulp of finger

direct

tip indirect

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RING OCCLUSION TEST

• Standing position after reduction of swelling

• Using thumb pressure over the deep inguinal ring (1/2 “ above mid inguinal point) & is asked to cough

• Occlude direct hernia but not direct hernia

• Similarly on saphenous opening= femoral hernia

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RING OCCLUSION TEST

• Swelling appears even when deep ring is occluded=direct hernia

• No swelling when deep ring is occluded = indirect hernia

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IN CASE OF A CHILD

• Inguinal hernia is invisible in child due to presence of thick pad of fat over inguinal region

• To make it visible ask him to jolt/jump/make it cry

• Gornalls test: child is held from back by both hands of the clinician on its abdomen,abdomen is pressed and child is lifted up

increased intra abdominal pressure

hernia more prominent

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PERCUSSION

• Resonant=enterocele

• Dull =omentum/extraperitoneal fatty tissue

Diff b/w a/c epididymitis

a/c filalrial funiclitis &

strangulated hernia

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AUSCULTATION

• Peristaltic sounds=enterocele

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EXAMINATION OF TESTIS ,SPERMATIC CORDS & EPIDIDYMIS

• Testis traction test: pull testis downwards

encysted hydrocele}descends slightly & become fixed

inguinal hernia}cant be fixed

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EXAMINATION OF TONE OF ABDOMINAL MUSCLES

• Inspectionprotrusion of lower abdominal wall

• Malgaigne’s bulging:

• oval shaped b/l bulge on straining above & parallel to medial half of inguinal ligament

• weakness of abdominal wall

• DIRECT HERNIA

• HERNIOPLASTY IS REQUIRED

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ABDOMINAL MUSCLE STRENGTH

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MALGAGNES BULGING

• Head or leg raising test: to test for abdominal muscle tone & malgaignesbulging

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SYSTEMIC EXAMINATION

• RESPIRATORY SYSTEM

• R/O

• C/C BRONCHITIS ,TB

• ABDOMEN

• MASS

• ASCITES

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• Abdominal examination

• Respiratory system

• Urinary systems

• Per rectal examination

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PER-RECTAL EXAMINATION

• 1. Benign Prostate hypertrophy—micturition difficulty

• 2.Malignant obstruction

• 3. Chronic fissure—constipation

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• Diagnosis

• • Side—right/left

• • Type—indirect/direct

• • Inguinal—femoral

• • Complete/Incomplete

• • Complicated/Uncomplicated

• • Content—enterocele/omentocele

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DIFFERENTIAL DIAGNOSIS

Inguinal Swelling

• 1. Enlarged lymph nodes

• 2. Undescended testis

• 3. Lipoma

• 4. Femoral hernia

• 5. Saphena varix

• 6. Psoas abscess

• 7. Femoral aneurysm

Inguinoscrotal Swelling

• 1. Encysted hydrocele of cord

• 2. Varicocele

• 3. Lymphvarix

• 4. Diffuse lipoma of cord

• 5. Inflammatory thickening of cord

Femoral Hernia

• 1. Inguinal hernia

• 2. Saphenavarix

• 3. Cloquet’s node

• 4. Lipoma

• 5. Femoral aneurysm

• 6. Psoas abscess

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DIFFERENTIAL DIAGNOSISIn males

• Hydrocele –infantile/encysted/large vaginal/

• Undescended testis

• Femoral hernia

• Lipoma of the cord

• Hydrocele of the canal of nuck (in females)

• Inguinal lymph node enlargement

• Groin abscess

In females

• hydrocele of the canal of Nuck –this is the most common dif-ferential diagnostic problem

• femoral hernia.

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MANAGEMENT

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• Investigations

• Treatment

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INVESTIGATIONS

• I. Routine• • Hemoglobin• • Bleeding time/Clotting time• • Total count, differential count, ESR• • Urine—albumin, sugar deposits• • Blood—urea, sugar• • Blood grouping/typing—for irreducible hernia/huge hernia

• II. Anesthetic Purpose• • X-ray chest (Chronic TB, Asthma—precipitate hernia)• • ECG all leads

• III. USG Abdomen and Pelvis• • In old age group—to find benign prostate hyperplasia calculate post-voidal

residual urine. If >100 ml it is significant• • To find any mass

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TREATMENT

• TREATMENT

• Treat the precipitating cause of hernia first.

• 1. Benign prostate hypertrophy

• 2. Tuberculosis

• 3. Stop smoking

• Conservative management

• indicated only in cases of very old man with direct hernia; since there is no chance of obstruction.

• TRUSS

• surgery

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TRUSS

• Not Curative for hernia.

• It is a special belt devised to keep the hernia reduced at the deep ring or Hesselbach triangle for those who are unfit or unwilling for surgery

• Hernia should be reducible to wear a truss.

• Contraindicated • cases of irreducible hernia,

• undescended testis,

• associated huge hydrocele,

• unintelligent people.

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TAXIS

• Supine hip & knee flexed hip internally rotated

• Contents are pushed with one hand directed with the other

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TREATMENT

• Surgery= treatment of choice

• Under LA/GA/spinal/epidural

surgery

Hernioplasty

herniorraphy

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Herniorraphy(strenghthening of posterior wall)

• 1. Original Bassini

• 2. Modified Bassini

• 3. McVay’s

• 4. Shouldice

Hernioplasty (prosthetic repair )

• 1. Lichtenstein

• 2. Gilbert’s plug

• 3. Prolene hernia system

• 4. Laparoscopic mesh repair

• 5. Stoppas repair

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HERNIORRHAPHY

• 1. Herniotomy

• 2. Narrowing of the deepring with 2'0 prolene (Lytle'sRepair)

• 3. Approximation of conjoint tendon with inguinal ligament using 1‘ polypropylene material

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HERNIOTOMY

• Dissecting out and opening of hernia sac ,reducing any contents ,transfixing neck of sac & removing the remainder

• NO NEED TO OPEN UP CANAL IN CHILDREN BECAUSE SUPERFICIAL AND DEEP RING ARE SUPERIMPOSED ……THERE FORE NO NEED OF REPAIR

• HENCE DONE ALONE IN CHILDREN,ADOLESCENT

In indirect inguinal hernia

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PROCEDURE

• ANAESTHESIA: spinal or G/A

• Incision is made parallel to medial 2/3rd of inguinal ligament about 1.25 cm above inguinal ligament

• After dividing superficial fascia and securing hemostasis

• Identify external oblique muscle & superficial inguinal ring

• External oblique Apo neurosis is incised in the line of its fibers and is reflected above and below.thus visualize inguinal ligament

• Ilioinguinal nerve is thus identified and preserved

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PROCEDURE

• Cremasteric muscle is opened

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• Herniotomy = ligation & excision of sac only

• Herniorraphy = herniotomy + repair of posterior wall

• Hernioplasty= herniotomy + reconstruction of posterior wall with prosthetics

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HERNIORRAPHY

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HERNIORRHAPHY

• HERNIOTOMY+ REPAIR OF THE POSTERIOR WALL OF INGUINAL CANAL BY APPOSING CONJOINED MUSCLE TO THE INGUINAL LIGAMENT

• INDN

• IN ALL INDIRECT HERNIA EXCEPT IN CHILDREN

• IN ADULTS WITH GOOD MUSCLE TONE

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BASSINI REPAIR• Is frequently used for indirect

inguinal hernias and small direct hernias

• The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

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BASSINI REPAIR

• The conjoined tendon is retracted upward

• the aponeurosis of the transversus abdominis muscle is approximated to the iliopubic tract that lies adjacent to the inguinal ligament with several interrupted 3-0 silk sutures.

• The second layer of the repair involves suturing the conjoined tendon to the inguinal ligament with interrupted 2-0 silk sutures.

• This suture line extends from the pubic tubercle to the medial border of the internal ring.

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MODIFIED BASSINIS REPAIR

• Most commonly used EARLIER

• Using non absorbable monofilament interrupted suture material strengthening of posterior wall of inguinal canal approximation of conjoint tendon to inguinal ligament

• Nonsorbable adequate tensile strength for about 6 months

• Monofilamentpolyfilament has crevices=infn

• Interrupted continuous suture= decrease blood supply interfere with healing

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MODIFIED BASSINIS REPAIR

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MCVAY REPAIR• inguinal and femoral canal defects

• The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally

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MC VAYS REPAIR

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SHOULDICE REPAIR

• With a no. 15 scalpel an incision is made in the transversalis fascia. This incision is extended from the internal ring to the pubic tubercle.

• The repair involves placing four lines of sutures.

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SHOULDICE REPAIR

• First, the transversalis fascia is divided from the internal inguinal ring to the pubic tubercle. The posterior wall repair is accomplished by imbricating the lateral and medial leaves of the divided transverse aponeurotic fascial fibers with a continuous suture. The superomedial flap is brought over the inferolateral flap. The first suture line begins at the pubic tubercle and is sewn in a continuous fashion up to the internal ring, suturing the free edge of the inferolateral flap to the underside of the superomedial flap. At the internal inguinal ring, the cranial portion of the cremastermay be included in the suture line. This gives additional strength to the internal inguinal ring. The suture line is then doubled back bringing the leading edge of the superomedial flap to the edge of the inguinal ligament. The lacunar ligament is included in this suture line to obliterate the dead space medial to the femoral vessels. A second suture, beginning at the internal ring, brings the internal oblique and transversus muscles down to the deep surface of the inguinal ligament. At the level of the pubic bone, this suture doubles back, attaching the same structures in a more superficial plane and the suture is tied to itself at the internal ring.

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SHOULDICE REPAIR

• The first suture line

• is started at the pubic tubercle using 3-0 continuous polypropylene, and the white line is approximated to the free edge of the inferior transversalis fascialflap.

• The 2nd suture line :

• At the internal ring the suture is tied and then continued medially by approximating the free edge of the superior flap to the shelving edge of the inguinal ligament. When the pubic tubercle is reached, the suture is tied and divided.

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SHOULDICE REPAIR

• The third suture line is started at the level of the internal ring where the conjoined tendon is approximated to the inguinal ligament and tied when the pubic tubercle is reached.

• Using the same suture, the fourth suture line attaches these same structures to one another and is tied at the level of the internal ring.

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SHOULDICE REPAIR

• The cord is replaced within the inguinal canal, and the external inguinal aponeurosis is reapproximated with continuous 2-0 absorbable sutures

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Tanner's muscle slide

DARNING

• • A type of herniorrhaphy which is done by suturing the conjoined tendon with inguinal ligament using 1 prolene without tension.

• • The suture material appears like mesh due to multiple crossings.

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TANNER'S MUSCLE SLIDE

• Basically all the herniorrhaphy are tension repairs

• To avoid tension in the rhaphy site, the incision made curvilinearly over the anterior rectus sheath

• This relaxes the conjoined muscles and thus gets approximated with inguinal ligament without tension

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HERNIOPLASTY

• SOME FORM OF supportive MATERIAL IS USED TO STRENGTHEN POSTERIOR ABDOMINAL WALL

HERNIOPLASTY

SYNTHETIC

BIOLOGICAL

Synthetic non

absorbable prolene,

Dacron are used

Tensor fascia

lata,temporal

fascia,skin

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INDICATION FOR HERNIOPLASTY

• Direct hernia,

• Indirect hernia with poor muscle tone

• Recurrent hernia

• Re-recurrent hernia

• Incisional hernia

• Old age

• Sliding hernia

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COMPLICATION

• Mesh extrusion

• Foreign body reaction

• infection

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PRINCIPLE

• Size of mesh >size of defect

• Attached above & below to conjoint tendon & inguinal ligament/abdominal wall using non absorbable sutures

• Haemostasis, reduce risk of infection

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TYPES OF MESH REPAIR

• 1. In lay mesh

• 2. On lay mesh

• 3. Nyhus preperitoneal mesh repair

• 4. Stoppa procedure

• 5. Gilbert mesh repair

• 6. Lichtenstein’s method

• 7. TAPP

• 8. TEP

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ONLAY MESH METHOD:

• repair by placing mesh in front…..using monofilament non absorbable suture material….above to conjoint tendon & below to inguinal ligament

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INLAY MESH METHOD

• mesh deep to conjoint tendon

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NYHUS PREPERITONEAL MESH REPAIR

• Broad mesh is kept in the preperitoneal space in b/l direct or recurrent hernia

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LICHTENSTEIN TENSION FREE MESH REPAIR

• Less recurrence

• Cord is covered with mesh and is sutured as in onlay method

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LICHENSTEIN TENSION FREE REPAIR

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TENSION – FREE REPAIR

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TENSION – FREE REPAIR

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LICHTENSTEIN TENSION-FREE REPAIR

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PROLENE HERNIA SYSTEM

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PROLENE HERNIAL SYSTEM

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STOPPAS REPAIR

• GPRVS (Giant Prosthesis for Reinforcement of Visceral Sac)

• OVER FRICHAUDS MYOPECTINEAL ORIFICE

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• The Stoppa Repair is a tension free type of hernia repair. It is performed by wrapping the lower part of the parietal peritoneum with prosthetic mesh and placing it at a preperitoneal level over Fruchauds myopectineal orifice. It was first described in 1975 by Rene Stoppa.[1] This operation is also known as giant prosthetic reinforcement of the visceral sac (GPRVS).[2]

• This technique has met particular success in the repair of bilateral hernias, large scrotal hernias, and recurrent or rerecurrent hernias in which conventional repair is difficult and carries a high morbidity and failure rate.

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LAPAROSCOPIC HERNIA REPAIR

• Transabdominal Preperitoneal Procedure (TAPP)

• Totally Extraperitoneal (TEP) Repair

• Indications include bilateral inguinal hernia, recurring hernia, need for early recovery

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TEP

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TEP

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TAPP

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COMPLICATIONS OF HERNIA REPAIR

IMMEDIATE

1. Injury to the blood vessels

(inferior epigastric and

femoral)

2. Injury to bowel and bladder

3. Injury to ilioinguinal and

iliohypogastric nerves

4. Injury to cord structures

EARLY

1. Urine retention

2. Hematoma

3. Infection

4. Periostitis of pubic tubercle (as

the stitch is taken from periosteum)

5. Postherniorrhaphy hydrocele

(due to obstruction of lymphatics

At deep ring when narrowed tightly)

LATE

1. Recurrence

2. Numbness over the

local region if the

nerve was cut during

surgery

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DISCUSSION

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INGUINAL HERNIA

• ANATOMY

Superficial inguinal ring: triangular opening in aponeurosis of external oblique muscle

1.25 above pubic tubercle

normally ring does not admit tip of little finger

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• Deep inguinal ring: u shaped defect in transversalis fascia 1.25cm above mid inguinal point

• Inguinal ligament: It is formed by the lower

border of the external oblique aponeurosis

which is

thickened and folded backwards on itself

, extending from

anterior superior iliac spine to pubic tubercle.

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• Inguinal canal

• :It is an oblique passage in lower part of abdominal wall, 4 cm long, situated above the medial ½ of inguinal ligament,

• extending from deep inguinal ring to superficial inguinal ring.

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BOUNDARIES

• Anteriorly: external oblique muscle

fleshy fibres of internal oblique lateral 1/3rd

skin & superficial fascia

• Posteriorly: transversalis fascia

conjoint tendon

reflected part of inguinal ligament

• Floor inguinal ligament

• Roof fibres of internal oblique

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1, External oblique fascia (fascia of Gallaudet); 2,

External oblique aponeurosis; 3, Internal oblique

muscle; 4, Transversus abdominis muscle and its

aponeurosis; 5, Transversalis fascia anterior lamina

(third layer); 6, External spermatic fascia; 7, Cooper's

ligament; 8, Pubic bone; 9, Pectineus muscle; 10,

Possible union of transversalis fascia laminae; 11,

Transversalis fascia posterior lamina (second layer);

12, Vessels (second space); 13, Peritoneum (first

layer); 14, Space of Bogros (first space); 15,

Preperitoneal fat; 16, Transversus abdominis

aponeurosis and anterior lamina of transversalis

fascia; 17, Femoral artery; 18, Femoral vein.

TONY 2010 MBBS

TONY 2010 MBBS

CONTENTS OF INGUINALCANAL

SPERMATIC CORD IN MALE

• Vas deferens

• Artery to vas

• Testicular & cremasteric artery

• Pampiniform plexus

• Remains of processus vaginalis

• Genital branch of genitofemoral nerve

• Sympathetic plexus

• lymphatics

ROUND LIGAMENT IN FEMALE

ILIO INGUINAL NERVE

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CONTENTS OF INGUINALCANAL

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COVERING OF SPERMATIC CORD

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DEFENCE MECHANISM OF INGUINAL CANAL

• Obliquity of inguinal canal

• Arching of conjoint tendon

• Shutter mechanism of internal oblique

• Ball valve mechanism due to contraction of cremasteric muscle

• Slit valve mechanism due to contraction of external oblique muscle

• hormone

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FRICHAUDS MYOPECTINEAL ORIFICE

The MPO is divided anteriorly by the inguinal

ligament, and posteriorly by the iliopubic tract. It is

bounded medially by the lateral border of the rectus

muscle, superiorly by the arching fibers of the

transversus abdominus and the internal oblique

muscles, laterally by the iliopsoas muscle and

inferiorly by the Cooper ligament.

ALL HERNOA ARE THROGH THI

ORIFICE

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TONY 2010 MBBS

FRUCHAUD’S MYOPECTINEAL ORIFICE

• osseo-myo-aponeurotic tunnel.

• medially

• lateral border of rectus sheath;

• above

• the arched fibres of internal oblique and transverse abdominis muscle;

• laterally

• by the iliopsoas muscle;

• below

by the pectin pubis and fascia covering it.

It Is through this tunnel all groin hernias occur.

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HASSELBACHS TRIANGLE

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The boundaries of the inguinal triangle are as follows

• Medial: Lower 5 cm of the lateral border of the

rectus abdominis muscle.

• Lateral: Inferior epigastric artery.

• Inferior: Medial half of the inguinal ligament.

• The floor of the triangle is covered by the

peritoneum, extraperitoneal tissue, and fascia

transversalis.

• The lateral umbilical ligament (obliterated umbilical artery) crosses the triangle and divides it into

• medial and lateral parts. The medial part of the floor of the triangle is strengthened by the conjoint tendon. The lateral part of the floor of the triangle is weak, hence direct inguinal hernia usually occurs through this part.

TONY 2010 MBBS

ETIOLOGY

• STRAININGC/C CONSTIPATION (HABITUAL,STRICTURE)

URINARY PROBLEMS OLD AGE =BPH, Ca prostate

YOUNG AGE=STRICTURE URETHRA

VERY YOUNG=PHIMOSIS,MEATAL STENOSIS

LIFTING OF HEAVY WEIGHT

• C/C COUGH =T.B, B.A, C/C BRONCHITIS

• OBESITY

• PREGNANCY

• SMOKING

• ASCITES

TONY 2010 MBBS

ETIOLOGY

• APPENDICECTOMY DESTROY ILIO INGUINAL NDIRECT INGUINALHERNIA

McBURNEYS INCISION

• FAMILIAL COLLAGEN DISORDER

• CONGENITAL PREFORMED SAC (REMAINS OF PROCESSUS VAGINALIS)

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PARTS OF A HERNIA

• SAC

• COVERING OF SAC

• CONTENTS OF SAC

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SAC

• A DIVERTICULUM OF PERITONEUM WITH MOUTH

NECK

BODY

FUNDUS

• NECK IS NARROW IN CASE OF INDIRECT WIDE IN CASE OF DIRECT

• HERNIA WITHOUT NECK: HERNIA WITH A WIDE MOUTH ,DIRCT HERNIA,INCISIONAL HERNIA

• SAC IS THIN IN INFANTS & CHILD THICK IN LONG STANDING & DIRECT HERNIA

• HERNIA WITHOUT SAC: EPIGASTRIC HERNIA(Protrusion of extra peritoneal pad of fat)

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COVERING OF SAC

• LAYERS OF ABDOMINAL WALL

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CONTENTS OF SAC

• OMENTOCELE: omentum….easy to reduce initially,…but difficult later

• ENTEROCELE: usuaslly SI,….difficult to reduce initially…easy later

• RICHTERS HERNIA :a portion of circumference of bowel

• LITTRE’S HERNIA: meckels diverticulum

• CYSTOCELE :bladder

• Ovary,fallopian tube

• Fluid :ascitic, blood from strangulated hernia, from congested bowel

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TONY 2010 MBBS

CLINICAL CLASSIFICATION

HER

NIA

REDUCIBLE HERNIA

IRREDUCIBLE HERNIA

OBSTRUCTED HERNIA

INCARCERATED HERNIA

STRANGULATED HERNIA

INFLAMMED HERNIA

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CLINICAL CLASSIFICATION

• REDUCIBLE HERNIA contents can be reduced by the patient or surgeon

expansile impulse on coughing

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• IRREDUCIBLE HERNIA can’t be reduced …due to adhesions b/w contents and sac…or due to crowding

irreducibility + no other symptoms}OMENTOCELE

Irreducibility predisposes to strangulation

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OBSTRUCTED HERNIA : bowel is obstructed…but blood supply is good

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INCARCERATED HERNIA

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.

In incarcerated hernia, sac and contents are densely

adherent to each other (contents are fixed to sac). It

is always irreducible; often obstructed but may not

be strangulated.

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STRANGULATED HERNIA blood supply is impaired ISCHAEMIAGANGRENE OF INTESTINE

TENDERNESS…. TENSE SAC

NO IMPULSE ON COUGHING

FEATURES OF INTESTINAL OBSTRUCTION

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• INFLAMMED HERNIA

inflammation of contents of hernia sac

appendicitis,salpingitis

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CLASSIFICATION

hernia

congenital

acquired

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TYPES OF INGUINAL HERNIA

Inguinal hernia

Direct

indirect

Through hesselbachs

triangle in posterior wall of

inguinal canal (medially

by lateral border of rectus

sheath,below by inguinal

ligament,laterally by

inferior epigastric artery)

Through deep ring along with

spermatic cord,lateral to

inferior epigastric artery

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Indirect inguinal hernia Direct inguinal hernia

1.any age from childhood to adult 1.Common in elderly

2.Occurs in a pre-existing sac 2.Always acquired

3. Protrusion through the deep ring; herniation

occurs later

3.Herniation through posterior wall of the

inguinal canal

4.Pyriform /oval in shape; descends obliquely

and downwards

4.Globular/round in shape;

descends directly forward bulge

5.Can become complete by

descending down into the scrotum

5.Rarely descend down into the scrotum

6.Sac is antero-lateral to the cord 6.Sac is posterior to the cord

7.Ring occlusion test no impulse after

occluding the deep ring

7. impulse even

after occluding the deep ring

8.Invagination test shows impulse on the tip of

the little finger

8.Invagination test shows impulse on the pulp

of the little finger

9.Zieman’s test impulse

on the index finger

9.impulse on the middle finger

10.Commonly unilateral may be bilateral 10.Commonly bilateral

11.Obstruction/strangulation

are common

11.Rare but can occurTONY 2010 MBBS

TONY 2010 MBBS

INDIRECT HERNIA

Deep ring

Whole of inguinal canal

Superficial ring

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Weak post wall of inguinal canal

(hesselbachs triangle)

Part of inguinal canal

Superficial ring

DIRECT HERNIA

INDIRECT INGUINAL HERNIA

• Commonest more in males

• Thin sac

• Narrow neck

• Lateral to inferior epigastric vessels

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TONY 2010 MBBS

CLASSIFICATION( BASED ON EXTENT)

Inguinal hernia

incomplete

bubonocele

funicular

complete

Sac is

confined to

inguinalcanal

Sac crosses

superficial

ring but not

reaches

bottom of

scrotumReaches

bottom of

scrotum

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TONY 2010 MBBS

TONY 2010 MBBS

TONY 2010 MBBS

NYHUS CLASSIFICATION SYSTEM

Type IINDIRECT HERNIA; internal abdominal ring normal; typically in infants, children,

small adults

Type IIINDIRECT HERNIA; internal ring enlarged without impingement on the floor of the

inguinal canal; does not extend to the scrotum

Type IIIA DIRECT HERNIA; size is not taken into account

Type IIIB

INDIRECT HERNIA that has enlarged enough to encroach upon the posterior

inguinal wall; INDIRECT SLIDING OR SCROTAL HERNIAS are usually placed in this category because they are commonly associated with EXTENSION TO THE DIRECT

SPACE; also includes PANTALOON HERNIAS

Type IIIC FEMORAL HERNIA

Type IVRECURRENT HERNIA; modifiers A–D are sometimes added, which correspond TO

INDIRECT, DIRECT, FEMORAL, AND MIXED, RESPECTIVELY

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DIRECT INGUINAL HERNIA

• ALWAYS ACQUIRED

• MEDIAL TO INFERIOR EPIGASTRIC ARTERY

• SAC IS THICK

• THROUGH HESSELBACHS TRIANGLE….. HESSELBACHS TRIANGLE IS DIVIDED IN TO LATERAL & MEDIAL HALVES BY OBLITERATED UMBILICAL ARTERY(LATERAL UMBILICAL LIGAMENT) DIRECT HERNIA CAN BE DIVIDED IN TO LATERAL AND MEDIAL BASED UPON THIS LIGAMENT

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Direct hernia

medial

lateral

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TONY 2010 MBBS

2 CLASSICAL SIGNS OF UNCOMPLICATED HERNIA

• Impulse on coughing

• Reducibility

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COMPLICATIONS OF HERNIA

• Irreducibility

• Obstructed hernia

• Strangulated hernia

• Inflammation

• Incarceration

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IRREDUCIBILITY

• Adhesions of its contents to each other

• Adhesion of its contents with the sac

• Adhesion of one part of sac to other

• Sliding hernia

• Massive hernia (scrotal abdomen)

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OBSTRUCTED HERNIA

• Irreducibility + intestinal obstruction ( lumen obstruction)

• It does not occur in

• Richters hernia

• Omentocele

• Littres hernia

• Features of obstructed hernia

• No expansile impulse on coughing

• Irreducible

• No pain

• Lax non tender

• symptoms

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INCARCERATED HERNIA

• When it contains a portion of colon with faeces indenting with fingers putty like feeling

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STRANGULATED HERNIA

• Irredudicibility + intestinal obstruction + arrest of blood supply

• Due to constriction at the neck

TONY 2010 MBBS

SIGNS OF STRANGULATED HERNIA

• Tense

• Tender

• No impulse on coughing

• irreducible

• Recent increase in size

TONY 2010 MBBS

TREATMENT

• Raise the foot end (gravityredn of hernia)

• Ice bag applin redue congestion & edema

• Nasogastric tube for gastric aspiration

• Iv fluid admn

• Parenteral antibiotics.

• Herniotomy open at the fundus & drain the fluid divide constriction ring & examine the bowel for viability

• Nonviable Bowel

• Small bowel—end to end resection anastomosis

• Omentum—excise the gangrenous part.

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• Non viable bowel

• Greenish/blackish in colour

• No peristalsis

• Gut is flaccid & lusture less

• Fluid of sac is bllod stained & foul smelling

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FEMORAL HERNIAFemoral canal

Saphenous opening

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ANATOMY

• Femoral canal: 2 x 2 cm size

• Medial compartment of femoral sheath

• Base: Femoral ring

• Bounded• Anteriorly—inguinal ligament

• Posteriorly—cooper’s ligament

• Medially—lacunar ligament

• Laterally—femoral vein

• Contents: • Cloquets node

• Lymphatics

• Areolar tissue

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TONY 2010 MBBS

SAPHENOUS OPENING

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• 4cm below & lateral to pubic

tubercle

• Covered by cribriform fascia• Upper & outer margin are sharp

will turn femoral hernia upwards

ANATOMY

TONY 2010 MBBS

COURSE OF FEMORAL HERNIA

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COVERINGS

• Skin

• Superficial fascia

• Cribriform fscia

• Anterior layer of femoral sheath

• Fatty content of femoral canal

• Femoral septum

• peritoneum

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• Increased chance of strangulation

• F>M

• Uncommon in children

• Symptoms

• Pain

• Swelling

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TONY 2010 MBBS

• Position

• Below & lateral to pubic tubercle

• Shape

• Globular/ retort (if large)

• Narrow neck

• Absent impulse on coughing

• Irreducible

• Strangulation

• consistency

• Position

• Zeimanns test

• Impulse on ring finger

• Invagination test

• Empty inguinal canal

• Ring occlusion of saphenous opening

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DD

• Saphena varix

• Aneurysm

• Psoas abscess

• Undescended ectopic testis

• Lipoma

• Psoas bursa

• Hydrocele of femoral hernia sac

TONY 2010 MBBS

TREATMENT

• High operation of McEvedy

• A incision above the inguinal ligament. Sac is dissected from below, neck

• from above and repair is done from above. It gives a

• very good exposure of both neck, fundus of sac and

• repair is also easier. strangulated femoral

• hernia

• Lotheissens operation

• Lockwood operation low approach

TONY 2010 MBBS

MAYDL’S HERNIA

• Bowel loop = W SHAPE (HERNIA IN W)

• CENTRAL PART CAN GET STRANGULATED

(INTRA ABDOMINAL)

• NO LOCAL TENDERNESS AS IN OTHER CASES

OF STRANGULATION

PERITONITIS

TONY 2010 MBBS

RICHTER’S HERNIA

• A portion of circumference of bowel

• Usually ANTIMESENTERIC BORDER

• ISCHEMIA IN HERNIATED PART

• NO OBSTRUCTION AS LUMEN NOT INVOLVED

TONY 2010 MBBS

SLIDING HERNIA

• Hernia –en-glissade

• Part of a viscus forms a part of herniating sac

• Usually occurs on left side( caeum) &

if on right side(sigmoid colon) bladder on both side

• In males

• Some times sac less

TONY 2010 MBBS

PANTALOON HERNIA DOUBLE HERNIA

• When both direct & indirect hernia sacs are present on the same side

• Hernias on both sides of epigatric vessels(like a pants)=pantaloons

• Recurrent hernia

TONY 2010 MBBS

SPIGELIAN HERNIA

• Lateral ventral hernia

• Herniate b/w muscles of abdomen

• At or blw arcuate line due to absence of posterior rectus sheath(half way b/w umbilicus & inguinal ligament)

• High risk of strangulation

• Rectus abdominis medially & arcuate line laterally

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TONY 2010 MBBS

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TONY 2010 MBBS

LUMBAR HERNIA

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UMBILICAL HERNIA

Um

bili

ca

l h

ern

ia

Exomphalos

Umbilical hernia in infants & children

Para umbilical hernia of adults

TONY 2010 MBBS

EXOMPHALOS

• Failure of all or part of the midgutto return to the abdominal cavity during early fetal life

• Outer } amniotic membrane

• Middle } whartons jelly

• Inner } peritoneum exomphalos

Exomphalosminor

Exomphalosmajor

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TONY 2010 MBBS

EXOMPHALOS MAJOR

• Umbilical cord attached to inferior aspect of large swelling

• Contains SI… LI & part of liver

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• Exomphalos major may burst

• So emergency Sx is needed

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EXOMPHALOS MINOR

• Sac is small

• Umbilical cord is attached to its summit

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TONY 2010 MBBS

UMBILICAL HERNIA IN INFANTS & CHILDRENS

• Through umbilical cicatrix

• Spherical in shape

• Increase in size in crying

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TONY 2010 MBBS

PARAUMBILICAL HERNIA OF ADULTS

• Not through umbilical cicatrix but through linea alba

• Above (supraumbilical)

• Below (infraumbilical)

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INTERSTITIAL HERNIA

• Hernial sac lies between muscle layers of abdominal wall

• Preperitoneal/intraparietal

• Interparietal

• Extraparietal

TONY 2010 MBBS

LITTRE’S HERNIA

• Meckels diverticulum is the content

TONY 2010 MBBS

CAUSES OF RECURRENCE OF INGUINAL HERNIA

• Failure to ligate the sac at the neck

• Increased tension

• Use of absorbable sutures

• Fault in selection of operation

• Infection

• Lifting of heavy weight with in 3 months

• Persistent predisposing factors

• Appearance of new hernia

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HERNIA OF A HYDROCELE

LOCALIZED THINNING OF TUNICA LEADING TO PSEUDOPODIUM-LIKE PROJECTION, USUALLY SEEN WHEN THE SAC IS THICK AND FLUID IS UNDER TENSION through

HYDROCELE OF A HERNIA

FLUID SEQUESTRATION IN A LOCULUS OF THE HERNIAL SAC, RESEMBLING HYDROCELE. THIS IS SEEN IN LONG STANDING CASES WITH ADHESIONS WITHIN THE SAC

MORE COMMON IN VENTRAL HERNIA CONTAING OMENTUM

OGILVIE HERNIA

• • Direct hernias are always acquired. Indirect may be congenital or acquired.

• • Only congenital direct hernia is ogilvie hernia; through a rigid circular orifice

• in the conjoined tendon just lateral to where it inserts into the rectus sheath.

TONY 2010 MBBS