Management of hernia

1. HERNIA:
MANAGEMENT
PRINCIPLES
AND
TREATMENTS
PRESENTED BY:SACHIN
OJHA(107)
BATCH’16 T.S.M.M.C.H

2. TYPES OF MANAGEMENT FOR
HERNIA
• CONSERVAT
IVE
• SURGICAL{Surgery is the treatment of
choice}

3. CONSERVAT
IVE
• WATCHFUL WAITING: In elderly people, if the
hernia is asymptomatic, small in size, can be
reduced easily and is not causing anxiety, then
observation alone should be sufficient.
• Small paraumbilical hernias are common and
they cause few symptoms and usually
contain fat or omentum with a very low risk of
complications.
• In obese and elderly patients, these risks may
outweigh the benefits of surgery so it is
common to adopt a conservative approach.

4. SURGICAL TREATMENT OF
HERNIA
• For any hernia the surgical option
comprises 2 components :
– Herniotomy
– Herniorrhaphy or hernioplasty
• It is either :
– Open repair
– Laparoscopic repair

5. INDICATIONS FOR
SURGERY
• All cases of femoral hernia should be
repaired surgically as they have higher
possibility of strangulation.
• Any case of irreducible hernia with pain and
tenderness, unless coexisting medical factors
place the patient at very high risk from
surgery or anaesthesia.
• Increasing difficulty in reduction and increasing
size.
• In younger adult patients as symptoms
and complications are likely over time.
• acute pain in a hernia and if it is irreducible,

6. SURGICAL APPROACHES TO
HERNIA
All surgical repairs follow the same basic
principles:
1. Reduction of the hernia content into the
abdominal cavity with removal of any non-
viable tissue and bowel repair if necessary.
2. Excision and closure of a peritoneal sac if
present or replacing it deep to the muscles.
3. Reapproximation of the walls of the neck of
the hernia if possible.
4. Permanent reinforcement of the abdominal
wall defect with sutures or mesh

7. HERNIAL SURGERY IN
INFANTS
• Only herniotomy is preferred in infants in
both hernia and hydrocele.
• This surgery is called as“Michaelis
plank operation”

8. HERNIAL SURGERY IN
ADULTS
1. HERNIOTOMY – excision of hernial sac
2. HERNIORRHAPHY – herniotomy +
posterior wall strengthening
3. HERNIOPLASTY – herniorraphy with
mesh usage

9. OPEN HERNIA
REPAIR

10. HERNIOTO
MY
• Anaesthesia: spinal or G/A or local anaesthesia
• Cleaning and draping ; skin is incised—1.25 cm above &
parallel to
the medial two/third of inguinal ligament.
• Superficial fascia & external oblique aponeurosis is
incised & inguinal ligament is exposed.
• Ilioinguinal nerve is safeguarded.
• Cremasteric muscle is opened.
• Cord structures dissected. Sac is identified as pearly
white in colour.
• 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 distally.

11. Skin incision—1.25 cm above
& parallel to the medial
two/third of inguinal ligament
Twisting of the sac to prevent
the contents to get in.

12. HERNIORRHA
PHY
• Modified bassini’s Herniorrhaphy
• Lytle’s repair
• Shouldice repair
• Desarda’s repair
• Tanner slide operation
• Darning (Abrahamson Nylon
Darning)
• Koontz operation
• Mcvay operation
• Nyhus repair
• Wilkinson method
• removal of cord at inguinal region.
• Andrew operation

13. BASSINI’S
HERNIORRHAPHY
1. The conjoined tendon is retracted upward
2. the aponeurosis of the transversus abdominis
muscle is approximated to the iliopubic tract
that lies adjacent to the inguinal ligament
with several interrupted sutures.
3. The second layer of the repair involves
suturing the conjoined tendon to the
inguinal ligament with interrupted sutures.
4. This suture line extends from the pubic
tubercle to the medial border of the internal
ring.

14. • Opening the fascia transversalis from pubic
tubercle to deep ring.
• Approximation with interrupted stitches
• Approximation of conjoint tendon & upper leaf of
fascia transversalis with inguinal ligament &
lower leaf of fascia transversalis

16. MODIFIED BASSINI’S
HERNIORRHAPHY
Approximation with continuous interlocking stitch
with prolene.
•Sutures are placed between the conjoint tendonabove and
the inguinal ligament below, extending from the pubic
tubercle to the deep inguinal ring.

17. LYTLE’S
REPAIR
• INTERNAL ring is NARROWED by placing
interrupted sutures over the MEDIAL SIDE
of the ring to the transversalis fascia using
either thread or silk (To narrow the ring and
push the cord laterally)

18. SHOULDICE
REPAIR
• 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.

19. • The first suture line is started at the pubic
tubercle using continuous polypropylene, and
the white line is approximated to the free edge
of the inferior transversalis fascial flap.

20. • The second 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.

21. • 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.

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

23. • The cord is replaced within the inguinal
canal, and the external inguinal
aponeurosis is reapproximated with
continuous absorbable sutures

24. Desarda’s
repair
• An operation where a 1- to 2-cm strip of
external oblique aponeurosis lying over the
inguinal canal is isolated from the main
muscle,
• The continuity with muscle and insertion is
kept intact both medially and laterally.
• It is then sutured to the conjoint tendon and
inguinal ligament, reinforcing the posterior
wall of the inguinal canal.
• As the abdominal muscles contract, this strip
of aponeurosis tightens to add further
physiological support to the posterior wall.

26. Tanner Slide
Operation
• To reduce the tension in the repair area,
relaxing incision is placed over the lower
rectus sheath after modified bassini’s
surgery so that conjoined tendon is allowed
to slide downward.

27. Darning (Abrahamson Nylon
Darning)
• Continuous non absorbable sutures are placed
between : conjoint tendon and inguinal
ligament to give good support to posterior wall
of inguinal hernia.

28. McVay
Operation
• It is repair by placing interrupted suture is
applied between transversalis fascia to
copper’s ligament starting from pubictubercle
medially towards femoral sheath and later
continued as suture repair between
transversalis fascia and iliopubic tract
laterally upto entrance of cord
• Covers all three groin defects- indirect,
direct, and femoral.

29. 1.Andrew’s Operation - It involves
overlapping of the external oblique
aponeurosis.
2.Nyhus Iliopubic Repair -
Transaponeurotic arch (transverse
abdominis muscle and transversalis
fascia) is sutured below to Copper’s
ligament and iliopubic tract.
3.Wilkinson Method - Transversus
abdominis and internal oblique are
sutured to inguinal ligament with
continuous monofi lament sutures

30. HERNIOPLA
STY
• Strengthening of the posterior wall of
inguinal canal with autologous tissue or
foreign material.

31. Tension – free
repair
• There are several options for placement
of mesh during anterior inguinal
herniorrhaphy, including
– The Lichtenstein approach
– The plug-and-patch technique
– The sandwich technique with both an anterior
and preperitoneal piece of mesh.

32. LICHTENSTEIN’SREPAIR.
• Lichtenstein described a tension-free, simple,
flat, polypropylene mesh repair for inguinal
hernia.
• The initial part of the operation is identical to Bassini’s.
Once the hernia sac has been removed and any medial
defect closed, a piece of mesh, measuring 8 × 15 cm, is
placed over the posterior wall, behind the spermatic
cord, and is split to wrap around the spermatic cord at
the deep inguinal ring.
• Loose sutures hold the mesh to the inguinal
ligament and conjoint tendon.
• Two major advantages are claimed:
– lowered hernia recurrence rates and

33. MES
H

34. MESH IN HERNIA
REPAIR
• Theterm ‘mesh’ refers to prosthetic material,either
a net or a flat sheet, which is used to strengthen
a hernia repair. Mesh can be used:
• To bridge a defect: the mesh is simply fixed over
the defect as a tension-free patch;
• To plug a defect: a plug of mesh is pushed into
the defect;
• To augment a repair: the defect is closed
with sutures and the mesh added for
reinforcement.
• A well-placed mesh should have good
overlap around all margins of the defect

35. Mesh
characteristics
• Woven, knitted or sheet
• Synthetic or biological – mainly synthetic
• Light, medium or heavyweight –
lightweight becoming more popular
• Large pore, small pore – large pore
causes less fibrosis andpain
• Intraperitoneal use or not – non-adhesive
mesh on one side
• Non-absorbable or absorbable – mainly
non- absorbable

36. Syntheti
c
mesh
• Avoided in infection
and strangulation.
• Eg.
– Prolene
– Polyester
– Vypro
(vicryl+prolene)
–
PTFE(polytetrafluoroethylene
)
Biologic
al
mesh
• Can be used where
there is infection.
• Eg:
• Alloderm
• Acellular
porcine dermis
• Acellular human
dermis

37. Physical or mechanical properties of
mesh materials

38. PROPERTIES OF IDEAL
MESH
• Possess good handling characteristics in the
OR
• Invoke a favorable host response
• Be strong enough to prevent recurrence
• Place no restrictions on post implantation
function
• Perform well in the presence of infection
• Resist shrinkage or degradation over time
• Make no restrictions on future access
• Block transmission of infectious disease
• Be inexpensive

39. Ventral hernia
mesh
positioning

40. ONLA
Y
JUST OUTSIDE THE MUSCLE IN THE
SUBCUTANEOUS SPACE
(ONLAY)

41. INLA
Y
WITHIN THE DEFECT (INLAY)
ONLY APPLIES TO MESH PLUGS IN SMALL

42. SUBL
AY
BETWEEN FASCIAL LAYERS IN THE ABDOMINAL WALL
(INTRAPARIETAL OR SUBLAY);IMMEDIATELY
EXTRAPERITONEALLY, AGAINST MUSCLE OR
FASCIA(ALSO SUBLAY);

43. INTRAPERITON
EAL

44. COMPLICATIONS OF
MESHPLASTY
• Mesh plug canform adense‘meshoma’ of plug
and collagen.
• Seroma’s develop with any mesh type but those with
larger pores may be less likely to do so.
• Migration, erosion into adjacent organs.
• Fistula formation
• Chronic pain
• Materials such as PTFE have a good profile for
adhesion risk but a high risk of infection.
• In contrast, polypropylene meshes are durable and
have a low infection risk but they have little flexibility
and a high adhesion risk.

45. Adhesions to
mesh
Seroma
s

46. LAPROSCOPIC HERNIA
REPAIR

47. LAPROSCOPIC
ANATOMY

48. • ‘Deep’ repair of inguinal hernia deals with the
issue from the ‘point of origin’ rather than
the ‘point of presentation’.
• This exercise has two important final
results.
– Firstly, the ‘inlay/ posterior’ meshplacement
provides amechanical edge on the ‘onlay/
anterior’ mesh placement.
– Secondly covering the entire ‘Myopectineal
orifice (of Fruchaud’) the ‘deep’ repair
handles all the potential sites in danger

49. MYOPECTINEAL ORIFICE OF
FRUCHAUD
• In 1956, Henry Fruchaud espoused the theory that
all groin (inguinofemoral) hernia and obturator
originate in a single weak area called the
Myopectineal orifice. This oval, funnel like,
‘potential’ orifice formed by the following structures,
forms the ‘Myopectineal orificeof Fruchaud’.
1. Superiorly Internal oblique and
transverses abdominis muscles.
2. Inferiorly Superior pubic ramus.
3. Medially Rectus muscle sheath.
4. Laterally Iliopsoas muscle.

51. THE PERITONEAL
LANDMARKS
• Since the growth and development of the
laparoscopic method for treating groin hernia
an
increased attention is being paid to ‘pure anatomy’
issues such as the infraumbilical fossae. These
types of fossae have two important roles-
– The fossae delineate the websites of groin
herniation.
– They are an essential landmark for orientation
during hernia repairs.
• The fossae are created by the presence of

52. Median Umbilical
Ligament This ligament
ascends within the median
plane in the apex of the bladder
towards the umbilicus. It
represents the obliterated
allantoic
duct and its lower part may be the
site
from the unusual urachal cyst.
Medial Umbilical
Ligament This ligament
symbolizes the obliterated
umbilical artery on both sides
and can be traced down to the
internal iliac artery.
Lateral Umbilical Ligament
It's the ridge of peritoneum, which
is raised by the Inferior Epigastric
artery and its companion two

53. • Supravesical fossae: The infra-umbilical area
between the median and medial umbilical
structures. This is actually the site for that source
of the supravesical hernia.
• Medial Umbilical fossae: The infra-umbilical area
between the medial and lateral umbilical ligaments.
This is the site for the ori- gin of the femoral and
direct inguinal hernia.
• Lateral Umbilical fossae: The infra-umbilical area
horizontal towards the lateral umbilical ligament.
This is actually the site for the origins of the
indirect inguinal hernia.

55. Peritoneal
reflection
media
l
Testicular
A (Aka)Electrical hazard
zone
Cautery is
c/i
Trapezoid of
disaster
Close to pubic
tubercle

57. Lat
.
Med
.

58. LAPROSCOPIC HERNIA
REPAIR
1. TOTAL EXTRAPERITONEAL
REPAIR (TEP)
2. TRANSABDOMINAL
PREPERITONEAL REPAIR
(TAPP)

59. TOTAL EXTRAPERITONEAL
REPAIR (TEP)
• Surgery performed above the
peritoneum without breaching it.

60. TRANSABDOMINAL
PREPERITONEAL
REPAIR (TAPP)
• Surgery is performed beneath the
peritoneum and hence breached.

61. INGUINAL
HERNIA

62. Operations for inguinal
hernia
 Herniotomy
TENSION
REPAIR
 Open suture repair
• Bassini
• Shouldic
e
• Desarda
Tension-free
Repair
1. Open flat mesh repair
• Lichtenstein
2. Open complex mesh
repair
• Plugs
• Hernia
systems
3. Open preperitoneal
repair
• Stoppa
4. Laparoscopic repair
• TEP
• TAPP

64. OPERATIONS FOR FEMORAL
HERNIA
OPE
N
LAPROSCO
PIC
HIGH APPROACH
(Above inguinal
ligament)
McEVE
DY
LOW
APPROACH
LOCKWO
OD
TE
P
TAP
P
Inguinal
approach
LOTHEISSEN

65. LOW APPROACH
(LOCKWOOD)
• This is the simplest operation for a femoral hernia
but suitable only when there is no risk of bowel
resection.
• It can easily be performed under local anaesthesia.
• A transverse incision is made over the hernia. The
sac of the hernia is opened and its contents
reduced.
• The sac is also reduced and non-absorbable sutures
are placed between the inguinal ligament above and
the fascia overlying the bone below.
• A small incision can be made in the medial lacunar
ligament to aid reduction but there may be an
abnormal branch of the obturator artery just deep to
it, which can bleed. The femoral vein, lateral to the
hernia, needs to be protected.

66. THE INGUINAL
APPROACH
(LOTHEISSEN)
• Theinitial incision is identical to that ofBassini’s or
Lichtenstein’s operation into the inguinalcanal.
• The spermatic cord (or round ligament) is mobilised
and the transversalis fascia opened from deep
inguinal ring to the pubic tubercle.
• A femoral hernia lies immediately below this incision
and can be reduced by a combination of pulling from
above and pushing from below.
• Once reduced, the neck of the hernia is closed with
sutures or a mesh plug, protecting the iliac vein
throughout.
• The layers are closed as for inguinal hernia and the
surgeon may place a mesh into the inguinal canal to
protect against development of an inguinal hernia.

67. HIGH APPROACH
(McEVEDY)
• This more complex operation is ideal in the emergency situation
where the risk of bowel strangulation is high.
• It requires regional or general anaesthesia.
1. A horizontal incision (classically vertical) is made in the lower
abdomen centred at the lateral edge of the rectus muscle.
2. The anterior rectus sheath is incised and the rectus muscle
displaced medially. The surgeon proceeds deep to the muscle in
the preperitoneal space.
3. The femoral hernia is reduced and the sac opened to allow
careful inspection of the bowel, and a decision made
regarding the need for bowel resection if necessary.
4. In dubious cases, the bowel is replaced into the peritoneal cavity
for 5 minutes and then re-examined. The femoral defect is then
closed with sutures, mesh or plug.
This approach allows a generous incision to be made in the
peritoneum,which aids inspection of the bowel and
facilitates bowel resection.

68. TREATMENT OF
OTHER
HERNIAS

69. UMBLICAL
HERNIA
Very small
defect (1-
2cm)
Mayo’s repair
(herniorraphy
)
Defects up to 2 cm in diameter may
be sutured primarily with minimal
tension, although, the larger the
defect,the more tension and the
more likely it is that mesh
OPE
N
Large defects
Meshplasty
LAPROSCO
PIC
INTRAPERITONEAL ONLAY
REPAIR
Approximation of the musculofascial
layers should be done with minimal
tension and prosthetic mesh should be
used to reduce the risk of recurrence.

70. UMBLICAL
HERNIA
• CONSERVATIVE MANAGEMENT (2-3
YEARS)
• IF PERSIST PROCEED WITH
SURGICAL REPAIR
PARAUMBLICAL
HERNIA
• DEFECT USUALLY SUPERIOR AND
RIGHT SIDE

71. LUMBER
HERNIA
• Management can be by open or laproscopic
surgery
• The Dowd-Ponka technique involves making an
incision over the hernia site, reducing the sac, and
placement of a prosthetic mesh which is sutured to
the external oblique, latissimus dorsi, and the
lumbar periosteum.
SPLEGIAN AND OBTURATOR
HERNIA
• OPEN
• LAPROSCOPIC (USUALLY TAPP IN

72. COMPLICATIONS OF
SURGERY
• Reduction of hernia content is essential for a
successful repair. extensive dissection can
lead to bowel injury.
• bowel resection with subsequent risks of
infection and bowel anastomotic
complications.
• There is risk of fluid formation within the
sac (seroma).
• simple closure of a hernia defect by sutures
alone leads to a high recurrence rate.
• Absorbable mesh has shown higher

73. THANK
YOU