Hernia is defined as an abnormal protrusion of an organ or tissue through an opening. The inguinal region is a common area for hernias due to weaknesses in the abdominal wall muscles. There are two main types of inguinal hernia: indirect and direct. Indirect hernias are more common in younger patients while direct hernias are more common in elderly patients. Treatment involves herniotomy to remove the hernia sac, with herniorrhaphy or hernioplasty used to repair the abdominal wall defect. Hernioplasty utilizing a mesh is now the preferred treatment approach.

1. HERNIA
ARUNI CS
FINAL YEAR

2. DEFINITION
Hernia means—’To bud’ or ‘to protrude’ ‘off
shoot’ (Greek)
‘rupture’ (Latin)
 Hernia is defined as an abnormal protrusion of a
viscous or a part of a viscous through an opening,
artificial or natural with a sac, covering it.

3. TYPES

4.  Inguinal hernia is the commonest hernia (73%)
because the muscular anatomy in the inguinal
region is weak and also due to the presence of
natural weakness like deep ring and cord
structures
 Femoral is 17%
 Umbilical is 8.5%
 Others are 1.5%

5. AETIOLOGY
• Straining
• Lifting of heavy weight
• Chronic cough (tuberculosis, chronic bronchitis,
bronchial asthma, emphysema)
• Chronic constipation (habitual, rectal stricture)
• Urinary causes
– Old age: BPH, carcinoma prostate
– Young age: stricture urethra
– Very young age: phimosis, meatal stenosis
• Obesity
• Pregnancy
• Smoking
• Ascites
• Appendicectomy
• Congenital
• Familial-collagen disorder—Prune Belly syndrome

6. PARTS OF HERNIA
• Covering
• Sac
• Content
 Coverings
of the sac are
the layers of
the abdominal wall through which the sac
passes

7.  Sac is a diverticulum of peritoneum with
mouth, neck,body and fundus
 Neck is narrow in indirect hernia but wide in
direct hernia
 Body of the sac is thin in infants, children
and in indirect sac thick in direct and long
standing hernia

8. Contents of Sac
• Omentum—Omentocele (Epiplocele) initially it can
be reduced easily difficult to reduce the sac later
• Intestine—Enterocele— commonly small bowel, but
sometimes even large bowel difficult to reduce the sac
initially
• Richter’s hernia- A portion of circumference of bowel
is the content
• Cystocele-Urinary bladder may be the content or part
of the posterial wall of the sac
• Ovary, often with fallopian tube
• Meckel’s diverticulum—Littre’s hernia

9. INGUINAL HERNIA
ANATOMY OF INGUINAL CANAL
Boundaries
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
DEF:It is an oblique passage in lower part
of
abdominal wall, 4 cm long extending from
deep inguinalring to superficial inguinal ring
Contents of inguinal canal
• Spermatic cord in males
• Round ligament in females
• Ilio-inguinal nerve

10. Superficial inguinal ring
triangular opening in the external oblique
aponeurosis and is 1.25 cm above the pubic
tubercle
bounded by a superomedial and inferolateral
crus
Deep inguinal ring
U-shaped condensation of the transversalis
fascia, lies 1.25 cm above the inguinal
ligament midway between the symphysis
pubis and the anterior superior iliac spine

11. Hesselbach’s triangle
Boundries
medially :
lateral border of
rectus muscle
laterally :
inferior epigastric
artery
below:
inguinal ligament

12. Contents of spermatic
cord
• Vas deferens
• Artery to vas
• Testicular and cremasteric
artery
• Genital branch of
genitofemoral nerve
• Pampiniform plexus of veins
• Sympathetic plexus around
the artery to vas
• Remains of processus
vaginalis
Coverings of
Spermatic Cord
• Internal spermatic
fascia from fascia
transversalis
• Cremasteric fascia
• External spermatic
fascia from external
oblique aponeurosis

15. Defence mechanism of inguinal
canal
• Obliquity of inguinal canal(flap valve
mechanism)
• Arching of conjoint tendon
• ‘Shutter mechanism’ of internal oblique
• ‘Ball valve mechanism’ due to contraction of
cremaster muscle which plugs to superficial
ring
• When external oblique muscle contracts
intercrural fibres of superficial ring appose
causing ‘slit valve mechanism’
• Hormones

16. CLASSIFICATION OF INGUINAL
HERNIA
1)Anatomical classification
Indirect hernia:
It comes out through internal ring along with the
cord
lateral to the inferior epigastric artery
Direct hernia:
It occurs through the posterior wall of the
inguinal canal through ‘Hesselbach’s triangle
medial to the inferior epigastric artery

18. Gilbert classification
Type I: Hernia has got snug internal ring through which
peritoneal sac passes out as indirect hernia
Type II: Hernia has a moderately enlarged internal ring which
admits one finger but lesser than two finger breadth
Type III: Hernia has got large internal ring with defect more
than two finger breadth Hernia descends into the scrotum or with
sliding hernia
Type IV: It is direct hernia with large full blow out of the
posterior wall of the inguinal canal internal ring is intact
Type V: It is a direct hernia protruding out through punched out
hole/defect in the transversalis fascia internal ring is intact
Type VI: Pantaloon/double hernia
Type VII: Femoral hernia
Type VI and VII are Robbin’s modifications

19. NYHUS classification
 Type I: Indirect hernia with normal deep
ring
 Type II: Indirect hernia with dilated deep
ring
 Type III: Posterior wall defect
a. Direct
b. Pantaloon hernia
c. Femoral hernia
 Type IV: Recurrent hernia

20. INDIRECT (OBLIQUE) INGUINAL
HERNIA
 This is the most common type of hernia (65%)
 It is more common in younger age group as
compared to direct inguinal hernia which is
more common in elderly

21. Coverings of indirect
hernia(from inside out)
• Extraperitoneal tissue
• Internal spermatic fascia
• Cremasteric fascia
• External spermatic fascia
• Skin

22. TYPES OF INDIRECT HERNIA
Bubonocele: Where the hernia
is limited to inguinal canal
Funicular:hernia present at the root of
the scrotum
Processus vaginalis is closed just above the
epididymis. Contents of the sac can be felt
separately from testis, which lies below the
hernia
Complete (Scrotal): hernia present in the
bottom of the scrotum
Testis appears to lie within the lower part of
hernia

23. DIRECT HERNIA
• 35% of inguinal hernias are direct.
• It is uncommon in females.
• It is always acquired, due to weakening of
posterior
wall of inguinal canal.
• Hernia is medial to the inferior epigastric artery

24. Coverings of direct hernia (from
inside out)
• Extraperitoneal tissue
• Fascia transversalis
• Conjoined tendon
• External spermatic fascia
• Skin

25. CLINICAL EXAMINATION
 Indirect hernia is most common in males and
and direct is uncommon in females
 Direct hernia is reducible on lying down
 Indirect is irreducible
 Shape : pyriform in indirect
spherical in direct
retort in femoral

26.  If swelling is soft and elastic : enterocele
firm and granular: omentocele
Cough impulse: a characteristic feature of hernia
can be felt on palpation seen as bulging in
inspection
Get above the swelling: complete scrotal
swelling its positive
Inguinoscrotal swelling will not be able to get
above the swelling

27. Internal ring occlusion test
Internal ring is located half inch above the mid-inguinal
point (center point between anterior superior iliac
spine and pubic symphysis) 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

29. Ring invagination test
After reduction of hernia, the little finger/index
finger of the examiner is used to invaginate
from the bottom of the scrotum, gradually
pushed up and rotated to enter the superficial
inguinal ring impulse on coughing if impulse is
felt at the
tip of the invaginated finger:indirect
Pulp of the inaginated finger : direct
This test is done only in males

30. Zieman’s test
The examiner places his index finger on the deep
inguinal ring and middle finger on the
superficial inguinal ring, ring finger over saphenous
Opening, 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,
 middle finger its direct hernia,
 Ring finger femoral hernia

31. Head or leg rising test
done to look for abdominal wall muscle tone and
Malgaigne bulgings
Malgaigne bulgings are It is protrusion of
abdominal wall muscles during leg rising test as
weak, soft, supple, swelling, which signifies
poor abdominal muscle tone

32. Indirect inguinal hernia
 Can occur in any age from childhood
to adult
 Occurs in a pre-existing sac
 Protrusion through the deep ring
 Pyriform/oval in shape;
descends obliquely and downwards
 Can become complete by descending
down into scrotum
 Neck of the sac is narrow
and lateral to inferior epigastric artery
 Sac is antero-lateral to the cord
 Ring occlusion test does not
show any impulse after occluding the ring
 ring Invagination test shows impulse
on the tip of the of the little finger
 Zieman’s test shows impulse on the
index finger
 Commonly unilateral but can be
bilateral
 Obstruction/strangulation are common
 Sac should be opened during surgery
Direct inguinal hernia
 Common in elderly
 Always acquired
 Protusion occurs through posterior wall
 Globular/round in shape
descends directly forwardwards bulge
 Descent down into the scrotum is rare
 Neck of sac is wide and medial to inferior
epigastric artery
 Sac is posterior to the cord
 Test shows impulse even after occluding the
deep ring
 Impulse is felt over the pulp
little finger
 Test shows impulse on the
middle finger
 Commonly bilateral
 Rare but can occur
 Sac is not necessarily opened unless
obstruction
is present

33. Differential diagnosis
• Hydrocele – infantile/encysted/large vaginal/
bilocular
• Undescended testis
• Femoral hernia
• Lipoma of the cord
• Hydrocele of the canal of nuck (in females)
• Inguinal lymph node enlargement
• Groin abscess

34. INVESTIGATIONS
 Routine investigations
 Chest xray
 USG abdomen & pelvis

35. Treatment
 Treat the precipitating cause first
 Surgeries are the treatment of choice
 In children always HERNIOTOMY is done
 In adults HERNIOTOMY
HERNIOPLASTY
HERNIORAPHY

36. Herniotomy
 excision of hernial sac
 Anaesthesia: Spinal or G/A
 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 (outerCamper’s
fascia and inner Scarpa’s fascia) are incised

37.  External oblique aponeurosis is incised
 Upper leaf is reflected above and lower leaf is reflected
downwards to visualise and expose the inguinal ligament
Ilioinguinal nerve is safeguarded
 Cremasteric muscle is opened Cord structures are
dissected
 Sac which is anterior and lateral to cord is identified and
is pearly white in colour
 Dissection is usually started from the fundus and
extended towards the neck which is identified by
extraperitoneal fat
 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

38. Herniorrhaphy
 Shouldice
 Mac Vay
 Modified Bassini
high recurrence rate as it is repair with tension

39. Modified Bassini’s
Herniorrhaphy
It is strengthening of the posterior wall of the
inguinal canal by approximation of the conjoint
tendon to inguinal ligament using
INTERUPPTED monofilament nonabsorbable
suture material
External oblique is closed and other layers are
also closed
 Commonly used suture material is either
polypropylene [prolene (blue in colour)] or
polyethylene [ethylon (black in colour)].

41. Shouldice Repair
 multilayered repair
After doing herniotomy ,transversalis fascia is
incised from deep ring to pubic tubercle
Lower flap of fascia is sutured to posterior
part of the upper flap
Upper flap is sutured to the inguinal ligament
It is called DOUBLE BREASTING of
transversalis fascia

42.  Then conjoint tendon and inguinal
 ligament is further approximated by two layers of
 continuous sutures. External oblique aponeurosis
is
 sutured in two layers (double-breasting) in front of
the
 cord. Hence the original Shouldice repair is 6
layered
 procedure. First two layers of transversalis fascia,
next
 two layers of conjoint tendon and last two layers

43. Complications of herniorrhaphy
• Haemorrhage
• Haematoma
• Infection–1-5%
• Haematocele
• Post-herniorrhaphy hydrocele, lymphocele
• Hyperaesthesia over the medial side of inguinal
canal due to injury to ilioinguinal nerve -
neuralgia
• Recurrence
• Osteitis pubis
• Injury to urinary bladder/bowel
• Testicular atrophy, penile oedema rarely can occur

44. 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 thread or silk. (To narrow the
ring and push the
cord laterally

45. Hernioplasty
It is strengthening of posterior inguinal wall in
case of
indirect hernia or in any large hernia with weak
abdominal wall using a supportive material. This
allows
and supports good fibroblast proliferation which
in turn
strengthens the weak posterior wall of inguinal
canal or
abdominal wall

46. Hernioplasty is the present choice (ideal) for all
inguinal and groin hernias
Mesh is placed either
onlay (over conjoint tendon to inguinal ligament)
or
inlay (in preperitoneal space)
Polypropylene mesh is used
Herniotomy is done prior to mesh placement
 Lichtenstein, Rives, Gilbert, Stoppa,TEP,
TAPP

47. Material Used
• Synthetic: Prolene mesh (white in colour)
Dacron
mesh, Morlex mesh, Mersilene sheath
• Biological: Tensor fascia lata, temporal fascia
and
skin. (presently biological materials are not well
accepted as infection is common and its efficacy
is
not proved

48. Indications
• Direct hernia.
• Recurrent hernia.
• Re-recurrent hernia.
• Incisional hernia.
• Old age.
• Hernia with weak abdominal muscle tone.
• Sliding hernia.
Complications
• Infection.
• Mesh extrusion.
• Foreign body reaction

49. 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

50.  Onlay mesh repair by placing mesh in front. It
is
sutured above to conjoint tendon and below to
inguinal ligament using monofilament non
absorbable
suture material.
 Inlay mesh repair by placing mesh deep to
conjoint
tendon

51. LICHENSTIEN METHOD
 Tension free , simple , flat polypropylene mesh
repair
 After HERNIOTOMY
a piece of mesh of 8*15cm is placed over
posterior wall and split to wrap the spermatic
cord at deep inguinal ring
interrupted sutures are made between mesh,
inguinal ligament and conjoint tendon

53. Transabdominal Pre Peritoneal
Mesh Repair (TAPP)
Done using Laparoscope
 This is used in large indirect hernia or irreducible inguinal hernia
 10 mm umbilical port is used for Laparoscope
 5 mm ports are placed one on each side on pararectal point at
the or above the level of umbilicus so as to achieve adequate
triangulation
 Contents of the hernia are reduced
 Hernial sac is dissected in preperitoneal plane after making
horizontal incision at the upper part of the sac opening
 Vas, gonadal vessels,pubic bone, inferior epigastric vessels are
identified
 Once sac is dissected and excised, a prolene/vipro/ultrapro
mesh of 15 × 10 cm sized or smaller is placed in preperitoneal
space
 It is fixed to pubic bone using tacks
 Peritoneum is closed with continuous prolene sutures

54. Totally Extra Peritoneal Repair
TEP Repair
Done using Laparoscope
 This technique is gaining more popularity than TAPP
 Through sub-umbilical incision (10 mm) extra peritoneal space is reached
 After CO2 insufflation, another 5 mm port is inserted 4 cm below the first port
in the midline
 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, iliopectineal ligament, laterally to iliac vessels, and inferior epigastric
vessels
 15 × 15 cm mesh is placed and spread
 Care should be taken not to have any folding in the mesh
 Mesh may be sutured to iliopectineal ligament
 Displacementof mesh is not common
 Other side also can be done together

56. Ports used for
TEP and for TAPP
TEP after dissection prior to placement of
mesh.
Direct defect, inferior epigastric artery,
pubic symphysis and
Cooper’s ligament

57. Conservative treatment
:
1. Taxis: Patient is placed in supine position with
hip and knee flexed and hip internally rotated.
Contents are pushed with one hand directing with
other hand
2. Use of Truss: Rat-tailed sprung truss is used.
Measurement is taken from the tip of greater
trochanter to third piece of sacrum circumferentially
– Complications are discomfort, ulceration,
strangulation, inflammation
– It may be used in elderly people, who are not
fit for anaesthesia and surgery
– Conservative treatment should be avoided in
hernia as much as possible
– Truss is absolutely contraindicated in femoral
and sliding hernia

58. Complications of hernia

59. •Irreducible hernia: Here contents cannot be returned
to the abdomen due to narrow neck, adhesions,
overcrowding
Irreducibility predisposes to strangulation
•Obstructed hernia: It is an irreducible hernia with
obstruction, but blood supply to the bowel is not interfered
It eventually leads to strangulation.
Garrey’s stricture: Constriction that occurs due to
ischaemic narrowing of small bowel which has reduced
from an obstructed hernia
Inflamed hernia: It is due to inflammation of thecontents of
the sac e.g. appendicitis, salpingitis. Here hernia is tender
but not tense; overlying skin is red and oedematous.

60. STRANGULATED HERNIA
.
It occurs when blood supply of the contents of hernia is
seriously impaired leading to formation of gangrene
 Strangulation commonly occurs in the small bowel
and also in large bowel
 Occasionally strangulated omentocele also can occur
without any intestinal obstruction
 Strangulation can occur in inguinal, femoral,
obturator, umbilical or any hernias.
 Indirect inguinal hernia is more prone for
strangulation
than direct inguinal hernia. It is due to
narrow neck, adhesions, narrow external ring in
children

61. Obstruction
↓
Initially venous return is impaired
↓
Congestion of the bowel
↓
Further dilatation of the bowel which
becomes purple coloured
↓
Fluid collects in the sac
↓
Eventually arterial blood supply is impaired
↓
Bowel becomes dark, brownish black
coloured with flabby and friable wall
↓
Bacteria migrate transerosally and
multiply in fluid of the sac
↓
Perforation occurs at the site of constriction ring
↓
Peritonitis occurs.

62. TREATMENT
 The patient is admitted.
 • Ryle’s tube aspiration.
 • Intravenous fluids to correct dehydration and
 electrolyte imbalance.
 • Antibiotics.
 • Catheterisation to maintain adequate urine
output.
 • Emergency HERNIOTOMY

63. Maydl’s Hernia (Hernia-in-W)
Here a loop of bowel in
the form of ‘W’ lies in the hernial sac and the
centre portion of the ‘W’ loop is strangulated
and lies within
The abdominal cavity

64. TYPES OF HERNIA

66. FEMORAL HERNIA
Surgical Anatomy of Femoral Canal
 It is the medial, most compartment of the femoral sheath, which
extends from femoral ring above to saphenous opening below
 It contains fat, lymphatics, lymph node of Cloquet
 It is 1.25 cm long and 1.25 cm wide at the base.
 Below it is closed by cribriform fascia.
Femoral ring is bounded
 anteriorly by inguinal Ligament
 posteriorly by ilio pectineal ligament of Cooper,
pubic bone and fascia covering the pectineus muscle;
 medially by concave, sharp lacunar (Gimbernat’s) Ligament
 laterally by a thin septum separating from
femoral vein

68. Clinical Features
• Common in females (2:1 ratio), common in multipara
• Rare before puberty. 20% occurs bilateral, however more common on
right side
• Presents as a swelling in the groin below and lateral
to the pubic tubercle. (Inguinal hernia is above and
medial to the pubic tubercle)
• Swelling, impulse on coughing, reducibility, gurgling
sound during reduction, dragging pain, are the usual
features
• When obstruction and strangulation occurs which is more common,
presents with features of intestinal obstruction—painful, tender,
inflamed, irreducible swelling without any impulse
They also present with abdominal distension, vomiting and features of
toxicity.

69. Femoral hernia repair
 Lockwood low operation
 Mc’Evedy-High operation
 Lotheissen’s operation
 AK Henry’s approach
Inguinal ligament is
approximated to Cooper’s
[Iliopectineal line] ligament
Lotheissen’s repair conjoined
tendon is sutured to ilio
pectineal line.

70. PANTALOON HERNIA (DOUBLE
HERNIA,
SADDLE HERNIA, ROMBERG
HERNIA)
Here both direct and indirect inguinal sacs are
present and clinically present as direct hernia.
• During surgery, indirect sac may be missed and
so
leads to recurrent hernia through indirect sac

71. SLIDING HERNIA (HERNIA-EN-
GLISSADE
• Here posterior wall of the sac is not only formed by
the parietal peritoneum, but also by sigmoid colon
on
left side; caecum on right side and often with portion
of the bladder (Both sides)
• Content of the sac is usually small bowel or
omentum.
• Sliding hernia occurs exclusively in males. Mainly
on the
left side, if it occurs on right side appendix and
caecum will be present on the posterior wall

72.  Large globular swelling will be present over
the inguinal region
 Treatment is always surgery
 Posterior wall of Sac should not be seperated
from the colon and other structures

73. VENTRAL HERNIA
Any protrusion through abdominal wall with the
exception of hernia through the inguinofemoral
region is defined as ventral hernia
Incisional hernia (80%) and primary defects in
abdominal fascia causing
umbilical hernia, epigastric hernia, paraumbilical
hernia or Spigelian hernia are grouped under
ventral
hernia.

74. Umbilical hernia
 Develops due to absence of umbilical fascia or
incomplete closure of umbilical defect
 It can be congenital or acquired
 Acquired through weak umbilical scar
 Congenital will be presented few months after birth
which presents as a swelling in the umbilical region
which increase during crying
TREATMENT
Initially conservative
INDICATIONS FOR SURGERY
Persists after two years of age
>2 cm size
acquired

75. PARAUMBILICAL HERNIA
(Supra- and Infraumbilical
Hernia
 It occurs commonly in adults. It is a protrusion or
herniation through linea alba, just above or below
the umbilicus
 It enlarges ovally, often attains a large size and
sags
downwards.
• Neck of the sac is relatively narrow. Contents are
usually omentum, small bowel, sometimes large
bowel.
• It has got tendency to go for adhesion, irreducibility
and obstruction

76.  It presents as a swelling in with smooth
surface, distinct edges and impulse on cough
 Surgery is the treatment of choice
 Common for umbilical and para umbilical
 Dissection of sac with mesh placement
 Mayo’s operation: sac is identified & reduced
sac is transfixed, rectus sheath is double
breasted

77. Incisional hernia
 It is herniation through a weak abdominal scar of previous
surgery
Predisposing Factors
• Vertical scar, midline scar, lower abdominal scar— may injure
the nerves of the abdominal muscles
• Scar of major surgeries (biliary, pancreatic)
• Scar of emergency surgeries (peritonitis, acute abdomen)
• Faulty technique of closure
• Poor nutritional status of the patient
• Presence of
cough,tuberculosis,jaundice,anaemia,hypoproteinaemia
• Malignancy, immunosuppression
• Smoking in postoperative period
• Causes which increases the intra-abdominal pressure
(BPH, straining, stricture urethra or rectum, ascites)

78. Clinical Features
• Swelling in the scar region
• Pain
• Impulse on coughing
• Gurgling sound
• Often bowel peristalsis may be visible under
the skin
• Eventually features of irreducibility, obstruction,
strangulation is seen

79. TREATMENT
Surgeries for incisional hernia
• Mesh repair—commonly done and ideal
Done either sublay or onlay method or combined
 Rive’s Stoppa’s method of placing mesh
between
posterior rectus sheath and rectus muscle
Laproscopically can also be placed
• Layer by layer closure—Cattell’s operation
• Double breasting of the rectus sheath

80. • Keel operation—not commonly used now
Sac in inverted using continuous/interrupted
inverting non-absorbable sutures, layer by layer until
the defect margins are apposed together which is then
again sutured with interrupted sutures
• Nuttall’s operation—not commonly used now
done for lower midline incisional Hernia
Recti attachments are detached from
the pubic bones and are crossed over to fix
to opposite
pubic bones so as to create a firm abdominal
wall support by crossed recti muscles

81. Spigelian hernia
 It is a type of interparietal hernia(between external
oblique and internal oblique)
 Hernial sac lies either deep to the internal oblique or between
external and internal oblique muscles
Clinical Features
• Presents as a soft, reducible mass lateral
to the rectusmuscle and below the umbilicus
impulse on Coughing
Strangulation is common
Treatment
• lengthy transverse incision herniotomy
and closure of the defect layer by layer using
Nonabsorbable interrupted sutures
• mesh is required to cover the defect
properly

82. Obturator hernia
It is hernia occurring through obturator canal between superior ramus of
pubis and obturator membrane
Presents with features of intestinal obstruction
Howship-Romberg sign
Referred pain in knee joint through geniculate branch of obturator nerve
Treatment
• Laparotomy is done and the sac
is identified dissected and ligated
If strangulation is present
resection and anastomosis is done
• Mesh placement is the ideal way
of repairing obturator defect

83. Epigastric hernia(Fatty hernia of
linea alba)
It occurs usually through a defect in the decussation
of the fibres of linea alba, any where between xiphoid
process and umbilicus.
• Extraperitoneal fat protrudes through the defect as
fatty hernia of the linea alba presenting like a swelling
in the upper midline with an impulse on coughing.
• It is sacless hernia
Swiss cheese type : hernias are multiple

84. Clinical Features
• Often symptomless
• Swelling in the epigastric region which is tender.
• Pain in epigastric region
TREATMENT
Through a vertical incision, sac is dissected
Defectis closed with non-absorbable interrupted
sutures
• Large defect is supported with preperitoneal

85. RICHTER’S HERNIA
It is a hernia in which the sac contains only a portion
of the circumference of the intestine (small bowel). It
is
usually seen in femoral and obturator hernia.
Clinical Features
• It mimics gastroenteritis with pain abdomen,
diarrhoea,
toxicity, vomiting
• Gangrene (strangulation) of a part of bowel occurs,
eventually leading to peritonitis
Treatment
Resection and anastomosis

86. LUMBAR HERNIA
• It is herniation either through superior or inferior
lumbar triangle
• Superior lumbar triangle (Grynfelt’s/Lesgaft’s triangle)
is bounded by sacrospinalis, 12th rib and posterior
border of internal oblique
• Inferior lumbar triangle is bounded by latissimus
dorsi, external oblique and iliac crest (triangle of Petit)
• Lumbar hernia is common through inferior lumbar
Triangle
Treatment
Repair using fascial flaps or mesh

87. SCIATIC HERNIA
• It is the protrusion of the peritoneal sac through the
greater or lesser sciatic foramen
Types
Classified based on their relationship to the pyriformis
muscle and ischial spine
1. Suprapyriformis
2. Infrapyriformis
3. Subpyriformis
Sac lies deep to gluteus maximus
Treatment
Defect is covered by fascia mobilised from pyriformis
muscle after reducing the sac contents

88. PHANTOM HERNIA
• It is a muscular bulge as a result of local
muscular paralysis due to interference with
nerve supply of the affected muscles, like
poliomyelitis in lumbar region

89. THANKU