This document provides an overview of inguinal hernia. It defines an inguinal hernia as a protrusion of abdominal contents through the abdominal wall in the groin region. It describes the anatomy of the inguinal canal and contents. It discusses the causes, types (direct vs indirect), presentations, tests used for diagnosis and differential diagnosis of inguinal hernia. It also summarizes treatment approaches including watchful waiting, truss use, taxis, and surgical options like herniotomy, herniorraphy and hernioplasty.

1. INGUINAL HERNIA
Done by,
Dr Anisha S Ashraf
Assistant Professor
Dept. Of Shalya Tantra, SJGAMC&H, Koppal

2. INTRODUCTION
 Hernia is derived from the Latin word ‘rupture’; means
to bud or to protrude.
 Although a hernia can occur at various sites of the body,
commonly involve the abdominal wall, particularly the
inguinal region.
 Abdominal wall hernias occur only at sites at which the
aponeurosis and fascia are not covered by striated
muscle.
 These sites most commonly include the inguinal,
femoral, and umbilical areas; linea alba; lower portion of
the semilunar line; and sites of prior incisions.

3. DEFINITION
 A hernia is defined as an abnormal protrusion or bulging
of part of the contents of the abdominal cavity through a
defect in the abdominal wall.

4.  An external hernia protrudes through all layers of the
abdominal wall, whereas an internal hernia is a
protrusion of intestine through a defect in the peritoneal
cavity.
 An interparietal hernia occurs when the hernia sac is
contained within a musculo aponeurotic layer of the
abdominal wall.
 In broad terms, most abdominal wall hernias can be
separated into inguinal and ventral hernias.

5. CAUSES OF HERNIA
 Basic design weakness
 Weakness due to structures entering & leaving the abdomen
 Developmental failures
 Genetic weakness of collagen
 Sharp & blunt trauma
 Weakness due to ageing & pregnancy
 Primary neurological & muscle disorders
 Straining
 Heavy weight lifting
 Chronic cough

6.  Chronic constipation
 Urinary causes
 Old age – BPH, CA Prostate
 Young age – stricture urethra
 Very young age – phimosis, meatal stenosis
 Obesity
 Smoking
 Ascites
 Appendicectomy through McBurney’s incision

7. PARTS OF HERNIA:
 Coverings of Sac
 Sac
 Contents of Sac
 Sac – pouch of peritoneum
 4 parts
 Mouth – through which the contents enter
sac
 Neck – narrow in indirect hernia
 Body
 Fundus – most dependent part

8.  Contents of Sac
 Omentocele – omentum is the content
 Maydl Hernia – small intestine forming “W” shape
 Richter’s Hernia – a portion of circumference of bowel
 Litter’s Hernia – If Meckel’s Diverticulum is the content
 Cystocele – bladder as content
 Enterocele – intestine
 Coverings of Sac
Layers of abdominal wall forms covering of the sac.

9. LAYERS OF ABDOMINAL WALL
 Skin
 Camper’s fascia
 Scarpa’s fascia
 External oblique
 Internal oblique
 Transverse abdominus
 Transversalis fascia
 Parietal compartment of preperitoneal space
 Membranous layer of preperitoneal tissue
 Preperitoneal fat
 Peritoneum

10. CLASSIFICATION
 Clinically classified as :
 Reducible –contents can be returned into the
abdominal cavity.
 Irreducible – contents cannot be returned into the
abdominal cavity.
 Obstructed – irreducibilty + intestinal obstruction, but
the blood supply is not impaired.
 Strangulated- irreducibilty + intestinal obstruction+
arrest of the blood supply.
 Inflammed- rare condition. Occurs when contents eg.
Appendix,meckel’s diverticulum is inflamed

11.  Groin
Inguinal
Indirect
Direct
Combined
Femoral
 Anterior
Umbilical
Epigastric
Spigelian
 Pelvic
Obturator
Sciatic
Perineal
 Posterior
Lumbar
 Superior triangle
 Inferior triangle
• Congenital & Acquired
• Acc to contents
• Acc to sites

13. DIFFERENT TYPES OF HERNIA
 Gibbon's hernia – hernia with hydrocoele.
 Berger's hernia – Hernia in pouch of Douglas.
 Romberg hernia – Saddle hernia.
 Obturator hernia – Hernia through obturator
foramen(canal).
 Grynfelt's hernia – Upper lumbar triangle hernia.
 Petit's hernia – Lower lumbar triangle hernia.
 Femoral hernia – Hernia medial to femoral vein.
 Cloquet's hernia – Hernia through pectineal fascia.

14.  Narath's hernia – Behind femoral artery, in congenital
dislocation of hip.
 Hesselbach's hernia –Lateral to femoral artery.
 Serofini's hernia – Behind femoral vessels.
 Laugier's hernia – Through lacunar ligament.
 Teale's hemia – In front of femoral vessels.
 Richter's hernia – Part of circumference of bowel wall is
gangrenous.
 Littre's hernia – Hernia with Meckel's diverticulum as the
content.

15.  Sliding hernia – Posterior wall of the sac is formed by
colon or bladder.
 Maydl's hernia - ‘W’ hernia.
 Phantom hernia – Localised muscle bulge following
muscular paralysis.
 Spigelian hernia – Hernia through spigelian fascia.
 Mery's hernia – Perineal hernia.
 Sciatic hernia – Hernia through greater or lesser sciatic
foramen.

16.  Beclard's hernia – Femoral hernia through the saphenous
opening.
 Barth's hernia – Hernia between abdominal wall and
persistent vitello intestinal duct.
 Holthouse's hernia – Inguinal hernia that has turned
outwards into the groin.

17. INGUINAL HERNIA
 SURGICAL ANATOMY OF INGUINAL CANAL
 Oblique passage in lower part of abdominal wall
 4cm long
 Situated above the medial half of inguinal ligament extending
from deep inguinal ring to superficial inguinal ring
 Superficial inguinal ring – triangular opening in the ext
oblique aponeurosis, 1.25cm above pubic tubercle
 Deep inguinal ring – U shaped condensation of
transversalis fascia, lies 1.25 cm above the inguinal
ligament midway b/w symphysis pubis & anterosuperior
iliac spine

18. CONTENTS OF INGUINAL CANAL
 Spermatic cord in males
 Round ligament in females
 Ilioinguinal nerve

19. CONTENTS OF SPERMATIC CORD
 Vas deferens
 Artery to vas
 Testicular & cremasteric
artery
 Genital branch of
genitofemoral nerve
 Pampiniform plexus of
veins
 Remains of processus
vaginalis
 Sympathetic plexus
around artery to vas

20. COVERINGS OF SPERMATIC CORD
 Internal spermatic fascia from fascia transversalis
 Cremasteric fascia
 External spermatic fascia from external oblique
aponeurosis

21. BOUNDARIES OF INGUINAL CANAL
 In front: External oblique
aponeurosis and conjoined muscle
laterally.
 Behind: Inferior epigastric artery,
fascia transversalis and conjoined
tendon medially.
 Above: Conjoined muscle (arched
fibres of internal oblique).
 Below: Inguinal ligament
(Poupart’s) and lacunar ligament
(Gimbernat).

22. HESSELBACH’S TRIANGLE
 Bounded medially by lateral border of Rectus
abdominis muscle
 Laterally by Inferior epigastric artery
 Below by Inguinal ligament

23. INCIDENCE
 Hernias are a common problem; however, their true incidence
is unknown.
 It is estimated that 5% of the population will develop an
abdominal wall hernia, but the prevalence may be even higher.
 About 75% of all hernias occur in the inguinal region – weak
muscular anatomy in the inguinal region & also due to the
presence of natural weakness like deep ring and cord
structures.
 Two thirds of these are indirect and the remaining are direct
inguinal hernias.

25. DEFENCE MECHANISM OF INGUINAL CANAL
 Obliquity of inguinal canal – two inguinal rings do not
lie opposite to each other. When intra abdominal pressure
rises, anterior & posterior walls of canal are
approximated, thus oblitering the passage.
 Arching of conjoint tendon
 Shutter mechanism of internal oblique – conjoined
tendon contracts & since it forms anterior, superior and
posterior boundaries, it closes the inguinal canal.

26.  Ball valve mechanism – due to contraction of cremaster
muscle – plugging effect at external ring – pulling of
deep ring upwards & laterally. This occludes the ring &
prevents herniation.
 Slit valve mechanism – when ext oblique muscle
contracts, inter crural fibres of superficial ring apposes

27. CLASSIFICATION
 Inguinal hernias are classified as direct or indirect.
 Indirect hernia – comes out through internal ring along
with the cord. Lateral to inferior epigastric artery
 Direct hernia – occurs through the posterior wall of
inguinal canal through Hesselbach’s triangle. Sac medial
to inferior epigastric artery
 A pantaloon –type hernia occurs when there is both an
indirect and direct hernia component.

29. GILBERT CLASSIFICATION
 Type I: Hernia has got snug internal ring through which a
peritoneal sac passes out as indirect sac.
 Type II: Hernia has a moderately enlarged internal ring
which admits one finger but is lesser than two
fingerbreadth. Once reduced it protrude during coughing
or straining.
 Type III : Hernia has got large internal ring with defect
more than two fingerbreadth. Hernia descends into the
scrotum or with sliding hernia. Once reduced it
immediately protrudes out without any straining.
 Type IV: It is direct hernia with large full blow out of the
posterior wall of the inguinal canal. The internal ring is
intact.
 Type V: It is a direct hernia protruding out through
punched out hole/ defect in the transversalis fascia. The
internal ring is intact.
 Type VI: Pantaloon/double hernia.
 Type VII: Femoral hernia.

30. NYHUS CLASSIFICATION SYSTEM
 Type I – Indirect hernia with normal deep ring
 Type II – Indirect hernia with dilated deep ring
 Type III – posterior wall defect
 Direct
 Pantaloon hernia
 Femoral hernia
 Type IV – recurrent hernia

31. BENDAVID CLASSIFICATION
 Type I – Anterolateral defect : indirect
 Type II – Anteromedial : direct
 Type III – Posteromedial : femoral
 Type IV – Posterior prevascular hernia :
 Type V – Anteroposterior defect : inguino femoral hernia
 CASTEN’S STAGING
 Stage 1 – an indirect hernia with a normal internal ring
 Stage 2 – an indirect hernia with enlarged internal ring
 Stage 3 – all direct or femoral hernias

32. HALVERSON & MCVAY CLASSIFICATION
 Class 1 small indirect hernia
 Class 2 medium indirect hernia
 Class 3 large indirect hernia or direct hernia
 Class 4 femoral hernia

33. INDIRECT INGUINAL HERNIA
 Most common
 Sac – thin
 Neck – narrow, lies lateral to inferior epigastric vessels
 Coverings of indirect hernia:
 Skin
 External spermatic fascia
 Cremasteric fascia
 Internal spermatic fascia
 Extraperitoneal tissue

34. TYPES
According to extent – 3
 Bubonocele – sac confined to inguinal canal
 Funicular – sac crosses the superficial inguinal ring, but
doesn’t reach the bottom of scrotum
 Complete - sac descends to the bottom of scrotum

35. CLINICAL FEATURES
 Prevalence of inguinal hernia is 25% in males; 2% in
females.
 Presents with dragging pain and swelling in the groin
which is better seen while coughing and standing; and
felt together with an expansile impulse
 In complete type, the content descends down to the
scrotum completely. On palpation, one cannot get above
the swelling.
 Usually reducible, but can go for irreducibility,
inflammation, obstruction, strangulation.

36.  Internal ring occlusion test: Internal ring is located half
inch above the mid-inguinal point. After reducing the
contents, in lying down position, internal ring is
occluded using the thumb. Patient is asked to cough. If a
swelling appears medial to the thumb, then it is a direct
hernia. If swelling does not appear and on releasing the
thumb swelling appears during coughing, then it is an
indirect hernia confirmed in standing position.
 Ring invagination test: After reduction of hernia, the
little finger/ index finger of the examiner is invaginated
from the bottom of the scrotum, gradually pushed up and
rotated to enter the superficial inguinal ring. The impulse
on coughing is felt at the tip of the invaginated finger.

37.  Zieman’s test: Index finger on the deep inguinal ring
and middle finger on the superficial inguinal ring, ring
finger over saphenous opening. The patient is asked to
cough or to hold the nose and blow. If the impulse is felt
on the index finger, it is indirect hernia.
 Head or leg rising test is done to look for abdominal
wall muscle tone and Malgaigne bulgings.
 Abdominal, respiratory, urological examination is done
to look for any precipitating factors like chronic
bronchitis, ascites, stricture urethra, BPH.
 Silk glove sign: Index finger is invaginated across
scrotum towards the external ring. When patient coughs,
inguinal hernia is felt as a slit like sensation.

38. DIFFERENTIAL DIAGNOSIS
 Femoral hernia – below and lateral to pubic tubercle
 Vaginal Hydrocele – swelling confined only to scrotum
 Undescended testis – firm swelling in inguinal region;
scrotum empty
 Lipoma of the cord – soft, lobulated, irreducible swelling
 Inguinal lymphadenitis – pain & nodular swelling below
inguinal ligament, irreducible, some source of infection
in lower limb usually present
 Saphena varix – swelling in the thigh, 2.5cms below
pubic tubercle, swelling disappearson leg elevation

39. MANAGEMENT
Non operative Treatment
 Watchful waiting: for asymptomatic or
minimally symptomatic
 Non operative inguinal hernia
treatment targets pain, pressure, and
protrusion of abdominal contents in the
symptomatic patient population.
 Hernia Truss is a mechanical appliance
,belt with a pad applied to groin after
spontaneous or manual reduction of
hernia
 The purpose is twofold: to maintain
reduction and to prevent enlargement.

40. TAXIS
 Used in irreducible or partially reducible hernia
 Reduction of hernia is tried by elevation, sedation &
taxis
 With flexion & medial rotation of hip, reduction of
hernia is tried
 Dangerous in obstructed & Maydl’s hernia
 No role in femoral hernia& strangulated hernia
 If tried, contusion & rupture of sac occurs

41.  In infants - Herniotomy through inguinal approach
 In adults –
 Herniotomy : excision of hernial sac
 Herniorraphy : strengthening of the posterior wall of inguinal
canal by tissue repair
 Hernioplasty : strengthening of the posterior wall of inguinal
canal by mesh
 Precipitating causes – treated first
 TURP for BPH
 Dilatation of stricture urethra
 Treatment of chronic bronchitis

42. HERNIOTOMY
 Anaesthesia: Spinal or G/A or local anaesthesia.
 Procedure
 After cleaning and draping, skin is incised 1.25 cm above and
parallel to the medial two third of inguinal ligament.
 Two layers of superficial fascia (outer Camper’s fascia and
inner Scarpa’s fascia) are incised.
 Superficial pudendal and superficial epigastric vessels are
ligated with catgut or cauterized.
 Self retaining mastoid or similar retractor is placed to retract
the skin edges.
 External oblique aponeurosis is incised along its long axis
parallel to the line of skin incision.
 Incision is extended on either ends of the incision; medially it
is extended to cut the margins of the superficial ring.

43.  Upper leaf is reflected above and held with haemostat; using
peanut dissection upper leaf is raised adequately to visualize
conjoined tendon and lateral rectus sheath.
 Lower leaf is reflected downwards to visualize and expose the
inguinal ligament.
 Entire inguinal ligament is dissected medially and exposed
with its shelving edge and iliopubic tract
 Ilioinguinal nerve is safeguarded.
 Cremasteric muscle with its fascia is opened longitudinally as
medial and lateral flaps.
 Cremaster vessel is ligated and cremaster muscle is excised
after ligating proximally and distally.
 Cremasterectomy is not essential.

44.  Cord structures are dissected.
 Sac lying anterior and lateral to cord is identified and is pearly
white in color.
 Dissection is usually started from the fundus and extended
towards the neck which is identified by the extra peritoneal
fat.
 The neck is narrow and is lateral to inferior epigastric artery.
 High dissection beyond the deep ring is done.
 Sac is opened at the fundus.
 Finger is passed to release any adhesions.
 Sac is twisted so as to prevent the content from coming back.
It is transfixed using absorbable suture material (chromic
catgut 2-0 or vicryl) and is excised (redundant sac) distally

45. High dissection above the internal ring is required in indirect
sac.

46. Vas deferens should be identified and safeguarded especially
in children.

48. Technique of transfixation of the sac.

49. HERNIA REPAIR
 It means repair or strengthening of the posterior wall of
the inguinal canal.
 By principle defective first layer which is transversalis
fascia should be used in repair.
 Strengthening can be done by tissue or prosthetic repair.
 Strengthening by tissue repair has got various
approaches where transversalis fascia or tendinous
fascio-aponeurotic upper part is approximated to
iliopubic tract or Cooper’s ligament or shelved edge of
the inguinal ligament

50.  Upper leaf taken for repair should be tendinous
fascioaponeurotic layer
 Non absorbable monofilament sutures like
polypropylene should be used ideally.
 Prosthetic repair is done by placing mesh or prosthesis
by onlay/inlay/sublay/sublay intraperitoneal method.
 Polypropylene mesh is commonly used with different
modifications.

51. TYPES OF REPAIR
 PURE TISSUE REPAIR
 SHOULDICE, MACVAY & MODIFIED BASSINI
 PROSTHETIC REPAIR
 LICHTENSTEIN, RIVES, GILBERT, STOPPA,TEP,TAPP
 Approaches :
 ANTERIOR REPAIR – through anterior inguinal
approach : Bassini’s, Shouldice, MacVay, darning,
Lichtenstein mesh repair, Rives preperitoneal repair
 POSTERIOR REPAIR – through suprainguinal
preperitoneal approach : Nyhus repair, Stoppas, TEP,
TAPP

52. HERNIOPLASTY
 Lichtenstein’s Inguinal Hernia Mesh Repair Under
LA
 20 mL of xylocaine 2% mixed with 10 mL of
bupivacaine 0.5%, 50 ml of normal saline, 1 mL of
1:1000 adrenaline solution with hyalase solution is used
for local anaesthesia.
 Different combinations are in use. 50:50 of xylocaine 1%
with 0.5% bupivacaine with 1 in 2,00,000 epinephrine in
normal saline is also used.
 45-50 mL of this prepared solution is sufficient.
 Propofol sedation with intravenous drip may be added.

53.  Anaesthetic agent is injected layer by layer.
 5ml is injected into subdermal plane along the line of
incision using 25 G long needle; 3 mL is injected
intradermally; 10 – 20 mL is injected deep
subcutaneously.
 After skin and subcutaneous incision, subaponeurotic
injection of anaesthetic agent is done (10 mL) first at
lateral end of the incision to anaesthetize all three nerves
of the inguinal canal; then along the line of the incision
up to the pubic tubercle.

54.  Incision - 1.25 cm above and parallel to the medial 2/3rd
of inguinal ligament
 Skin is incised.
 Using cautery or scalpel blade skin incision is deepened.
 Two layers of superficial fascia, outer Camper and inner
Scarpa’s fascia are incised.
 Superficial epigastric, superficial circumflex, superficial
external pudendal veins are ligated using fine absorbable
sutures (3 zero vicryl/catgut).
 External oblique aponeurosis is identified by its shining
fibers.

55.  Exposed above, below up to inguinal ligament and
medially up to pubic tubercle and midline and incised
 Cut edges of the aponeurosis are held with artery
forceps.
 Aponeurosis is incised medially and laterally along the
line of the incision.
 Medially it is extended often up to the external ring to
open it.
 Two leaves of the aponeurosis are elevated above to
visualize the conjoined tendon and below to visualize the
shining inguinal ligament.

56.  Iliohypogastric nerve is identified above and medially which
after piercing the internal oblique enters the external oblique.
 In the inguinal canal, cord is covered by cremasteric muscle
and internal spermatic fascia; external spermatic fascia covers
the cord below the level of the superficial inguinal ring.
 Ilioinguinal nerve is in the inguinal canal outside the cord
which enters the canal through a gap between external and
internal oblique muscles, passes through superficial inguinal
ring.
 Genital branch of genitofemoral nerve passes through the cord
structures. Both nerves supply the anterior 1/3rd of the scrotum
and penis.

57.  Posterior 2/3rd of the scrotum is supplied by the
posterior scrotal nerves and perineal branch of the
posterior cutaneous nerve of the thigh.
 Ilioinguinal nerve is safeguarded after careful dissection.
 Cremaster muscle (cremaster box) is opened
 Medial dissection is done beyond the pubic tubercle.
 Hernial sac is identified.
 Sac is pearly white in colour which is anterolateral in
position with respect to cord in case of indirect sac.
 Fundus, body and neck of the sac are dissected using
scissor or cautery.

58.  Cord is held using thin gauze or penrose drain and kept
aside (usually below the inguinal ligament).
 Cord is dissected 2 cm beyond the pubic tubercle.
 Neck of the sac is identified by its narrow area, being
lateral to inferior epigastric vessels and by presence of
extraperitoneal pad of fat.
 Sac is dissected high up above the level of the internal
ring; sac is opened on the summit of the fundus; held
with two artery forceps; finger is passed into the sac to
confirm that all contents are reduced

59.  Sac is twisted adequately so that no contents will return
back to the sac during ligation
 Sac is transfixed high above the internal ring using 3
zero vicryl or monocryl and ligated.
 Redundant sac is excised to complete the herniotomy.
 Polypropylene mesh is used for repair (10 × 6 cm size);
size is decided based on the width of the defect; adequate
sized mesh covering 2.5 cm above and medially should
be used.
 Mesh of required size is cut. Mesh is sutured below to
the inguinal ligament; medial most suture is taken from a
point very close to the pubic tubercle.

60.  Size should accommodate defect well beyond pubic
tubercle (2 cm), superior margin (4 cm) and deep ring (6
cm) laterally.
 Suturing of mesh is done using interrupted non
absorbable monofilament polypropylene or polyethylene
sutures below to inguinal ligament.
 Continuous sutures also can be used while suturing lower
flap of mesh to inguinal ligament.
 Mesh is sutured below to inguinal ligament up to the
level of deep ring not beyond

61.  Upper end of the mesh is sutured to the conjoined tendon
in front with loose sutures (air lock sutures) just to keep
mesh in place.
 Cord and ilioinguinal nerve is placed back in the inguinal
canal.
 External oblique is sutured using absorbable vicryl
sutures.
 Subcutaneous interrupted sutures are placed.
 Skin is closed with continuous subcuticular monocryl 3
zero sutures or monofilament 3 zero interrupted sutures.
 Sutures if non absorbable are removed in 7 days.

62. PROCEDURE

69. DIFFERENT TYPES OF HERNIOPLASTY
 Onlay mesh repair is placing mesh in front: It is sutured
above to conjoined tendon and below to inguinal
ligament using monofilament non absorbable suture
material.
 Inlay mesh repair is done by placing mesh deep to
conjoined tendon at par with muscular or aponeurotic
plane (bridging).
 Lichtenstein tension free onlay mesh repair where the
cord is encircled with mesh which is often done under
local anaesthesia. Suturing of mesh is done similar to
onlay mesh repair. It has got less recurrence rate.

70. NYHUS PREPERITONEAL MESH REPAIR
(SUBLAY)
 It is done through suprainguinal horizontal incision
(posterior approach) above the pubic symphysis and
internal ring.
 Preperitoneum is approached through lateral border of
the lower part of rectus muscle by making an opening in
the posterior rectus sheath.
 Mesh is placed in the preperitoneal space deep to the
cord, conjoined tendon, and transversalis fascia.
 Below, it is folded deep to the iliopectineal ligament of
Cooper and sutured to it using two or three interrupted
nonabsorbable sutures.
 It is sutured to transverse abdominis above and
transversalis fascia from deep.

71.  Modified Rives preperitoneal mesh repair
 It is preperitoneal mesh repair through transinguinal
approach (anterior approach).
 Direct sac is inverted with sutures.
 For indirect sac a high dissection and ligation is done.
 Here mesh is placed in preperitoneal space, folded and
sutured below to iliopectineal ligament, above to the
transverse abdominis in deeper plane.
 Often transversalis fascia opened earlier is sutured back
using non-absorbable suture material in front of the
placed mesh

72. GILBERT MESH REPAIR (PATCH AND PLUG)
 After herniotomy, internal ring is plugged by cone
shaped (umbrella plug) piece of prolene mesh.
 Later onlay/inlay mesh repair of posterior wall of the
inguinal canal is done.
 This plug is sewn to the surrounding tissues and held in
place by an additional overlying mesh patch.
 This patch may not need to be secured by sutures,
However, to do so requires dissection to create a
sufficient space between the external and internal oblique
muscles for the patch to lie flat over the inguinal canal.

73. BASSINI’S REPAIR
 Aim to strengthen the posterior wall of the inguinal canal
by stitching the lower margin of the muscles (internal
oblique & transversus) and the conjoined tendon to the
inner margin of the inguinal ligament behind the cord
 Opening the fascia transversalis from pubictubercle to
deep ring
 Approximation with interrupted stitches
 Sutured the internal oblique, transversus abdominis
muscle & upper leaf of transversalis fascia (triple layer)
to lower leaf of transversalis fascia and inguinal ligament
(double layer) in a single row
 Then reapproximated the external oblique aponeurosis
over cord structures

74. MODIFIED BASSINI REPAIR
 Conjoint tendon & inguinal ligament are approximated
using interrupted non absorbable monofilament sutures
 Medial most stitch is taken from the periosteum of pubic
tubercle, called Bassini’s stitch
 External oblique is closed followed by closure of other
layers
 It is strengthening of post wall of the inguinal canal by
approximation of the conjoint tendon to inguinal
ligament using monofilament non absorbable suture
material
 Sutures are placed between the conjoint tendon above
and the inguinal ligament below, extending from the
pubic tubercle to the deep inguinal ring.

75.  Complications of Herniorrhaphy
 Haemorrhage.
 Haematoma.
 Infection (5%).
 Haematocele.
 Post herniorrhaphy hydrocele, lymphocele.
 Hyperaesthesia over the medial side of inguinal canal due to
injury to ilioinguinal or iliohypogastric nerve.
 Recurrence.
 Osteitis pubis.
 Injury to urinary bladder/bowel.
 Testicular atrophy, penile oedema rarely can occur.

76. SHOULDICE REPAIR
 Even though transversalis fascia is thin, it is a tough
layer and so double breasting of this fascia using
continuous sutures (with non absorbable material)
strengthens the posterior wall of the inguinal canal.
 Multilayered repair. Continuous sutures provide even
distribution of tension throughout the repair
 Often cremasteric resection is done in Shouldice in order
to have proper revelation of the posterior inguinal wall.
 Cremasteric vessels (located at lateral part of the cord
along with genital branch of genitofemoral nerve) need
ligation during cremasterectomy.

77.  After doing herniotomy as in any other inguinal hernia,
transversalis fascia is incised along the line of the wound
from deep ring to pubic tubercle.
 Lower flap of fascia is sutured to posterior part of upper
flap
 Upper flap sutured to inguinal ligament
 Causes double breasting of transversalis fascia
 Conjoined tendon & inguinal ligament further
approximated by 2 layers of continuous sutures
 Ext oblique aponeurosis is sutured in 2 layers in front of
cord
 Original shouldice repair – 6 layers

78. DARNING
 Continuous intervening network of non absorbable
sutures are placed between conjoined tendon and
inguinal ligament to give good support to posterior
inguinal wall.

79. LYTLE’S REPAIR
 Often internal ring is narrowed by placing interrupted
sutures over the medial side of the ring to the
transversalis fascia using either silk or polypropylene

80. MCVAY OPERATION (COOPER’S
LIGAMENT REPAIR)
 Repaired by placing interrupted sutures between the edge
of transversus abdominis to Copper’s ligament starting
from pubic tubercle medially towards femoral sheath
 Later continued as suture repair between transversus
abdominis and iliopubic tract laterally up to the entrance
of cord.
 Pure tissue repair.
 Requires relaxing vertical/ curvilinear oblique incision at
the lateral border of the anterior rectus sheath from pubic
tubercle to a point superiorly for 4 cm.
 It covers all three groin defects (myopectineal orifice)—
indirect, direct and femoral.

81. COMPLICATIONS
 During surgery
 Injury to iliac vessels
 Injury to bladder
 Early post operative period
 Pain
 Bleeding
 Urinary retention
 Abdominal distension

82.  Intermediate – b/w 3 to 7 days
 Seroma
 Wound infection
 Late
 Very rare
 Inguinodynia

83. TRANSABDOMINAL PREPERITONEAL MESH
REPAIR (TAPP) USING LAPAROSCOPE
 Used in large indirect hernia or irreducible inguinal
hernia.
 10 mm umbilical port is used for laparoscope.
 5 mm ports on pararectal point at the or above the level
of the umbilicus one on each side are used so as to
achieve adequate triangulation.
 Contents of the hernia are reduced.
 Hernial sac is dissected in preperitoneal plane after
making curved horizontal incision at the upper part of the
opening of sac.

84.  Incision over the peritoneum is made from lateral to
medial.
 From a point around 3-4 cm lateral to lateral umbilical
ligament (inferior epigastric vessels) horizontal incision
is made across internal ring on its upper part medially up
to medial umbilical ligament.
 Preperitoneal space is dissected to identify pubic bone,
Cooper’s ligament, vas, gonadal vessels, and inferior
epigastric vessels.
 Once sac is dissected and excised, a
prolene/vipro/ultrapro mesh of 15 × 10 cm sized is
placed in preperitoneal pace.

85.  It is fixed to pubic bone/ Cooper’s ligament using tacks
 Peritoneum is closed with continuous prolene sutures
from lateral to medial.
 It is mainly used in irreducible and large hernias. Thus
reperitonealisation should be done properly.
 TAPP without reperitonealisation (TAPPWR) can be
done if dual mesh with ePTFE on inner visceral side can
be placed after complete dissection in retroperitoneal
space without suturing/apposing the peritoneum.

86.  ePTFE prevents viscera from getting adherent and
eroded by mesh.
 Neoperitoneum develops on the ePTFE mesh in 10 days.
 Complications of TAPP are similar to TEP.
 Additional problems of bowel injury by trocars,
problems of pneumoperitoneum can occur.
 Advantage of TAPP is larger working space.

87. TOTALLY EXTRAPERITONEAL REPAIR (TEP)
 Does not breach the peritoneal cavity.
 Useful for bilateral and recurrent hernias.
 Contraindicated in previous midline surgical scar,
previous caesarean, previous pelvic surgery or pelvic
radiation.
 Patient is ideally catheterized.
 Surgeon should stand opposite to the side of the hernia
 Camera man stands on the same side proximal to the
surgeon.
 Scrub nurse stands on the opposite side.
 Monitor is kept near the foot end side on the side of the
hernia.

88.  Through subumbilical vertical/horizontal incision (10
mm) extra peritoneal space is reached.
 Often special type of balloon is used to create the same.
 Better to use zero degree telescopes initially to reach the
pubic bone.
 Touching of the telescope over the hard pubic bone can
be felt during dissection.
 Further dissection allows visualization of the bone as
light house sign.
 Immediate laterally Cooper’s ligament can be identified.

89.  After CO2 insufflation, another 5 mm port is inserted 4
cm below the first port in the midline.
 It is often better to put a hypodermic needle (needle of a
syringe) into the space from midline to identify the site
of the further ports.
 Third 5 mm port is inserted in the same line 4 cm below
or in the right iliac fossa.
 Dissection is carried out downwards carefully, then
medially up to the pubic tubercle, ilio-pectineal ligament,
laterally to iliac vessels, and inferior epigastric vessels.

91.  At this stage 30° telescope is used.
 Direct sac when present is immediately visualised.
 It is dissected proximally by traction and countertraction
over the white pseudosac (attenuated transversalis fascia)
in front.
 After complete separation many practice to pull this
pseudosac proximally to fix it to anterior abdominal wall
to prevent the formation of seroma.
 Entire sac should be dissected down and behind to
visualize wide direct defect medial to inferior epigastric
vessels.
 Inferior epigastric vessels are properly seen only after
dissection of the sac in case of direct one.

92.  Whereas in indirect sac, first inferior epigastric vessels
are seen; then peritoneal sac is seen lateral to it running
upwards, medially and proximally in the anterior
abdominal wall.
 Hernial sac descends downwards into the internal ring.
 Sac is dissected from the deep ring. Usually entire sac
can be dissected proximally.
 Large complete sac is transected at internal ring with
placing an endoloop on proximal part of the sac; distal
part of cut sac is left open without ligation.

93.  Mesh is passed through 10 mm port using a reducer after
removing the telescope.
 If difficulty arises in passing mesh then port knob is removed
and mesh is directly pushed into the space through the port.
 Once adequate space is dissected 15 × 15 cm sized mesh is
placed and spread.
 Care should be taken not to have any folding in the mesh.
 Mesh may be sutured to ilio-pectineal ligament.
 Deflation of gas is done at the end to keep the mesh in place.
 Port sites are sutured.
 10 mm port site needs deeper vicryl suture

94.  INDICATIONS :
 Recurrent hernia
 Bilateral hernia
 Indirect/direct/femoral hernia
 CONTRAINDICATIONS :
 Obstructed/strangulated inguinal hernias
 Ascites
 Bleeding disorders

95. DIFFICULTIES & COMPLICATIONS IN TEP
REPAIR
 Difficulty in dissecting indirect sac. Cord/vas injury
 Inadvertent opening of the sac/peritoneum and creation
of pneumoperitoneum.
 Injuries to major structures like iliac vessels: 0.5-1.0%
 Displacement of mesh or erosion into the structures like
urinary bladder—rare
 Nerve injury: lateral cutaneous nerve of thigh and
femoral branch of genitofemoral nerve
 Formation of seroma/haematoma
 Infection
 Recurrence
 Prolapsed of the mesh into the direct hernial defect

96. ADVANTAGES OF TEP REPAIR
 Approach is totally extraperitoneal
 Small incision
 Proper placement of mesh in right space that is
preperitoneal space
 Peritoneal cavity is intact and not opened

97. DIRECT INGUINAL HERNIA
 10-15% Hernias – direct
 Always acquired – due to weakening of posterior wall of
inguinal canal
 Wide neck, medial to inferior epigastric artery
 Sac – thick
 Medial wall/ content may be bladder
 Occurs through hesselbach’s triangle
 Classified as medial or lateral on which part of the
triangle, it is arising from

98.  Coverings of direct hernia :
 Skin
 External spermatic fascia
 Conjoined tendon
 Fascia transversalis
 Extraperitoneal tissue
 Treatment :
 Ideally hernioplasty
 If bilateral – Laparoscopic approach or suprapubic
approach
 Bladder should be emptied before surgery

99. STRANGULATED HERNIA
 Occurs when blood supply of the contents of hernia is
seriously impaired leading to formation of gangrene
 Occurs in small bowel & large bowel
 Indirect inguinal hernia is more prone for strangulation –
due to narrow neck, adhesions, narrow external ring in
children

100. TREATMENT
 Ryle’s tube aspiration
 IV fluids to correct dehydration & electrolyte imbalance
 Antibiotics
 Catheterization to maintain adequate urine output
Emergency surgery :
 Groin incision is made – sac is exposed
 Constriction ring & superficial ring is released
 Sac opened carefully
 Fluid sucked with suction apparatus
 Bowel held with fingers so as to prevent it from getting
reduced

101.  Viability of bowel is checked by colour, peristalsis,
pulsation,bleeding
 When gangrenous, resection & anastomosis is done &
drain is placed
 Bassini’s repair done
 Drain removed in 4-5 days

102. VRIDDHI
 वातपित्तश्लेष्मशोपितमेदोमूत्रान्त्रपिपमत्तााः सप्त वृद्धयो भवन्ति|
तासाां मूत्रान्त्रपिपमत्ते वृद्धी वातसमुत्थे, क
े वलमुत्पपत्तहेतुरन्यतमाः |
Su.Ni.12/3
7 types of Vriddhi is mentioned
Vata
Pitta
Kapha
Shonita
Medha
Mutra
Antra

103. SAMPRAPTI
 अधाः प्रक
ु पितोऽन्यतमो पह दोषाः फलकोशवापहिीरपभप्रिद्य
धमिीाः फलकोशयोवृृन्तद्धां जियपत, ताां वृन्तद्धपमत्यााक्षतते||
Su.Ni.12/4
One of the doshas gets aggravated
Moves downwards
Reaches फलकोश वापहिी srotas
Produces vriddhi of फलकोश
Vriddhi Roga

104. PURVARUPA
 तासाां भपवष्यतीिाां िूवृरूिापि- बन्तिकटीमुष्कमेढ्रेषु वेदिा
मारुतपिग्रहाः फलकोशशोफश्चेपत |
 Pain in pelvic region, waist, scrotum & penis
 Swelling in scrotum
 Obstruction of vayu

105. ANTRA VRIDDHI
 भारहरिबलवपिग्रहवृ्षतप्रितिापदपभरायासपवशेषैवाृयुरपभप्रवृ
द्धाः प्रक
ु पितश्च…
 स्थूलान्त्रस्येतरस्य कैकदेशां पवगुिमादायाधो गत्वा
वङ्क्षिसन्तिमुिेत्या …
 ग्रन्तिरूिेि न्तस्थत्वाऽप्रपतपियमािे क कालािरेि फलकोशां
प्रपवश्य..
 मुष्कशोफमािादयपत, आध्मातो बन्तिररवातताः प्रदीर्ृाः स शोफो
भवपत, सशब्दमविीपितश्चोर्ध्ृमुिैपत, पवमुक्तश्च िुिराध्मायते ,
तामन्त्रवृन्तद्धमसाध्यापमत्यााक्षतते |
SU.Su 12/6

106. ANTRA VRIDDHI
Vata prakopa due to Bharaharana, Balavat vigraha, Vrksha
Patana
Carries a part or whole of the small or large intestine to
Vankshana Sandhi(inguinal region)
Stays there for a long time as Granthi
If not treated, desends to फलकोश (scrotum)
Produces sweling - like inflated bladder
On pressure goes upwards with sound & when left again
blows up -- Antravriddhi -- Asadhya

107. CHIKITSA OF ANTRA VRIDDHI
 Not descended to फलकोश
 All Vatahara kriyas are to be done
 If Present in Vakshana Pradesha
 Agnikarma done using Ardhendu Vaktra Shalaka
to obstruct the path
 Descended to फलकोश
 Varjayeth

108. Other procedures:
 Sira vyadha – Above Shanka Near Karna Moola –
opposite side
 Agnikarma – After incising - Angushta madhya

109. THANK YOU