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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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Hernia
This document provides information about hernia surgery. It describes the different types of hernias including inguinal, incisional, femoral, umbilical, and epigastric hernias. It discusses the common presenting complaints of a hernia such as a lump or pain and precipitating factors. The document outlines the process of examining a patient for a hernia including inspection, palpation, and tests like the cough impulse and Zeimann's technique to determine the type of hernia. It also provides guidance on examining other related areas like abdominal muscles and performing a full systemic examination of the patient.
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Hernia
- 1. HERNIA SURGERY TONY2010 MBBS
- 2. HERNIA • PROTRUSIONOF A VISCUS OR A PART OF VISCUS THROUGH A NORMAL OR ABNORMAL OPENING IN THE WALLS OF ITS CONTAINING CAVITY TONY 2010 MBBS
- 3. HERNIA COMMON INGUINAL INCISIONAL FEMORAL UMBILICAL EPIGASTRIC RARE OBTURATOR SPIGELIAN GLUTEAL LUMBAR DIAPHRAGMATIC TONY 2010 MBBS
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- 7. HISTORY • AGE: YOUNG •INDIRECT OLD AGE (weak musculature) •DIRECT TONY 2010 MBBS
- 8. HISTORY • OCCUPATION=STRENOUS STRENOUS WORK PERSISTENT PROCESSUS VAGINALIS WEAK ABDOMINAL WALL HERNIATION TONY 2010 MBBS
- 9. • SEX •MOST COMMON HERNIA (BOTH IN MALES & FEMALES) INDIRECT • FEMORAL HERNIA IS COMMON IN FEMALES • DIRECT HERNIA IS ABSENT IN FEMALES & CHILDREN TONY 2010 MBBS IN FEMALES PELVIS IS TILTED ANTERIORLY APEX & BASE OF HSSELBACH TRIANGLE AT THE SAME LEVEL OBLITERATEDLESS CHANCE
- 10. PRESENTING COMPLAINTS TONY2010 MBBS
- 11. • ABOUT LUMP • COMPLICATIONS • ETIOLOGY (PRECIPITATING FACTORS) TONY 2010 MBBS
- 12. 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 TONY 2010 MBBS
- 13. 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 itself THOUGH CONGENITAL CAN APPEAR AT ANY AGE due to preformed sac TONY 2010 MBBS
- 14. PAIN • PAIN=DRAGGING & ACHING TYPE Appears b4 the swelling Increase with time Subsides when it is fully formed TONY 2010 MBBS
- 15. PAIN Acute pain around umbilicus tenderness strangulation Due to drag on mesentry TONY 2010 MBBS
- 16. PAIN • Instrangulation due to drag on mesentry pain all over the abdomen TONY 2010 MBBS
- 17. HISTORY SUGGESTIVE OF COMPLICATIONS: • Irreducibility, • severe pain in the groin over the swelling and also • colicky abdominal pain, abdominal distension, vomiting, • constipation TONY 2010 MBBS
- 18. acquired } smallinitially ↑ size gradually • REDUCIBILITY Reduces on lying down DIRECT Does not reduce on lying down INDIRECT TONY 2010 MBBS
- 19. • SYMPTOMS OFOBSTRUCTION COLICKY ABDOMINAL PAIN VOMITING •BILIOUS •FAECAL (USUALLY) ABDOMINAL DISTENSION ABSOLUTE CONSTIPATION TONY 2010 MBBS
- 20. 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 TONY 2010 MBBS OBSTRUCTION
- 21. PAST HISTORY •TB BA • PREVIOUS SURGERY •Damage to ilioinguinal nerve weak abdominal wall DIRECT hernia APPENDICECTOMY •Same side •Opposite side RECURRENT HERNIA TONY 2010 MBBS
- 22. FAMILY HISTORY •CONNECTIVE TISSUE DISORDERS TONY 2010 MBBS
- 23. PERSONAL HISTORY •History of Smoking: • Smoking leads to chronic bronchitis • Collagen deficiency occurs in smokers. TONY 2010 MBBS
- 24. LOCAL EXAMINATION TONY2010 MBBS
- 25.
- 26. INSPECTION • Patientin 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 TONY 2010 MBBS
- 27. INSPECTION • EXPOSE4M UMBILICUSMID THIGH POSITION OF PATIENT STANDING Inguinal, lumbar, femoral, epigastric, obturator, gluteal, spigelian SUPINE TONY 2010 MBBS
- 28. SWELLING shape sphericalfemoral direct pyriform indirect TONY 2010 MBBS
- 29. POSITION & EXTENT • Inguinal hernia above the inner part of inguinal ligament Inguinal hernia Congenital (complete) Extend in to scrotum acquired (funicular) Stops above testis TONY 2010 MBBS
- 30. POSITION & EXTENT • Femoral hernia starts below the inginal ligament and ascend over it TONY 2010 MBBS
- 31. VISIBLE PERISTALSIS •Invisible = femoral hernia • Visible in case of inguinal hernia when skin is thin as in case of recurrent hernia TONY 2010 MBBS
- 32. SKIN OVER THESWELLING • Uncomplicated=normal • Strangulated=reddened • Truss 4 long time=discolouration, due to deposition of hemosiderin streaks, • Scar=recurrence • Wide irregular puckered=wound infectionrecurrence TONY 2010 MBBS
- 33. 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 TONY 2010 MBBS
- 34. POSITION OF PENIS • Deviation of penis to opposite side= in large complete inguinal hernia TONY 2010 MBBS
- 35.
- 36. 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. TONY 2010 MBBS
- 37. 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 TONY 2010 MBBS
- 38. HOW TO IDENTIFYPUBIC TUBERCLE TONY 2010 MBBS
- 39. GET ABOVE THESWELLING • 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 TONY 2010 MBBS
- 40. GET ABOVE THESWELLING INGUINAL HERNIA • NOT ABLE TO GET ABOVE THE SWELLING SCROTAL SWELLING • ABLE TO GET SBOVE THE SWELLING TONY 2010 MBBS
- 41.
- 42.
- 43. CONSISTENCY • DOUGHY& GRANULAR} OMENTUM=OMENTOCELE • ELASTIC} INTESTINE=ENTEROCELE • TENSE & TENDER} STRANGULATED HERNIA TONY 2010 MBBS
- 44. RELATION OF THESWELLING 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 TONY 2010 MBBS
- 45. CLASSICAL SIGNS OFAN UNCOMPLICATED HERNIA TONY 2010 MBBS
- 46. 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 TONY 2010 MBBS
- 47.
- 48. EXPANSILE IMPULSE ISALSO PRESENT IN • Meningocele • Laryngocele • Empyema necessitans TONY 2010 MBBS
- 49. 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 finger superficial inguinal ring (superomedial to pubic tubercle) Ring finger saphenous opening (4cm blw & lateral 2 pubic tubercle) Hold the nose & blow or cough TONY 2010 MBBS
- 50. ZEIMANN’S TECHNIQUE Impulseon Index finger Middle finger Ring finger Indirect inguinal hernia Direct inguinal hernia Femoral hernia TONY 2010 MBBS
- 51. 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 TONY 2010 MBBS
- 52. HOW TO IDENTIFYDEEP RING TONY 2010 MBBS
- 53. HOW TO IDENTIFYDEEP RING TONY 2010 MBBS
- 54.
- 55. REDUCIBILITY • Reduceson lying down direct hernia • Using TAXIS • Flexes the thigh • Adduct the thigh • Rotate internally Relaxes superficial inguinal ring + oblique muscles • Reduces with gurgling=>ENTEROCELE Difficult to reduce initially but last part slips of easily • First part reduces easily last part difficultomentocele TONY 2010 MBBS
- 56.
- 57. 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 TONY 2010 MBBS
- 58. INVAGINATION TEST TONY2010 MBBS
- 59. INVAGINATION TEST TONY2010 MBBS
- 60. INVAGINATION TEST Fingergoes directly backward=direct hernia TONY 2010 MBBS
- 61. INVAGINATION TEST Fingergoes upwards, backwards, outwards= indirect TONY 2010 MBBS
- 62. INVAGINATION TEST Impulseon coughing Pulp of finger direct tip indirect TONY 2010 MBBS
- 63. 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 TONY 2010 MBBS
- 64. RING OCCLUSION TEST • Swelling appears even when deep ring is occluded=direct hernia • No swelling when deep ring is occluded = indirect hernia TONY 2010 MBBS
- 65.
- 66. IN CASE OFA 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 TONY 2010 MBBS
- 67. PERCUSSION • Resonant=enterocele • Dull =omentum/extraperitoneal fatty tissue Diff b/w a/c epididymitis a/c filalrial funiclitis & strangulated hernia TONY 2010 MBBS
- 68. AUSCULTATION • Peristalticsounds=enterocele TONY 2010 MBBS
- 69. EXAMINATION OF TESTIS ,SPERMATIC CORDS & EPIDIDYMIS • Testis traction test: pull testis downwards encysted hydrocele}descends slightly & become fixed inguinal hernia}cant be fixed TONY 2010 MBBS
- 70. EXAMINATION OF TONEOF 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 TONY 2010 MBBS
- 71. ABDOMINAL MUSCLE STRENGTH TONY 2010 MBBS
- 72. MALGAGNES BULGING •Head or leg raising test: to test for abdominal muscle tone & malgaignes bulging TONY 2010 MBBS
- 73. SYSTEMIC EXAMINATION •RESPIRATORY SYSTEM • R/O • C/C BRONCHITIS ,TB • ABDOMEN • MASS • ASCITES TONY 2010 MBBS
- 74. • Abdominal examination • Respiratory system • Urinary systems • Per rectal examination TONY 2010 MBBS
- 75. PER-RECTAL EXAMINATION •1. Benign Prostate hypertrophy—micturition difficulty • 2.Malignant obstruction • 3. Chronic fissure—constipation TONY 2010 MBBS
- 76. • Diagnosis •• Side—right/left • • Type—indirect/direct • • Inguinal—femoral • • Complete/Incomplete • • Complicated/Uncomplicated • • Content—enterocele/omentocele TONY 2010 MBBS
- 77. DIFFERENTIAL DIAGNOSIS InguinalSwelling • 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 TONY 2010 MBBS
- 78. DIFFERENTIAL DIAGNOSIS Inmales • 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. TONY 2010 MBBS
- 79.
- 80. • Investigations •Treatment TONY 2010 MBBS
- 81. 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 TONY 2010 MBBS
- 82. 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 TONY 2010 MBBS
- 83. TRUSS • NotCurative 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. TONY 2010 MBBS
- 84. TAXIS • Supinehip & knee flexed hip internally rotated • Contents are pushed with one hand directed with the other TONY 2010 MBBS
- 85. TREATMENT • Surgery=treatment of choice • Under LA/GA/spinal/epidural surgery Hernioplasty herniorraphy TONY 2010 MBBS
- 86. Herniorraphy(strenghthenin g ofposterior 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 TONY 2010 MBBS
- 87. 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 TONY 2010 MBBS
- 88. HERNIOTOMY In indirectinguinal hernia • 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 TONY 2010 MBBS
- 89.
- 90. 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 TONY 2010 MBBS
- 91. PROCEDURE • Cremastericmuscle is opened TONY 2010 MBBS
- 92. • Herniotomy =ligation & excision of sac only • Herniorraphy = herniotomy + repair of posterior wall • Hernioplasty= herniotomy + reconstruction of posterior wall with prosthetics TONY 2010 MBBS
- 93.
- 94. 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 TONY 2010 MBBS
- 95. 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 TONY 2010 MBBS
- 96.
- 97. 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. TONY 2010 MBBS
- 98. 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 TONY 2010 MBBS
- 99. MODIFIED BASSINIS REPAIR TONY 2010 MBBS
- 100. MCVAY REPAIR •inguinal and femoral canal defects • The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally TONY 2010 MBBS
- 101. MC VAYS REPAIR TONY 2010 MBBS
- 102. 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. TONY 2010 MBBS
- 103. 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 cremaster may 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. TONY 2010 MBBS
- 104. 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 fascial flap. • 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. TONY 2010 MBBS
- 105. 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. TONY 2010 MBBS
- 106. SHOULDICE REPAIR •The cord is replaced within the inguinal canal, and the external inguinal aponeurosis is reapproximated with continuous 2-0 absorbable sutures TONY 2010 MBBS
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- 108.
- 109.
- 110.
- 111. TONY 2010 MBBS Tanner's muscle slide
- 112. 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. TONY 2010 MBBS
- 113. 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 TONY 2010 MBBS
- 114. HERNIOPLASTY • SOMEFORM 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 TONY 2010 MBBS
- 115. INDICATION FOR HERNIOPLASTY • Direct hernia, • Indirect hernia with poor muscle tone • Recurrent hernia • Re-recurrent hernia • Incisional hernia • Old age • Sliding hernia TONY 2010 MBBS
- 116. COMPLICATION • Meshextrusion • Foreign body reaction • infection TONY 2010 MBBS
- 117. PRINCIPLE • Sizeof mesh >size of defect • Attached above & below to conjoint tendon & inguinal ligament/abdominal wall using non absorbable sutures • Haemostasis, reduce risk of infection TONY 2010 MBBS
- 118. TYPES OF MESHREPAIR • 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 TONY 2010 MBBS
- 119.
- 120. ONLAY MESH METHOD: • repair by placing mesh in front…..using monofilament non absorbable suture material….above to conjoint tendon & below to inguinal ligament TONY 2010 MBBS
- 121. INLAY MESH METHOD • mesh deep to conjoint tendon TONY 2010 MBBS
- 122. NYHUS PREPERITONEAL MESH REPAIR • Broad mesh is kept in the preperitoneal space in b/l direct or recurrent hernia TONY 2010 MBBS
- 123. LICHTENSTEIN TENSION FREEMESH REPAIR • Less recurrence • Cord is covered with mesh and is sutured as in onlay method TONY 2010 MBBS
- 124. LICHENSTEIN TENSION FREEREPAIR TONY 2010 MBBS
- 125. TENSION – FREEREPAIR TONY 2010 MBBS
- 126. TENSION – FREEREPAIR TONY 2010 MBBS
- 127. LICHTENSTEIN TENSION-FREE REPAIR TONY 2010 MBBS
- 128. PROLENE HERNIA SYSTEM TONY 2010 MBBS
- 129. PROLENE HERNIAL SYSTEM TONY 2010 MBBS
- 130.
- 131. STOPPAS REPAIR •GPRVS (Giant Prosthesis for Reinforcement of Visceral Sac) • OVER FRICHAUDS MYOPECTINEAL ORIFICE TONY 2010 MBBS
- 132. • The StoppaRepair 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. TONY 2010 MBBS
- 133. LAPAROSCOPIC HERNIA REPAIR • Transabdominal Preperitoneal Procedure (TAPP) • Totally Extraperitoneal (TEP) Repair • Indications include bilateral inguinal hernia, recurring hernia, need for early recovery TONY 2010 MBBS
- 134.
- 135. TEP TONY 2010MBBS
- 136. TEP TONY 2010MBBS
- 137. TAPP TONY 2010MBBS
- 138. 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 TONY 2010 MBBS
- 139.
- 140. 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 TONY 2010 MBBS
- 141. • Deep inguinalring: 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. TONY 2010 MBBS
- 142.
- 143. • 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. TONY 2010 MBBS
- 144. 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 TONY 2010 MBBS
- 145. TONY 2010 MBBS 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.
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- 147.
- 148. 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 TONY 2010 MBBS
- 149. CONTENTS OF INGUINALCANAL TONY 2010 MBBS
- 150. COVERING OF SPERMATICCORD TONY 2010 MBBS
- 151. 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 TONY 2010 MBBS
- 152. 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 TONY 2010 MBBS
- 153.
- 154. 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. TONY 2010 MBBS
- 155. HASSELBACHS TRIANGLE TONY2010 MBBS 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.
- 156. • The lateralumbilical 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
- 157. ETIOLOGY • STRAINING C/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
- 158. ETIOLOGY • APPENDICECTOMY DESTROY ILIO INGUINAL NDIRECT INGUINALHERNIA McBURNEYS INCISION • FAMILIAL COLLAGEN DISORDER • CONGENITAL PREFORMED SAC (REMAINS OF PROCESSUS VAGINALIS) TONY 2010 MBBS
- 159. PARTS OF AHERNIA • SAC • COVERING OF SAC • CONTENTS OF SAC TONY 2010 MBBS
- 160. SAC • ADIVERTICULUM 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) TONY 2010 MBBS
- 161. COVERING OF SAC • LAYERS OF ABDOMINAL WALL TONY 2010 MBBS
- 162. 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 TONY 2010 MBBS
- 163.
- 164. CLINICAL CLASSIFICATION HERNIA REDUCIBLE HERNIA IRREDUCIBLE HERNIA OBSTRUCTED HERNIA INCARCERATED HERNIA STRANGULATED HERNIA INFLAMMED HERNIA TONY 2010 MBBS
- 165. CLINICAL CLASSIFICATION •REDUCIBLE HERNIA contents can be reduced by the patient or surgeon expansile impulse on coughing TONY 2010 MBBS
- 166. • IRREDUCIBLE HERNIAcan’t be reduced …due to adhesions b/w contents and sac…or due to crowding irreducibility + no other symptoms}OMENTOCELE Irreducibility predisposes to strangulation TONY 2010 MBBS
- 167. OBSTRUCTED HERNIA: bowel is obstructed…but blood supply is good TONY 2010 MBBS
- 168. 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. TONY 2010 MBBS
- 169. STRANGULATED HERNIA bloodsupply is impaired ISCHAEMIAGANGRENE OF INTESTINE TENDERNESS…. TENSE SAC NO IMPULSE ON COUGHING FEATURES OF INTESTINAL OBSTRUCTION TONY 2010 MBBS
- 170. • INFLAMMED HERNIA inflammation of contents of hernia sac appendicitis,salpingitis TONY 2010 MBBS
- 171. CLASSIFICATION hernia congenital acquired TONY 2010 MBBS
- 172. TYPES OF INGUINALHERNIA 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 TONY 2010 MBBS
- 173. Indirect inguinal herniaDirect 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 occur TONY 2010 MBBS
- 174.
- 175. INDIRECT HERNIA Deepring Whole of inguinal canal Superficial ring TONY 2010 MBBS DIRECT HERNIA Weak post wall of inguinal canal (hesselbachs triangle) Part of inguinal canal Superficial ring
- 176. INDIRECT INGUINAL HERNIA • Commonest more in males • Thin sac • Narrow neck • Lateral to inferior epigastric vessels TONY 2010 MBBS
- 177.
- 178. CLASSIFICATION( BASED ON EXTENT) Inguinal hernia incomplete bubonocele funicular complete Sac is confined to inguinalcanal Sac crosses superficial ring but not reaches bottom of scrotum Reaches bottom of scrotum TONY 2010 MBBS
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- 182. NYHUS CLASSIFICATION SYSTEM Type I INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, small adults Type II INDIRECT 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 IV RECURRENT HERNIA; modifiers A–D are sometimes added, which correspond TO INDIRECT, DIRECT, FEMORAL, AND MIXED, RESPECTIVELY TONY 2010 MBBS
- 183. 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 TONY 2010 MBBS
- 184. Direct hernia medial lateral TONY 2010 MBBS
- 185.
- 186. 2 CLASSICAL SIGNSOF UNCOMPLICATED HERNIA • Impulse on coughing • Reducibility TONY 2010 MBBS
- 187. COMPLICATIONS OF HERNIA • Irreducibility • Obstructed hernia • Strangulated hernia • Inflammation • Incarceration TONY 2010 MBBS
- 188. IRREDUCIBILITY • Adhesionsof 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) TONY 2010 MBBS
- 189. 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 TONY 2010 MBBS
- 190. INCARCERATED HERNIA •When it contains a portion of colon with faeces indenting with fingers putty like feeling TONY 2010 MBBS
- 191. STRANGULATED HERNIA •Irredudicibility + intestinal obstruction + arrest of blood supply • Due to constriction at the neck TONY 2010 MBBS
- 192. SIGNS OF STRANGULATEDHERNIA • Tense • Tender • No impulse on coughing • irreducible • Recent increase in size TONY 2010 MBBS
- 193. TREATMENT • Raisethe 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. TONY 2010 MBBS
- 194. • Non viablebowel • Greenish/blackish in colour • No peristalsis • Gut is flaccid & lusture less • Fluid of sac is bllod stained & foul smelling TONY 2010 MBBS
- 195. FEMORAL HERNIA Femoral canal Saphenous opening TONY 2010 MBBS
- 196. ANATOMY • Femoralcanal: 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 TONY 2010 MBBS
- 197.
- 198. SAPHENOUS OPENING TONY2010 MBBS • 4cm below & lateral to pubic tubercle • Covered by cribriform fascia • Upper & outer margin are sharp will turn femoral hernia upwards
- 199.
- 200. COURSE OF FEMORALHERNIA TONY 2010 MBBS
- 201. COVERINGS • Skin • Superficial fascia • Cribriform fscia • Anterior layer of femoral sheath • Fatty content of femoral canal • Femoral septum • peritoneum TONY 2010 MBBS
- 202. • Increased chanceof strangulation • F>M • Uncommon in children • Symptoms • Pain • Swelling TONY 2010 MBBS
- 203. • Position •Below & lateral to pubic tubercle • Shape • Globular/ retort (if large) • Narrow neck • Absent impulse on coughing • Irreducible • Strangulation • consistency TONY 2010 MBBS
- 204. • Position •Zeimanns test • Impulse on ring finger • Invagination test • Empty inguinal canal • Ring occlusion of saphenous opening TONY 2010 MBBS
- 205. DD • Saphenavarix • Aneurysm • Psoas abscess • Undescended ectopic testis • Lipoma • Psoas bursa • Hydrocele of femoral hernia sac TONY 2010 MBBS
- 206. TREATMENT • Highoperation 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
- 207. 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
- 208. 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
- 209. 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
- 210. 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
- 211. 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 TONY 2010 MBBS
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- 215. LUMBAR HERNIA TONY2010 MBBS
- 216. UMBILICAL HERNIA Umbilicalhernia Exomphalos Umbilical hernia in infants & children Para umbilical hernia of adults TONY 2010 MBBS
- 217. EXOMPHALOS • Failureof all or part of the midgut to return to the abdominal cavity during early fetal life • Outer } amniotic membrane • Middle } whartons jelly • Inner } peritoneum exomphalos Exomphalos minor Exomphalos major TONY 2010 MBBS
- 218.
- 219. EXOMPHALOS MAJOR •Umbilical cord attached to inferior aspect of large swelling • Contains SI… LI & part of liver TONY 2010 MBBS
- 220. • Exomphalos majormay burst • So emergency Sx is needed TONY 2010 MBBS
- 221. EXOMPHALOS MINOR •Sac is small • Umbilical cord is attached to its summit TONY 2010 MBBS
- 222.
- 223. UMBILICAL HERNIA ININFANTS & CHILDRENS • Through umbilical cicatrix • Spherical in shape • Increase in size in crying TONY 2010 MBBS
- 224.
- 225. PARAUMBILICAL HERNIA OF ADULTS • Not through umbilical cicatrix but through linea alba • Above (supraumbilical) • Below (infraumbilical) TONY 2010 MBBS
- 226. INTERSTITIAL HERNIA •Hernial sac lies between muscle layers of abdominal wall • Preperitoneal/intraparietal • Interparietal • Extraparietal TONY 2010 MBBS
- 227. LITTRE’S HERNIA •Meckels diverticulum is the content TONY 2010 MBBS
- 228. CAUSES OF RECURRENCEOF 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 TONY 2010 MBBS
- 229. HERNIA OF AHYDROCELE LOCALIZED THINNING OF TUNICA LEADING TO PSEUDOPODIUM-LIKE PROJECTION, USUALLY SEEN WHEN THE SAC IS THICK AND FLUID IS UNDER TENSION through
- 230. HYDROCELE OF AHERNIA 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
- 231. 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