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HERNIA 
SURGERY 
TONY 2010 MBBS
HERNIA 
• PROTRUSION OF A VISCUS OR A PART OF VISCUS THROUGH A NORMAL OR 
ABNORMAL OPENING IN THE WALLS OF ITS CONTAINING CAVITY 
TONY 2010 MBBS
HERNIA COMMON 
INGUINAL 
INCISIONAL 
FEMORAL 
UMBILICAL 
EPIGASTRIC 
RARE 
OBTURATOR 
SPIGELIAN 
GLUTEAL 
LUMBAR 
DIAPHRAGMATIC 
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TONY 2010 MBBS
TONY 2010 MBBS
HISTORY 
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HISTORY 
• AGE : 
YOUNG 
•INDIRECT 
OLD AGE (weak musculature) 
•DIRECT 
TONY 2010 MBBS
HISTORY 
• OCCUPATION =STRENOUS 
STRENOUS 
WORK 
PERSISTENT 
PROCESSUS 
VAGINALIS 
WEAK 
ABDOMINAL 
WALL 
HERNIATION 
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• SEX 
• MOST COMMON HERNIA (BOTH IN MALES & FEMALES) INDIRECT 
• FEMORAL HERNIA IS COMMON IN FEMALES 
• DIRECT HERNIA IS ABSENT IN FEMALES & CHILDREN 
TONY 2010 MBBS 
IN FEMALES 
PELVIS IS TILTED ANTERIORLY APEX & BASE OF 
HSSELBACH TRIANGLE AT THE SAME LEVEL  
OBLITERATEDLESS CHANCE
PRESENTING COMPLAINTS 
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• ABOUT LUMP 
• COMPLICATIONS 
• ETIOLOGY (PRECIPITATING FACTORS) 
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LUMP 
• 1. Duration 
• 2. Onset: Suddenly/gradually 
• 3. Site of start: 
• From groin to scrotum (hernia) 
• From scrotum to groin (hydrocele and varicocele) 
• 4. Aggravating factors: 
• – On straining 
• – On standing 
• – On coughing 
• 5. Relieving factors: 
• – By lying down 
• – Manuallybyhimself 
• 6. Associated with pain: Usually painless 
TONY 2010 MBBS
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
PAIN 
• PAIN= DRAGGING & ACHING TYPE 
Appears b4 
the swelling 
Increase 
with time 
Subsides 
when it is 
fully formed 
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PAIN 
Acute pain 
around 
umbilicus 
tenderness strangulation 
Due to drag 
on mesentry 
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PAIN 
• In strangulation due to drag on mesentry pain all over the abdomen 
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HISTORY SUGGESTIVE OF 
COMPLICATIONS: 
• Irreducibility, 
• severe pain in the groin over the swelling and also 
• colicky abdominal pain, abdominal distension, vomiting, 
• constipation 
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acquired } small initially ↑ size gradually 
• REDUCIBILITY 
Reduces on lying down DIRECT 
Does not reduce on lying 
down INDIRECT 
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• SYMPTOMS OF OBSTRUCTION 
COLICKY ABDOMINAL PAIN 
VOMITING 
•BILIOUS 
•FAECAL (USUALLY) 
ABDOMINAL DISTENSION 
ABSOLUTE CONSTIPATION 
TONY 2010 MBBS
PRECIPITATING FACTORS 
• C/C COUGH=TB ,BA,C/C BRONCHITIS 
• STRAINING IN 
• CONSTIPATION 
• FREQUENCY OF MICTURITION 
• URGENCY OF BENIGN ENLARGEMENT OF PROSTATE 
• PHIMOSIS 
• PINHOLE MEATUS 
• PENILE STRICTURES 
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OBSTRUCTION
PAST HISTORY 
• TB BA 
• PREVIOUS SURGERY 
•Damage to ilioinguinal nerve 
 weak abdominal wall 
DIRECT hernia 
APPENDICECTOMY 
•Same side 
•Opposite side 
RECURRENT HERNIA 
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FAMILY HISTORY 
• CONNECTIVE TISSUE DISORDERS 
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PERSONAL HISTORY 
• History of Smoking: 
• Smoking leads to chronic bronchitis 
• Collagen deficiency occurs in smokers. 
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LOCAL EXAMINATION 
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INSPECTION 
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INSPECTION 
• Patient in standing position 
• 1. Site 
• 2. Size 
• 3. Shape 
• 4. Extent 
• 5. Surface 
• 6. Skin over the swelling 
• 7. Visible peristalsis 
• 8. Cough impulse 
• 9. Draining lymph nodes 
• 10. Penis 
• 11. Urethral meatus 
• 12. Opposite scrotum 
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INSPECTION 
• EXPOSE 4M UMBILICUSMID THIGH 
POSITION OF 
PATIENT 
STANDING 
Inguinal, lumbar, 
femoral, 
epigastric, 
obturator, gluteal, 
spigelian 
SUPINE 
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SWELLING 
shape spherical femoral 
direct 
pyriform indirect 
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POSITION & EXTENT 
• Inguinal hernia  above the inner part of inguinal ligament 
Inguinal 
hernia 
Congenital 
(complete) 
Extend in to 
scrotum 
acquired 
(funicular) 
Stops 
above testis 
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POSITION & EXTENT 
• Femoral hernia  starts below the inginal ligament and ascend over it 
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VISIBLE PERISTALSIS 
• Invisible = femoral hernia 
• Visible in case of inguinal hernia when skin is thin as in case of recurrent 
hernia 
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SKIN OVER THE SWELLING 
• Uncomplicated=normal 
• Strangulated=reddened 
• Truss 4 long time=discolouration, due to deposition of hemosiderin 
streaks, 
• Scar=recurrence 
• Wide irregular puckered=wound infectionrecurrence 
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IMPULSE ON COUGHING 
• Characteristic of hernia 
Impulse on 
coughing 
present 
Expansile impulse 
on coughing 
(increase in size 
with coughing) 
Momentary bulge 
synchronous with 
coughing 
absent obstructed 
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POSITION OF PENIS 
• Deviation of penis to opposite side= in large complete inguinal hernia 
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PALPATION 
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PALPATION 
• 1. Temperature 
• 2. Tenderness 
• 3. Site 
• 4. Size 
• 5. Shape 
• 6. Extent 
• 7. Surface 
• 8. Skin over the swelling 
• 9. Consistency 
• 10. Reducibility 
• 11. Get above the swelling 
• 12. Cough impulse 
• 13. Invagination test 
• 14. Ring occlusion test 
• 15. Zieman's technique. 
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POSITION & EXTENT 
• SWELLING REACHING SCROTUM/LABIA MAJORA}INGUINAL HERNIA 
Swelling in the groin 
Above inguinal 
ligament 
Medial to pubic 
tubercle 
INGUINAL 
Below inguinal 
ligament 
Lateral to pubic 
tubercle 
FEMORAL 
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HOW TO IDENTIFY PUBIC TUBERCLE 
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GET ABOVE THE SWELLING 
• DISTINGUISH B/W INGUINAL & INGUINOSCROTAL SWELLING 
• NO USE IN FEMORAL HERNIA 
ROOT OF SCROTUM IS HELD B/W THUMB IN FRONT & 
OTHER FINGERS BEHIND THE SWELLING IN AN ATTEMPT 
TO GET ABOVE THE SWELLING 
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GET ABOVE THE SWELLING 
INGUINAL HERNIA 
• NOT ABLE TO GET ABOVE THE 
SWELLING 
SCROTAL SWELLING 
• ABLE TO GET SBOVE THE SWELLING 
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CONSISTENCY 
• DOUGHY & GRANULAR} OMENTUM=OMENTOCELE 
• ELASTIC} INTESTINE=ENTEROCELE 
• TENSE & TENDER} STRANGULATED HERNIA 
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RELATION OF THE SWELLING TO 
THE TESTIS & SPERMATIC CORD 
INGUINAL HERNIA 
•Remains in front & sides of spermatc cord and 
testes which remains incorporated in front and sides 
FUNICULAR 
• Stops just above the testis 
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CLASSICAL SIGNS OF AN UNCOMPLICATED 
HERNIA 
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EXPANSILE IMPULSE ON 
COUGHING 
• STANDING POSITION 
• ABSENT IN CASE OF STRANGULATED & INCARCERATED HERNIA 
1. MOMENTARY BULGE IN SUPERFICIAL RING ON COUGHUING 
2. ROOT OF SCROTUM B/W INDEX FINGER & THUMB IS SEPARATED ON 
COUGHING 
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EXPANSILE IMPULSE IS ALSO 
PRESENT IN 
• Meningocele 
• Laryngocele 
• Empyema necessitans 
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ZEIMANN’S TECHNIQUE 
• Distinguish b/w direct, indirect or femoral hernia 
• Can be used only when the swelling is completely reduce 
when there is no visible swelling 
Index finger deep inguinal ring (1/2 “ above mid inguinal point) 
Middle finger superficial inguinal ring (superomedial to pubic tubercle) 
Ring finger saphenous opening (4cm blw & lateral 2 pubic tubercle) 
Hold the nose & blow or cough 
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ZEIMANN’S TECHNIQUE 
Impulse on 
Index finger 
Middle finger 
Ring finger 
Indirect inguinal hernia 
Direct inguinal hernia 
Femoral hernia 
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ZEIMANN’S TECHNIQUE 
• In presence of swelling  coughing  expansile impulse on coughing 
Movement of swelling is not a criterion 
bcz as these swellings move with 
coughing 
Encysted hydrocele of 
cord : localized swelling 
of spermatic cord 
Undescended testis 
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HOW TO IDENTIFY DEEP RING 
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HOW TO IDENTIFY DEEP RING 
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REDUCIBILITY 
• Reduces on lying down  direct hernia 
• Using TAXIS 
• Flexes the thigh 
• Adduct the thigh 
• Rotate internally 
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 difficultomentocele 
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REDUCIBILITY 
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INVAGINATION TEST 
• After reduction of hernia in recumbent position 
• Using little finger  rt. Hand side for rt. Side 
lt. hand side for lt. side 
• Invaginate skin 4m the bottom of scrotum & the little finger is pushed to 
palpate pubic tubercle 
• Finger is then rotated & pushed further up in to superficial inguinal ring 
• Nail will be against spermatic cord pulp will feel walls of ring 
• Normal ring transmits only tip of finger ,>1 finger}abnormally large 
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INVAGINATION TEST 
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INVAGINATION TEST 
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INVAGINATION TEST 
Finger goes 
directly 
backward=direct 
hernia 
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INVAGINATION TEST 
Finger goes upwards, 
backwards, 
outwards= indirect 
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INVAGINATION TEST 
Impulse on 
coughing 
Pulp of 
finger 
direct 
tip indirect 
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RING OCCLUSION TEST 
• Standing position after reduction of swelling 
• Using thumb pressure over the deep inguinal ring (1/2 “ above mid inguinal 
point) & is asked to cough 
• Occlude direct hernia but not direct hernia 
• Similarly on saphenous opening= femoral hernia 
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RING OCCLUSION TEST 
• Swelling appears even when deep ring is occluded=direct hernia 
• No swelling when deep ring is occluded = indirect hernia 
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IN CASE OF A CHILD 
• Inguinal hernia is invisible in child due to presence of thick pad of fat over 
inguinal region 
• To make it visible ask him to jolt/jump/make it cry 
• Gornalls test: child is held from back by both hands of the clinician on its 
abdomen,abdomen is pressed and child is lifted up 
increased intra abdominal pressure 
hernia more prominent 
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PERCUSSION 
• Resonant=enterocele 
• Dull =omentum/extraperitoneal fatty tissue 
Diff b/w a/c epididymitis 
a/c filalrial funiclitis & 
strangulated hernia 
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AUSCULTATION 
• Peristaltic sounds=enterocele 
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EXAMINATION OF TESTIS 
,SPERMATIC CORDS & EPIDIDYMIS 
• Testis traction test: pull testis downwards 
encysted hydrocele}descends slightly & become fixed 
inguinal hernia}cant be fixed 
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EXAMINATION OF TONE OF 
ABDOMINAL MUSCLES 
• Inspectionprotrusion of lower abdominal wall 
• Malgaigne’s bulging: 
• oval shaped b/l bulge on straining above & parallel to medial half of inguinal 
ligament 
• weakness of abdominal wall 
• DIRECT HERNIA 
• HERNIOPLASTY IS REQUIRED 
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ABDOMINAL MUSCLE STRENGTH 
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MALGAGNES BULGING 
• Head or leg raising test: to test for abdominal muscle tone & malgaignes 
bulging 
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SYSTEMIC EXAMINATION 
• RESPIRATORY SYSTEM 
• R/O 
• C/C BRONCHITIS ,TB 
• ABDOMEN 
• MASS 
• ASCITES 
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• Abdominal examination 
• Respiratory system 
• Urinary systems 
• Per rectal examination 
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PER-RECTAL EXAMINATION 
• 1. Benign Prostate hypertrophy—micturition difficulty 
• 2.Malignant obstruction 
• 3. Chronic fissure—constipation 
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• Diagnosis 
• • Side—right/left 
• • Type—indirect/direct 
• • Inguinal—femoral 
• • Complete/Incomplete 
• • Complicated/Uncomplicated 
• • Content—enterocele/omentocele 
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DIFFERENTIAL DIAGNOSIS 
Inguinal Swelling 
• 1. Enlarged lymph 
nodes 
• 2. Undescended 
testis 
• 3. Lipoma 
• 4. Femoral hernia 
• 5. Saphena varix 
• 6. Psoas abscess 
• 7. Femoral aneurysm 
Inguinoscrotal Swelling 
• 1. Encysted 
hydrocele of cord 
• 2. Varicocele 
• 3. Lymphvarix 
• 4. Diffuse lipoma of 
cord 
• 5. Inflammatory 
thickening of cord 
Femoral Hernia 
• 1. Inguinal hernia 
• 2. Saphenavarix 
• 3. Cloquet’s node 
• 4. Lipoma 
• 5. Femoral aneurysm 
• 6. Psoas abscess 
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DIFFERENTIAL DIAGNOSIS 
In males 
• Hydrocele – 
infantile/encysted/large vaginal/ 
• Undescended testis 
• Femoral hernia 
• Lipoma of the cord 
• Hydrocele of the canal of nuck 
(in females) 
• Inguinal lymph node 
enlargement 
• Groin abscess 
In females 
• hydrocele of the canal of Nuck – 
this is the most common dif-ferential 
diagnostic problem 
• femoral hernia. 
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MANAGEMENT 
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• Investigations 
• Treatment 
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INVESTIGATIONS 
• I. Routine 
• • Hemoglobin 
• • Bleeding time/Clotting time 
• • Total count, differential count, ESR 
• • Urine—albumin, sugar deposits 
• • Blood—urea, sugar 
• • Blood grouping/typing—for irreducible hernia/huge hernia 
• II. Anesthetic Purpose 
• • X-ray chest (Chronic TB, Asthma—precipitate hernia) 
• • ECG all leads 
• III. USG Abdomen and Pelvis 
• • In old age group—to find benign prostate hyperplasia calculate post-voidal 
residual urine. If >100 ml it is significant 
• • To find any mass 
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TREATMENT 
• TREATMENT 
• Treat the precipitating cause of hernia first. 
• 1. Benign prostate hypertrophy 
• 2. Tuberculosis 
• 3. Stop smoking 
• Conservative management 
• indicated only in cases of very old man with direct hernia; since there is no 
chance of obstruction. 
• TRUSS 
• surgery 
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TRUSS 
• Not Curative for hernia. 
• It is a special belt devised to keep the hernia reduced at the deep ring or 
Hesselbach triangle for those who are unfit or unwilling for surgery 
• Hernia should be reducible to wear a truss. 
• Contraindicated 
• cases of irreducible hernia, 
• undescended testis, 
• associated huge hydrocele, 
• unintelligent people. 
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TAXIS 
• Supine hip & knee flexed hip internally rotated 
• Contents are pushed with one hand directed with the other 
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TREATMENT 
• Surgery= treatment of choice 
• Under LA/GA/spinal/epidural 
surgery 
Hernioplasty 
herniorraphy 
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Herniorraphy(strenghthenin 
g of posterior wall) 
• 1. Original Bassini 
• 2. Modified Bassini 
• 3. McVay’s 
• 4. Shouldice 
Hernioplasty (prosthetic 
repair ) 
• 1. Lichtenstein 
• 2. Gilbert’s plug 
• 3. Prolene hernia system 
• 4. Laparoscopic mesh repair 
• 5. Stoppas repair 
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HERNIORRHAPHY 
• 1. Herniotomy 
• 2. Narrowing of the deepring with 2'0 prolene (Lytle'sRepair) 
• 3. Approximation of conjoint tendon with inguinal ligament using 1‘ 
polypropylene material 
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HERNIOTOMY 
In indirect inguinal 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 
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PROCEDURE 
• ANAESTHESIA: spinal or G/A 
• Incision is made parallel to medial 2/3rd of inguinal ligament about 1.25 cm 
above inguinal ligament 
• After dividing superficial fascia and securing hemostasis 
• Identify external oblique muscle & superficial inguinal ring 
• External oblique Apo neurosis is incised in the line of its fibers and is reflected 
above and below.thus visualize inguinal ligament 
• Ilioinguinal nerve is thus identified and preserved 
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PROCEDURE 
• Cremasteric muscle is opened 
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• Herniotomy = ligation & excision of sac only 
• Herniorraphy = herniotomy + repair of posterior wall 
• Hernioplasty= herniotomy + reconstruction of posterior wall with prosthetics 
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HERNIORRAPHY 
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HERNIORRHAPHY 
• HERNIOTOMY+ REPAIR OF THE POSTERIOR WALL OF INGUINAL CANAL BY 
APPOSING CONJOINED MUSCLE TO THE INGUINAL LIGAMENT 
• INDN 
• IN ALL INDIRECT HERNIA EXCEPT IN CHILDREN 
• IN ADULTS WITH GOOD MUSCLE TONE 
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BASSINI REPAIR 
• Is frequently used for indirect 
inguinal hernias and small 
direct hernias 
• The conjoined tendon of the 
transversus abdominis and the 
internal oblique muscles is 
sutured to the inguinal 
ligament 
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BASSINI REPAIR 
• The conjoined tendon is retracted upward 
• the aponeurosis of the transversus abdominis muscle is approximated to the 
iliopubic tract that lies adjacent to the inguinal ligament with several 
interrupted 3-0 silk sutures. 
• The second layer of the repair involves suturing the conjoined tendon to the 
inguinal ligament with interrupted 2-0 silk sutures. 
• This suture line extends from the pubic tubercle to the medial border of the 
internal ring. 
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MODIFIED BASSINIS REPAIR 
• Most commonly used EARLIER 
• Using non absorbable monofilament interrupted suture material 
strengthening of posterior wall of inguinal canal approximation of conjoint 
tendon to inguinal ligament 
• Nonsorbable  adequate tensile strength for about 6 months 
• Monofilamentpolyfilament has crevices=infn 
• Interrupted continuous suture= decrease blood supply interfere with 
healing 
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MODIFIED BASSINIS REPAIR 
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MCVAY REPAIR 
• inguinal and 
femoral canal 
defects 
• The conjoined 
tendon is sutured to 
Cooper’s ligament 
from the pubic 
cubicle laterally 
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MC VAYS REPAIR 
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SHOULDICE REPAIR 
• With a no. 15 scalpel an incision is made in the transversalis fascia. This 
incision is extended from the internal ring to the pubic tubercle. 
• The repair involves placing four lines of sutures. 
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SHOULDICE REPAIR 
• First, the transversalis fascia is divided from the internal inguinal ring to the pubic 
tubercle. The posterior wall repair is accomplished by imbricating the lateral and 
medial leaves of the divided transverse aponeurotic fascial fibers with a continuous 
suture. The superomedial flap is brought over the inferolateral flap. The first suture line 
begins at the pubic tubercle and is sewn in a continuous fashion up to the internal 
ring, suturing the free edge of the inferolateral flap to the underside of the 
superomedial flap. At the internal inguinal ring, the cranial portion of the 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. 
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SHOULDICE REPAIR 
• The first suture line 
• is started at the pubic tubercle using 3-0 continuous polypropylene, and the 
white line is approximated to the free edge of the inferior transversalis 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. 
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SHOULDICE REPAIR 
• The third suture line is started at the level of the internal ring where the 
conjoined tendon is approximated to the inguinal ligament and tied when 
the pubic tubercle is reached. 
• Using the same suture, the fourth suture line attaches these same structures 
to one another and is tied at the level of the internal ring. 
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SHOULDICE REPAIR 
• The cord is replaced within the inguinal canal, and the external inguinal 
aponeurosis is reapproximated with continuous 2-0 absorbable sutures 
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Tanner's muscle slide
DARNING 
• • A type of herniorrhaphy which is done by suturing the conjoined tendon 
with inguinal ligament using 1 prolene without tension. 
• • The suture material appears like mesh due to multiple crossings. 
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TANNER'S MUSCLE SLIDE 
• Basically all the herniorrhaphy are tension repairs 
• To avoid tension in the rhaphy site, the incision made curvilinearly over the 
anterior rectus sheath 
• This relaxes the conjoined muscles and thus gets approximated with inguinal 
ligament without tension 
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HERNIOPLASTY 
• SOME FORM OF supportive MATERIAL IS USED TO STRENGTHEN POSTERIOR 
ABDOMINAL WALL 
HERNIOPLASTY 
SYNTHETIC 
BIOLOGICAL 
Synthetic non 
absorbable prolene, 
Dacron are used 
Tensor fascia 
lata,temporal 
fascia,skin 
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INDICATION FOR HERNIOPLASTY 
• Direct hernia, 
• Indirect hernia with poor muscle tone 
• Recurrent hernia 
• Re-recurrent hernia 
• Incisional hernia 
• Old age 
• Sliding hernia 
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COMPLICATION 
• Mesh extrusion 
• Foreign body reaction 
• infection 
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PRINCIPLE 
• Size of mesh >size of defect 
• Attached above & below to conjoint tendon & inguinal ligament/abdominal 
wall using non absorbable sutures 
• Haemostasis, reduce risk of infection 
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TYPES OF MESH REPAIR 
• 1. In lay mesh 
• 2. On lay mesh 
• 3. Nyhus preperitoneal mesh repair 
• 4. Stoppa procedure 
• 5. Gilbert mesh repair 
• 6. Lichtenstein’s method 
• 7. TAPP 
• 8. TEP 
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TONY 2010 MBBS
ONLAY MESH METHOD: 
• repair by placing mesh in front…..using monofilament non absorbable suture 
material….above to conjoint tendon & below to inguinal ligament 
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INLAY MESH METHOD 
• mesh deep to conjoint tendon 
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NYHUS PREPERITONEAL MESH 
REPAIR 
• Broad mesh is kept in the preperitoneal space in b/l direct or recurrent hernia 
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LICHTENSTEIN TENSION FREE MESH 
REPAIR 
• Less recurrence 
• Cord is covered with mesh and is sutured as in onlay method 
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LICHENSTEIN TENSION FREE REPAIR 
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TENSION – FREE REPAIR 
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TENSION – FREE REPAIR 
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LICHTENSTEIN 
TENSION-FREE REPAIR 
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PROLENE HERNIA SYSTEM 
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PROLENE HERNIAL SYSTEM 
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STOPPAS REPAIR 
• GPRVS (Giant Prosthesis for 
Reinforcement of Visceral Sac) 
• OVER FRICHAUDS MYOPECTINEAL 
ORIFICE 
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• The Stoppa Repair is a tension free type of hernia repair. It is performed by 
wrapping the lower part of the parietal peritoneum with prosthetic mesh and 
placing it at a preperitoneal level over Fruchauds myopectineal orifice. It 
was first described in 1975 by Rene Stoppa.[1] This operation is also known 
as giant prosthetic reinforcement of the visceral sac (GPRVS).[2] 
• This technique has met particular success in the repair of bilateral hernias, 
large scrotal hernias, and recurrent or rerecurrent hernias in which 
conventional repair is difficult and carries a high morbidity and failure rate. 
TONY 2010 MBBS
LAPAROSCOPIC 
HERNIA REPAIR 
• Transabdominal Preperitoneal Procedure (TAPP) 
• Totally Extraperitoneal (TEP) Repair 
• Indications include bilateral inguinal hernia, recurring 
hernia, need for early recovery 
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TEP 
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TEP 
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TAPP 
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COMPLICATIONS OF HERNIA 
REPAIR 
IMMEDIATE 
1. Injury to the blood vessels 
(inferior epigastric and 
femoral) 
2. Injury to bowel and 
bladder 
3. Injury to ilioinguinal and 
iliohypogastric nerves 
4. Injury to cord structures 
EARLY 
1. Urine retention 
2. Hematoma 
3. Infection 
4. Periostitis of pubic tubercle (as 
the stitch is taken from periosteum) 
5. Postherniorrhaphy hydrocele 
(due to obstruction of lymphatics 
At deep ring when narrowed tightly) 
LATE 
1. Recurrence 
2. Numbness over the 
local region if the 
nerve was cut during 
surgery 
TONY 2010 MBBS
DISCUSSION 
TONY 2010 MBBS
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
• Deep inguinal ring: u shaped defect in transversalis fascia 1.25cm above 
mid inguinal point 
• Inguinal ligament: It is formed by the lower 
border of the external oblique aponeurosis 
which is 
thickened and folded backwards on itself 
, extending from 
anterior superior iliac spine to pubic tubercle. 
TONY 2010 MBBS
TONY 2010 MBBS
• 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
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
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.
TONY 2010 MBBS
TONY 2010 MBBS
CONTENTS OF INGUINALCANAL 
SPERMATIC CORD IN 
MALE 
• Vas deferens 
• Artery to vas 
• Testicular & cremasteric artery 
• Pampiniform plexus 
• Remains of processus vaginalis 
• Genital branch of 
genitofemoral nerve 
• Sympathetic plexus 
• lymphatics 
ROUND LIGAMENT IN 
FEMALE 
ILIO INGUINAL NERVE 
TONY 2010 MBBS
CONTENTS OF INGUINALCANAL 
TONY 2010 MBBS
COVERING OF SPERMATIC CORD 
TONY 2010 MBBS
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
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
TONY 2010 MBBS
FRUCHAUD’S MYOPECTINEAL ORIFICE 
• osseo-myo-aponeurotic tunnel. 
• medially 
• lateral border of rectus sheath; 
• above 
• the arched fibres of internal oblique and transverse abdominis muscle; 
• laterally 
• by the iliopsoas muscle; 
• below 
by the pectin pubis and fascia covering it. 
It Is through this tunnel all groin hernias occur. 
TONY 2010 MBBS
HASSELBACHS TRIANGLE 
TONY 2010 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.
• The lateral umbilical ligament (obliterated umbilical artery) crosses the 
triangle and divides it into 
• medial and lateral parts. The medial part of the floor of the triangle is 
strengthened by the conjoint tendon. The lateral part of the floor of the triangle 
is weak, hence direct inguinal hernia usually occurs through this part. 
TONY 2010 MBBS
ETIOLOGY 
• 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
ETIOLOGY 
• APPENDICECTOMY  DESTROY ILIO INGUINAL NDIRECT INGUINALHERNIA 
McBURNEYS INCISION 
• FAMILIAL COLLAGEN DISORDER 
• CONGENITAL PREFORMED SAC (REMAINS OF PROCESSUS VAGINALIS) 
TONY 2010 MBBS
PARTS OF A HERNIA 
• SAC 
• COVERING OF SAC 
• CONTENTS OF SAC 
TONY 2010 MBBS
SAC 
• A DIVERTICULUM OF PERITONEUM WITH 
 MOUTH 
 NECK 
 BODY 
 FUNDUS 
• NECK IS NARROW IN CASE OF INDIRECT WIDE IN CASE OF DIRECT 
• HERNIA WITHOUT NECK: HERNIA WITH A WIDE MOUTH ,DIRCT 
HERNIA,INCISIONAL HERNIA 
• SAC IS THIN IN INFANTS & CHILD THICK IN LONG STANDING & DIRECT HERNIA 
• HERNIA WITHOUT SAC: EPIGASTRIC HERNIA(Protrusion of extra peritoneal pad 
of fat) 
TONY 2010 MBBS
COVERING OF SAC 
• LAYERS OF ABDOMINAL WALL 
TONY 2010 MBBS
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
TONY 2010 MBBS
CLINICAL CLASSIFICATION 
HERNIA 
REDUCIBLE 
HERNIA 
IRREDUCIBLE 
HERNIA 
OBSTRUCTED 
HERNIA 
INCARCERATED 
HERNIA 
STRANGULATED 
HERNIA 
INFLAMMED 
HERNIA 
TONY 2010 MBBS
CLINICAL CLASSIFICATION 
• REDUCIBLE HERNIA contents can be reduced by the patient or surgeon 
expansile impulse on coughing 
TONY 2010 MBBS
• IRREDUCIBLE HERNIA can’t be reduced …due to adhesions b/w contents 
and sac…or due to crowding 
irreducibility + no other symptoms}OMENTOCELE 
Irreducibility predisposes to strangulation 
TONY 2010 MBBS
 OBSTRUCTED HERNIA : bowel is obstructed…but blood supply is good 
TONY 2010 MBBS
 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
STRANGULATED HERNIA blood supply is impaired ISCHAEMIAGANGRENE 
OF INTESTINE 
TENDERNESS…. TENSE SAC 
NO IMPULSE ON COUGHING 
FEATURES OF INTESTINAL OBSTRUCTION 
TONY 2010 MBBS
• INFLAMMED HERNIA 
inflammation of contents of hernia sac 
appendicitis,salpingitis 
TONY 2010 MBBS
CLASSIFICATION 
hernia 
congenital 
acquired 
TONY 2010 MBBS
TYPES OF INGUINAL HERNIA 
Inguinal 
hernia 
Direct 
indirect 
Through hesselbachs 
triangle in posterior wall of 
inguinal canal (medially 
by lateral border of rectus 
sheath,below by inguinal 
ligament,laterally by 
inferior epigastric artery) 
Through deep ring along with 
spermatic cord,lateral to 
inferior epigastric artery 
TONY 2010 MBBS
Indirect inguinal hernia Direct inguinal hernia 
1.any age from childhood to adult 1.Common in elderly 
2.Occurs in a pre-existing sac 2.Always acquired 
3. Protrusion through the deep ring; herniation 
occurs later 
3.Herniation through posterior wall of the 
inguinal canal 
4.Pyriform /oval in shape; descends obliquely 
and downwards 
4.Globular/round in shape; 
descends directly forward bulge 
5.Can become complete by 
descending down into the scrotum 
5.Rarely descend down into the scrotum 
6.Sac is antero-lateral to the cord 6.Sac is posterior to the cord 
7.Ring occlusion test no impulse after 
occluding the deep ring 
7. impulse even 
after occluding the deep ring 
8.Invagination test shows impulse on the tip of 
the little finger 
8.Invagination test shows impulse on the pulp 
of the little finger 
9.Zieman’s test impulse 
on the index finger 
9.impulse on the middle finger 
10.Commonly unilateral may be bilateral 10.Commonly bilateral 
11.Obstruction/strangulation 
are common 
11.Rare but can occur 
TONY 2010 MBBS
TONY 2010 MBBS
INDIRECT HERNIA 
Deep ring 
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
INDIRECT INGUINAL HERNIA 
• Commonest more in males 
• Thin sac 
• Narrow neck 
• Lateral to inferior epigastric vessels 
TONY 2010 MBBS
TONY 2010 MBBS
CLASSIFICATION( BASED ON 
EXTENT) 
Inguinal 
hernia 
incomplete 
bubonocele 
funicular 
complete 
Sac is 
confined to 
inguinalcanal 
Sac crosses 
superficial 
ring but not 
reaches 
bottom of 
scrotum 
Reaches 
bottom of 
scrotum 
TONY 2010 MBBS
TONY 2010 MBBS
TONY 2010 MBBS
TONY 2010 MBBS
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
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
Direct 
hernia 
medial 
lateral 
TONY 2010 MBBS
TONY 2010 MBBS
2 CLASSICAL SIGNS OF 
UNCOMPLICATED HERNIA 
• Impulse on coughing 
• Reducibility 
TONY 2010 MBBS
COMPLICATIONS OF HERNIA 
• Irreducibility 
• Obstructed hernia 
• Strangulated hernia 
• Inflammation 
• Incarceration 
TONY 2010 MBBS
IRREDUCIBILITY 
• Adhesions of its contents to each other 
• Adhesion of its contents with the sac 
• Adhesion of one part of sac to other 
• Sliding hernia 
• Massive hernia (scrotal abdomen) 
TONY 2010 MBBS
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
INCARCERATED HERNIA 
• When it contains a portion of colon with faeces  indenting with fingers 
putty like feeling 
TONY 2010 MBBS
STRANGULATED HERNIA 
• Irredudicibility + intestinal obstruction + arrest of blood supply 
• Due to constriction at the neck 
TONY 2010 MBBS
SIGNS OF STRANGULATED HERNIA 
• Tense 
• Tender 
• No impulse on coughing 
• irreducible 
• Recent increase in size 
TONY 2010 MBBS
TREATMENT 
• Raise the foot end (gravityredn 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
• Non viable bowel 
• Greenish/blackish in colour 
• No peristalsis 
• Gut is flaccid & lusture less 
• Fluid of sac is bllod stained & foul smelling 
TONY 2010 MBBS
FEMORAL HERNIA 
Femoral 
canal 
Saphenous 
opening 
TONY 2010 MBBS
ANATOMY 
• Femoral canal: 2 x 2 cm size 
• Medial compartment of femoral sheath 
• Base: Femoral ring 
• Bounded 
• Anteriorly—inguinal ligament 
• Posteriorly—cooper’s ligament 
• Medially—lacunar ligament 
• Laterally—femoral vein 
• Contents: 
• Cloquets node 
• Lymphatics 
• Areolar tissue 
TONY 2010 MBBS
TONY 2010 MBBS
SAPHENOUS OPENING 
TONY 2010 MBBS 
• 4cm below & lateral to pubic 
tubercle 
• Covered by cribriform fascia 
• Upper & outer margin are sharp 
will turn femoral hernia upwards
ANATOMY 
TONY 2010 MBBS
COURSE OF FEMORAL HERNIA 
TONY 2010 MBBS
COVERINGS 
• Skin 
• Superficial fascia 
• Cribriform fscia 
• Anterior layer of femoral sheath 
• Fatty content of femoral canal 
• Femoral septum 
• peritoneum 
TONY 2010 MBBS
• Increased chance of strangulation 
• F>M 
• Uncommon in children 
• Symptoms 
• Pain 
• Swelling 
TONY 2010 MBBS
• Position 
• Below & lateral to pubic tubercle 
• Shape 
• Globular/ retort (if large) 
• Narrow neck 
• Absent impulse on coughing 
• Irreducible 
• Strangulation 
• consistency 
TONY 2010 MBBS
• Position 
• Zeimanns test 
• Impulse on ring finger 
• Invagination test 
• Empty inguinal canal 
• Ring occlusion of saphenous opening 
TONY 2010 MBBS
DD 
• Saphena varix 
• Aneurysm 
• Psoas abscess 
• Undescended ectopic testis 
• Lipoma 
• Psoas bursa 
• Hydrocele of femoral hernia sac 
TONY 2010 MBBS
TREATMENT 
• High operation of McEvedy 
• A incision above the inguinal ligament. Sac is dissected from below, neck 
• from above and repair is done from above. It gives a 
• very good exposure of both neck, fundus of sac and 
• repair is also easier. strangulated femoral 
• hernia 
• Lotheissens operation 
• Lockwood operation low approach 
TONY 2010 MBBS
MAYDL’S HERNIA 
• Bowel loop = W SHAPE (HERNIA IN W) 
• CENTRAL PART CAN GET STRANGULATED 
(INTRA ABDOMINAL) 
• NO LOCAL TENDERNESS AS IN OTHER CASES 
OF STRANGULATION 
PERITONITIS 
TONY 2010 MBBS
RICHTER’S HERNIA 
• A portion of circumference of bowel 
• Usually ANTIMESENTERIC BORDER 
• ISCHEMIA IN HERNIATED PART 
• NO OBSTRUCTION AS LUMEN NOT INVOLVED 
TONY 2010 MBBS
SLIDING HERNIA 
• Hernia –en-glissade 
• Part of a viscus forms a part of herniating sac 
• Usually occurs on left side( caeum) & 
if on right side(sigmoid colon) bladder on both side 
• In males 
• Some times sac less 
TONY 2010 MBBS
PANTALOON HERNIA DOUBLE 
HERNIA 
• When both direct & indirect hernia sacs are present on the same side 
• Hernias on both sides of epigatric vessels(like a pants)=pantaloons 
• Recurrent hernia 
TONY 2010 MBBS
SPIGELIAN HERNIA 
• Lateral ventral hernia 
• Herniate b/w muscles of abdomen 
• At or blw arcuate line due to absence of posterior rectus sheath(half way 
b/w umbilicus & inguinal ligament) 
• High risk of strangulation 
• Rectus abdominis medially & arcuate line laterally 
TONY 2010 MBBS
TONY 2010 MBBS
TONY 2010 MBBS
TONY 2010 MBBS
LUMBAR HERNIA 
TONY 2010 MBBS
UMBILICAL HERNIA 
Umbilical hernia 
Exomphalos 
Umbilical hernia in 
infants & children 
Para umbilical 
hernia of adults 
TONY 2010 MBBS
EXOMPHALOS 
• Failure of 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
TONY 2010 MBBS
EXOMPHALOS MAJOR 
• Umbilical cord attached to inferior aspect of large swelling 
• Contains SI… LI & part of liver 
TONY 2010 MBBS
• Exomphalos major may burst 
• So emergency Sx is needed 
TONY 2010 MBBS
EXOMPHALOS MINOR 
• Sac is small 
• Umbilical cord is attached to its summit 
TONY 2010 MBBS
TONY 2010 MBBS
UMBILICAL HERNIA IN INFANTS & 
CHILDRENS 
• Through umbilical cicatrix 
• Spherical in shape 
• Increase in size in crying 
TONY 2010 MBBS
TONY 2010 MBBS
PARAUMBILICAL HERNIA OF 
ADULTS 
• Not through umbilical cicatrix but through linea alba 
• Above (supraumbilical) 
• Below (infraumbilical) 
TONY 2010 MBBS
INTERSTITIAL HERNIA 
• Hernial sac lies between muscle layers of abdominal wall 
• Preperitoneal/intraparietal 
• Interparietal 
• Extraparietal 
TONY 2010 MBBS
LITTRE’S HERNIA 
• Meckels diverticulum is the content 
TONY 2010 MBBS
CAUSES OF RECURRENCE OF 
INGUINAL HERNIA 
• Failure to ligate the sac at the neck 
• Increased tension 
• Use of absorbable sutures 
• Fault in selection of operation 
• Infection 
• Lifting of heavy weight with in 3 months 
• Persistent predisposing factors 
• Appearance of new hernia 
TONY 2010 MBBS
HERNIA OF A HYDROCELE 
LOCALIZED THINNING OF TUNICA LEADING TO PSEUDOPODIUM-LIKE 
PROJECTION, USUALLY SEEN WHEN THE SAC IS THICK AND FLUID IS UNDER 
TENSION through
HYDROCELE OF A HERNIA 
FLUID SEQUESTRATION IN A LOCULUS OF THE HERNIAL SAC, RESEMBLING 
HYDROCELE. THIS IS SEEN IN LONG STANDING CASES WITH ADHESIONS WITHIN 
THE SAC 
MORE COMMON IN VENTRAL HERNIA CONTAING OMENTUM
OGILVIE HERNIA 
• • Direct hernias are always acquired. Indirect may be congenital or 
acquired. 
• • Only congenital direct hernia is ogilvie hernia; through a rigid circular 
orifice 
• in the conjoined tendon just lateral to where it inserts into the rectus sheath. 
TONY 2010 MBBS

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Hernia

  • 2. HERNIA • PROTRUSION OF 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
  • 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  OBLITERATEDLESS CHANCE
  • 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 • In strangulation 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 } small initially ↑ size gradually • REDUCIBILITY Reduces on lying down DIRECT Does not reduce on lying down INDIRECT TONY 2010 MBBS
  • 19. • SYMPTOMS OF OBSTRUCTION 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
  • 26. INSPECTION • Patient in standing position • 1. Site • 2. Size • 3. Shape • 4. Extent • 5. Surface • 6. Skin over the swelling • 7. Visible peristalsis • 8. Cough impulse • 9. Draining lymph nodes • 10. Penis • 11. Urethral meatus • 12. Opposite scrotum TONY 2010 MBBS
  • 27. INSPECTION • EXPOSE 4M UMBILICUSMID THIGH POSITION OF PATIENT STANDING Inguinal, lumbar, femoral, epigastric, obturator, gluteal, spigelian SUPINE TONY 2010 MBBS
  • 28. SWELLING shape spherical femoral 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 THE SWELLING • Uncomplicated=normal • Strangulated=reddened • Truss 4 long time=discolouration, due to deposition of hemosiderin streaks, • Scar=recurrence • Wide irregular puckered=wound infectionrecurrence 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
  • 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 IDENTIFY PUBIC TUBERCLE TONY 2010 MBBS
  • 39. GET ABOVE THE SWELLING • DISTINGUISH B/W INGUINAL & INGUINOSCROTAL SWELLING • NO USE IN FEMORAL HERNIA ROOT OF SCROTUM IS HELD B/W THUMB IN FRONT & OTHER FINGERS BEHIND THE SWELLING IN AN ATTEMPT TO GET ABOVE THE SWELLING TONY 2010 MBBS
  • 40. GET ABOVE THE SWELLING INGUINAL HERNIA • NOT ABLE TO GET ABOVE THE SWELLING SCROTAL SWELLING • ABLE TO GET SBOVE THE SWELLING TONY 2010 MBBS
  • 43. CONSISTENCY • DOUGHY & GRANULAR} OMENTUM=OMENTOCELE • ELASTIC} INTESTINE=ENTEROCELE • TENSE & TENDER} STRANGULATED HERNIA TONY 2010 MBBS
  • 44. RELATION OF THE SWELLING TO THE TESTIS & SPERMATIC CORD INGUINAL HERNIA •Remains in front & sides of spermatc cord and testes which remains incorporated in front and sides FUNICULAR • Stops just above the testis TONY 2010 MBBS
  • 45. CLASSICAL SIGNS OF AN 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
  • 48. EXPANSILE IMPULSE IS ALSO 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 Impulse on 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 IDENTIFY DEEP RING TONY 2010 MBBS
  • 53. HOW TO IDENTIFY DEEP RING TONY 2010 MBBS
  • 55. REDUCIBILITY • Reduces on 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 difficultomentocele TONY 2010 MBBS
  • 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
  • 60. INVAGINATION TEST Finger goes directly backward=direct hernia TONY 2010 MBBS
  • 61. INVAGINATION TEST Finger goes upwards, backwards, outwards= indirect TONY 2010 MBBS
  • 62. INVAGINATION TEST Impulse on 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
  • 66. IN CASE OF A CHILD • Inguinal hernia is invisible in child due to presence of thick pad of fat over inguinal region • To make it visible ask him to jolt/jump/make it cry • Gornalls test: child is held from back by both hands of the clinician on its abdomen,abdomen is pressed and child is lifted up increased intra abdominal pressure hernia more prominent 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 • Peristaltic sounds=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 TONE OF ABDOMINAL MUSCLES • Inspectionprotrusion 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 Inguinal Swelling • 1. Enlarged lymph nodes • 2. Undescended testis • 3. Lipoma • 4. Femoral hernia • 5. Saphena varix • 6. Psoas abscess • 7. Femoral aneurysm Inguinoscrotal Swelling • 1. Encysted hydrocele of cord • 2. Varicocele • 3. Lymphvarix • 4. Diffuse lipoma of cord • 5. Inflammatory thickening of cord Femoral Hernia • 1. Inguinal hernia • 2. Saphenavarix • 3. Cloquet’s node • 4. Lipoma • 5. Femoral aneurysm • 6. Psoas abscess TONY 2010 MBBS
  • 78. DIFFERENTIAL DIAGNOSIS In males • Hydrocele – infantile/encysted/large vaginal/ • Undescended testis • Femoral hernia • Lipoma of the cord • Hydrocele of the canal of nuck (in females) • Inguinal lymph node enlargement • Groin abscess In females • hydrocele of the canal of Nuck – this is the most common dif-ferential diagnostic problem • femoral hernia. TONY 2010 MBBS
  • 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 • Not Curative for hernia. • It is a special belt devised to keep the hernia reduced at the deep ring or Hesselbach triangle for those who are unfit or unwilling for surgery • Hernia should be reducible to wear a truss. • Contraindicated • cases of irreducible hernia, • undescended testis, • associated huge hydrocele, • unintelligent people. TONY 2010 MBBS
  • 84. TAXIS • Supine hip & 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 of posterior wall) • 1. Original Bassini • 2. Modified Bassini • 3. McVay’s • 4. Shouldice Hernioplasty (prosthetic repair ) • 1. Lichtenstein • 2. Gilbert’s plug • 3. Prolene hernia system • 4. Laparoscopic mesh repair • 5. Stoppas repair 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 indirect inguinal 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
  • 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 • Cremasteric muscle 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
  • 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
  • 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 • Monofilamentpolyfilament 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
  • 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 • SOME FORM OF supportive MATERIAL IS USED TO STRENGTHEN POSTERIOR ABDOMINAL WALL HERNIOPLASTY SYNTHETIC BIOLOGICAL Synthetic non absorbable prolene, Dacron are used Tensor fascia lata,temporal fascia,skin 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 • Mesh extrusion • Foreign body reaction • infection TONY 2010 MBBS
  • 117. PRINCIPLE • Size of mesh >size of defect • Attached above & below to conjoint tendon & inguinal ligament/abdominal wall using non absorbable sutures • Haemostasis, reduce risk of infection TONY 2010 MBBS
  • 118. 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 TONY 2010 MBBS
  • 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 FREE MESH REPAIR • Less recurrence • Cord is covered with mesh and is sutured as in onlay method TONY 2010 MBBS
  • 124. LICHENSTEIN TENSION FREE REPAIR TONY 2010 MBBS
  • 125. TENSION – FREE REPAIR TONY 2010 MBBS
  • 126. TENSION – FREE REPAIR TONY 2010 MBBS
  • 128. PROLENE HERNIA SYSTEM TONY 2010 MBBS
  • 129. PROLENE HERNIAL SYSTEM TONY 2010 MBBS
  • 131. STOPPAS REPAIR • GPRVS (Giant Prosthesis for Reinforcement of Visceral Sac) • OVER FRICHAUDS MYOPECTINEAL ORIFICE TONY 2010 MBBS
  • 132. • 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. 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
  • 135. TEP TONY 2010 MBBS
  • 136. TEP TONY 2010 MBBS
  • 137. TAPP TONY 2010 MBBS
  • 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
  • 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 inguinal ring: u shaped defect in transversalis fascia 1.25cm above mid inguinal point • Inguinal ligament: It is formed by the lower border of the external oblique aponeurosis which is thickened and folded backwards on itself , extending from anterior superior iliac spine to pubic tubercle. TONY 2010 MBBS
  • 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.
  • 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 SPERMATIC CORD 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
  • 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 TONY 2010 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 lateral umbilical ligament (obliterated umbilical artery) crosses the triangle and divides it into • medial and lateral parts. The medial part of the floor of the triangle is strengthened by the conjoint tendon. The lateral part of the floor of the triangle is weak, hence direct inguinal hernia usually occurs through this part. TONY 2010 MBBS
  • 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 NDIRECT INGUINALHERNIA McBURNEYS INCISION • FAMILIAL COLLAGEN DISORDER • CONGENITAL PREFORMED SAC (REMAINS OF PROCESSUS VAGINALIS) TONY 2010 MBBS
  • 159. PARTS OF A HERNIA • SAC • COVERING OF SAC • CONTENTS OF SAC TONY 2010 MBBS
  • 160. SAC • A DIVERTICULUM OF PERITONEUM WITH  MOUTH  NECK  BODY  FUNDUS • NECK IS NARROW IN CASE OF INDIRECT WIDE IN CASE OF DIRECT • HERNIA WITHOUT NECK: HERNIA WITH A WIDE MOUTH ,DIRCT HERNIA,INCISIONAL HERNIA • SAC IS THIN IN INFANTS & CHILD THICK IN LONG STANDING & DIRECT HERNIA • HERNIA WITHOUT SAC: EPIGASTRIC HERNIA(Protrusion of extra peritoneal pad of fat) 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
  • 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 HERNIA can’t be reduced …due to adhesions b/w contents and sac…or due to crowding irreducibility + no other symptoms}OMENTOCELE Irreducibility predisposes to strangulation 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 blood supply is impaired ISCHAEMIAGANGRENE 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 INGUINAL HERNIA Inguinal hernia Direct indirect Through hesselbachs triangle in posterior wall of inguinal canal (medially by lateral border of rectus sheath,below by inguinal ligament,laterally by inferior epigastric artery) Through deep ring along with spermatic cord,lateral to inferior epigastric artery TONY 2010 MBBS
  • 173. Indirect inguinal hernia Direct inguinal hernia 1.any age from childhood to adult 1.Common in elderly 2.Occurs in a pre-existing sac 2.Always acquired 3. Protrusion through the deep ring; herniation occurs later 3.Herniation through posterior wall of the inguinal canal 4.Pyriform /oval in shape; descends obliquely and downwards 4.Globular/round in shape; descends directly forward bulge 5.Can become complete by descending down into the scrotum 5.Rarely descend down into the scrotum 6.Sac is antero-lateral to the cord 6.Sac is posterior to the cord 7.Ring occlusion test no impulse after occluding the deep ring 7. impulse even after occluding the deep ring 8.Invagination test shows impulse on the tip of the little finger 8.Invagination test shows impulse on the pulp of the little finger 9.Zieman’s test impulse on the index finger 9.impulse on the middle finger 10.Commonly unilateral may be bilateral 10.Commonly bilateral 11.Obstruction/strangulation are common 11.Rare but can occur TONY 2010 MBBS
  • 175. INDIRECT HERNIA Deep ring 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
  • 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
  • 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
  • 186. 2 CLASSICAL SIGNS OF 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 • Adhesions of its contents to each other • Adhesion of its contents with the sac • Adhesion of one part of sac to other • Sliding hernia • Massive hernia (scrotal abdomen) 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 STRANGULATED HERNIA • Tense • Tender • No impulse on coughing • irreducible • Recent increase in size TONY 2010 MBBS
  • 193. TREATMENT • Raise the foot end (gravityredn 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 viable bowel • 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 • Femoral canal: 2 x 2 cm size • Medial compartment of femoral sheath • Base: Femoral ring • Bounded • Anteriorly—inguinal ligament • Posteriorly—cooper’s ligament • Medially—lacunar ligament • Laterally—femoral vein • Contents: • Cloquets node • Lymphatics • Areolar tissue TONY 2010 MBBS
  • 198. SAPHENOUS OPENING TONY 2010 MBBS • 4cm below & lateral to pubic tubercle • Covered by cribriform fascia • Upper & outer margin are sharp will turn femoral hernia upwards
  • 200. COURSE OF FEMORAL HERNIA 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 chance of 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 • Saphena varix • Aneurysm • Psoas abscess • Undescended ectopic testis • Lipoma • Psoas bursa • Hydrocele of femoral hernia sac TONY 2010 MBBS
  • 206. TREATMENT • High operation of McEvedy • A incision above the inguinal ligament. Sac is dissected from below, neck • from above and repair is done from above. It gives a • very good exposure of both neck, fundus of sac and • repair is also easier. strangulated femoral • hernia • Lotheissens operation • Lockwood operation low approach TONY 2010 MBBS
  • 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
  • 215. LUMBAR HERNIA TONY 2010 MBBS
  • 216. UMBILICAL HERNIA Umbilical hernia Exomphalos Umbilical hernia in infants & children Para umbilical hernia of adults TONY 2010 MBBS
  • 217. EXOMPHALOS • Failure of 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
  • 219. EXOMPHALOS MAJOR • Umbilical cord attached to inferior aspect of large swelling • Contains SI… LI & part of liver TONY 2010 MBBS
  • 220. • Exomphalos major may 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
  • 223. UMBILICAL HERNIA IN INFANTS & CHILDRENS • Through umbilical cicatrix • Spherical in shape • Increase in size in crying TONY 2010 MBBS
  • 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 RECURRENCE OF INGUINAL HERNIA • Failure to ligate the sac at the neck • Increased tension • Use of absorbable sutures • Fault in selection of operation • Infection • Lifting of heavy weight with in 3 months • Persistent predisposing factors • Appearance of new hernia TONY 2010 MBBS
  • 229. HERNIA OF A HYDROCELE LOCALIZED THINNING OF TUNICA LEADING TO PSEUDOPODIUM-LIKE PROJECTION, USUALLY SEEN WHEN THE SAC IS THICK AND FLUID IS UNDER TENSION through
  • 230. HYDROCELE OF A HERNIA FLUID SEQUESTRATION IN A LOCULUS OF THE HERNIAL SAC, RESEMBLING HYDROCELE. THIS IS SEEN IN LONG STANDING CASES WITH ADHESIONS WITHIN THE SAC MORE COMMON IN VENTRAL HERNIA CONTAING OMENTUM
  • 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