This document provides information on hernias, including their meaning, causes, parts, classifications, and inguinal hernia anatomy and types. Some key points: 1. A hernia is an abnormal protrusion of an organ or tissue through an opening. It is usually defined as a protrusion through the abdominal wall. 2. Hernias can be caused by straining, heavy lifting, coughing, obesity, pregnancy, smoking, and other factors that increase intra-abdominal pressure. 3. Inguinal hernias are the most common type and are classified as direct or indirect based on their anatomy through the inguinal canal. 4. Treatment of hernias

1. HERNIA

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

3. AETIOLOGY
 Straining.
 Lifting of heavy weight.
 Chronic cough
 Chronic constipation
 Urinary causes
 Old age—BPH, carcinoma prostate.
 Young age—stricture urethra.
 Very young age—phimosis, meatal
stenosis.
 Obesity.
 Pregnancy and pelvic anatomy
 Smoking.
 Ascites.
 Appendicectomy through McBurney’s
incision causes direct inguinal hernia.
 An indirect inguinal hernia occurs in a
congenital cause like remains of
processus vaginalis
 Familial collagen disorder—Prune
Belly syndrome.
 Acquired herniation is also probably
due to collagen deficiency called as
metastatic emphysema of Read.

4. with direct inguinal hernia. It
is due to injury to ilioinguinal
nerve during
appendicectomy.
 Inguinal hernia in a patient who
is having benign prostatic
hyperplasia (BPH)

5. PARTS OF HERNIA
Covering
 Sac
 Content

6. COVERING
layers of the abdominal wall through which the sac passes.

7. SAC
 IT IS “diverticulum of peritoneum with MOUTH, NECK, BODY and
FUNDUS.”
 NECK-Neck is narrow in indirect sac but wide in direct sac.
 BODY-Body of the sac is thin in infants, children and in indirect sac ;but
is thick in direct and long-standing hernia.

8. CONTENTS OF SAC
 Omentum
 Intestine
 Richter’s hernia: A portion of circumference of bowel is the content.
 Urinary bladder
 Ovary often with fallopian tube.
 Meckel’s diverticulum—Littre’s hernia.
 Fluid

9. Littre’s hernia with Meckel’s diverticulum as
content.

10. CLASSIFICATION OF THE HERNIA
Clinical classification
Reducible hernia
Irreducible hernia
Obstructed hernia
Inflamed hernia
Strangulated hernia

11. REDUCIBLE HERNIA
 Hernia gets reduced on its own or by the patient or by the
surgeon.
 Intestine reduces with gurgling and it is difficult to reduce the
first portion.
 Omentum is doughy, and it is difficult to reduce the last
portion.
 Expansile impulse on coughing present.

12. IRREDUCIBLE HERNIA
 Here contents cannot be returned to the abdomen due to
narrow neck, adhesions, over crowding.
 Irreducibility predisposes to strangulation.

13. OBSTRUCTED HERNIA
 It is an irreducible hernia with obstruction, but blood supply to
the bowel is not interfered.
 It eventually leads to strangulation.

14. INFLAMED HERNIA
 It is due to inflammation of the contents of the sac ;e.g.
appendicitis, salpingitis.
 Here hernia is tender but not tense; overlying skin is red and
oedematous.

15. STRANGULATED HERNIA
 It is an irreversible hernia with obstruction to blood flow.
 The swelling is tense, tender, with no impulse on coughing
and with features of intestinal obstruction.
 Features of intestinal obstruction may be absent in case of
omentocele, Richter’s hernia, Littre’s hernia.

16. Classification II
Congenital—Common
 It occurs in a preformed sac/defect.
 present at a later period by precipitating causes like in indirect inguinal hernia.
 Acquired
 secondary to any causes increases intra-abdominal pressure
 leading into weakening of the area like in direct inguinal hernia.

17. CLASSIFICATION III: BASED ON SITES
 Inguinal hernia—occurring in inguinal canal.
 Femoral hernia—occurring in femoral canal.
 Obturator hernia.
 Diaphragmatic hernia.
 Lumbar hernia.
 Spigelian hernia.
 Umbilical hernia.
 Epigastric hernia.

18. CLASSIFICATION IV – BASED ON
CONTENTS
 Omentocele—omentum.
 Enterocele—intestine.
 Cystocele—urinary bladder.
 Littre’s hernia—Meckel’s diverticulum.
 Maydl’s hernia.
 Sliding hernia.
 Richter’s hernia—part of the bowel wall.

19. INGUINAL HERNIA

20. SURGICAL ANATOMY
 SUPERFECIAL INGUINAL RING
 DEEP INGUINAL RING
 INGUINAL LIGAMENT
 INGUINAL CANAL

22.  Superficial inguinal ring : a triangular opening in external oblique aponeurosis
(1.25 cm above the pubic tubercle & bounded by superomedial and inferolateral crus.)
 Deep inguinal ring: is U-shaped condensation of transversalis fascia
(1.25 cm above the inguinal ligament midway between symphysis pubis and ASIS.)
 Inguinal ligament: is formed by lower border of external oblique aponeurosis
(which is thickened and folded backwards on itself, extending from ASIS to pubic tubercle.)
 Inguinal canal: It is an oblique passage in lower part of abdominal wall
(4 cm long, situated above medial ½ of inguinal ligament, extending from deep inguinal ring to superficial inguinal ring.)

23.  In infants both superficial and deep rings are superimposed
 Inguinal canal in female is called as ‘canal of Nuck.’
 Inguinal ligament is also called as Poupart’s ligament

24. Contents of inguinal canal
 Spermatic cord in males
 Round ligament in females
 Ilioinguinal nerve

25. BOUNDARIES OF INGUINAL CANAL
 In front: External oblique aponeurosis and conjoined muscle laterally.
 Behind: Inferior epigastric artery, fascia transversalis and conjoined tendon medially.
 Above: Conjoined muscle (Arched fibres of internal oblique).
 Below: Inguinal ligament.

26. CLASSIFICATION OF INGUINAL
HERNIA

27. ANATOMICAL CLASSIFICATION
 Indirect hernia
 It comes out through “internal
ring” along with the cord. It is
lateral to the inferior
epigastric artery.
 Direct hernia
 It occurs through posterior
wall of the inguinal canal
through ‘Hesselbach’s triangle’

28. ACCORDING TO THE EXTENT
Incomplete
 Bubonocele: Here sac is confined to the
inguinal canal.
 Funicular: Here sac crosses the superficial
inguinal ring, but does not reach the
bottom of the scrotum.
COMPLETE
 Here sac descends to the bottom of the
scrotum.
 Saddle-bag or pantaloon hernial sac has
got both medial and lateral component.

29. NEWER CLASSIFICATIONS
 Gilbert classification
 Nyhus classification
 Bendavid classification
 Casten classification
 Halverson and mcvay classification
 Ponka’s classification

30. INDIRECT INGUINAL HERNIA
 most common type (65%).
 more common in young age whereas direct is more in adults.
 more common on Right side in 1st decade; but in 2nd decade incidence is equal on
both sides.
 Hernia is bilateral in 30% of cases.
 Sac is thin in indirect type. Neck is narrow and lies lateral to inferior epigastric
vessels.

31. TYPES OF INDIRECT INGUINAL
HERNIA
 Bubonocele – limited to inguinal canal
 Funicular - Processus vaginalis is closed just above the epididymis.
 Contents of the sac can be felt separately from testis, which lies below the hernia.
 Complete - Testis appears to lie in lower part of hernia.
contents descend into pre-existing sac, only when there are precipitating causes
which
force the content down.

32. CLINICAL FEATURES
 Prevalence is 25% (males); 2% (females).
 Patient presents with dragging pain and swelling in the groin which is better seen
while coughing and standing with an expansile impulse.
 In infants, swelling appears when the child cries and is often translucent.
 It is usually reducible, but can go for irreducibility, inflammation, obstruction,
strangulation.

33. CLINICAL EXAMINATION
 Internal ring occlusion test
 Ring invasion test
 Zeiman test
 Head or leg raising test
 Per rectal test

35. Indirect inguinal hernia
 Can occur in any age from childhood
 to adult
 Occurs in a pre-existing sac
 Protrusion through the deep ring; herniation
occurs later
 Pyriform/oval in shape; descends obliquely and
downwards
 Sac is anterolateral to cord
 No Impulse felt after occlusion of deep ring
Direct inguinal hernia
 common in elderly
 Always acquired
 Herniation through posterior wall of the inguinal
canal
 Globular/round in shape; descends directly
forward bulge
 Sac is posterior to cord
 Impulse felt even after occlusion of deep ring.

37. THANK YOU

38. MANAGEMENT OF INGUINAL HERNIA

39. Investigations
 Chest X-ray to rule out chronic bronchitis.
 Ultrasound of abdomen.
 Tests relevant for precipitating causes.

40. TREATMENT
 Always surgery is preferred in the cases of the
hernia.

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

42. HERNIAL SURGERY IN
ADULTS
 It includes two steps:
 HERNIOTOMY - excision
 HERNIORRHAPHY – posterior wall strengthening
 HERNIOPLASTY – posterior wall strengthening with
mesh usage

43. HERNIOTOMY
 Anaesthesia: Spinal or G/A or local anaesthesia
 cleaning and draping ; skin is incised—1.25 cm above & parallel to the
medial two/third of inguinal ligament.
 superficial fascia & External oblique aponeurosis is incised & inguinal ligament is
exposed.
 Ilioinguinal nerve is safeguarded. Cremasteric muscle is opened.
 Cord structures dissected. Sac is identified as pearly white in colour.
 Sac is opened at the fundus. Finger is passed to release any adhesions. Sac is
twisted so as to prevent the content from coming back.
 It is transfixed using absorbable suture material (chromic catgut 2-0 or vicryl) and
is excised distally.

44.  skin incision—1.25 cm above &
parallel to the medial two/third
of inguinal ligament.
 twisting of the sac to prevent the
contents to get in.

45. HERNIORRHAPHY
 Modified bassini’s
herniorrhaphy
 Lytle’s repair
 Shouldice repair
 Tanner side operation
 Daming
 Koontz operation
 Mcvay operation
 Nyhus repair
 Wilkinson method
 removal of cord at
inguinal region.
 Andrew operation

46. MODIFIED BASSINI’S HERNIORRHAPHY
 ‘CONJOINT TENDON’ and ‘INGUINAL LIGAMENT’
are APPROXIMATED using interrupted
NONABSORBABLE sutures usually prolene.
 Medial most stitch is taken from the PERIOSTEUM
OF PUBIC TUBERCLE.
 ABSORBABLE suture material like catgut NOT be
used as 50% of its tensile strength will be lost in 7
days.

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

48. SHOULDICE REPAIR
 strengthening the posterior wall by DOUBLE BREASTING of TRANSVESALIS
FASCIA using continuous sutures using nonabsorbable material.
 After herniotomy - transversalis fascia is INCISED along the line of the wound
 LOWER FLAP of fascia is sutured to posterior part of the upper flap.
 UPPER FLAP is sutured to the inguinal ligament.
 Then conjoint tendon and inguinal ligament is further approximated by two
layers of continuous sutures.
 External oblique aponeurosis is sutured in two layers (double-breasting) in
front of the cord. Hence the original Shouldice repair is 6 layered procedure.

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

50. Darning (Abrahamson Nylon Darning)
Continuous nonabsorbable sutures are placed between :
 conjoint tendon and inguinal ligament to give good support to posterior wall
of inguinal hernia.

51. Koontz Operation
 ORCHIDECTOMY is done along with removal of entire cord, testis
and total closure posteriorly
 It is generally done in the aged persons.

52. Other procedures
 Andrew’s Operation - It involves overlapping of the external oblique apo-
neurosis.
 McVay Operation - It is repair by placing interrupted sutures between
transversalis fascia to Copper’s ligament (superior pubic ligament)
 Nyhus Iliopubic Repair - Transaponeurotic arch (transverse abdominis
muscle and transversalis fascia) is sutured below to Copper’s ligament and
iliopubic tract.
 Wilkinson Method - Transversus abdominis and internal oblique are sutured
to inguinal ligament with continuous monofi lament sutures

54. CONTENTS
 INTRODUCTION
 SURGICAL ANATOMY
 INDICATIONS
 PROCEDURE
 COMPLICATIONS

55. What HERNIOPLASTY is actually?
IT is strengthening of posterior wall using a supportive material.
This allows good fibroblast proliferation
strengthens the weak posterior wall
popularized by LICHTENSTEIN after recognizing that
Tension is the main cause of Recurrence.

56. MATERIALS USED FOR SUPPORT
 Two types synthetic and biological
 SYNTHETIC: Prolene mesh
vipro mesh
Dacron mesh
Morlex mesh
Merselene sheath
 BIOLOGCAL: Tensor fascia lata
Temporal fascia
skin

57. INDICATIONS
 Direct hernia
 Recurrent hernia
 Re-recurrent hernia
 Incicional hernia
 Old age
 Hernia with weak abdominal muscle tone
 Sliding hernia
(presently it is done for all cases of hernia except in the paediatric
age group and it is the gold standard in the treatment of
hernias.)

58. TYPES OF MESH REPAIR
 Onlay repair (lichtenstein tension free repair)
 Inlay repair ( mesh is placed at myopectineal level)
 Underlay repair (mesh is placed in the preperitoneal space) ex: nyhus repair
 Gillbert patch and plug repair (onlay+sublay sandwich technique)
 Stoppa’s giant prosthesis reinforcement
 Laparoscopic surgeries-
TAPP (trans abdominal pre peritoneal laparoscopic mesh repair)
TEP (totally extra peritoneal laparoscopic mesh repair)

59. LICHTENSTEIN TENSION FREE ONLAY
MESH REPAIR PROCEDURE
Pre-operative medications:
 Opioids (morphine, pethedine)
 Sedatives and anti-anxiety drugs(diazepam)
 Anticholinergics (atropine)
 Neuroleptics (chlorpromazine)
 Antiemetics (metoclopramide, domperidone, ondansetron)

60. Pre-operative preparation
 detail history about previous experience with surgery and anesthesia,
 medical history and drug history.
 Routine blood investigations, electrolytes, liver function tests, urine
analysis, ECG, chest radiography, HIV
 Starvation for 4 hours for liquids and 6 hrs for solids
 Bowel & bladder should be emptied { enema, catheterization}
 The patient is asked to take a scrub bath, dressed with a sterile gown and
exposed adequately.

61.  The region to be operated is painted with povidone iodine and draped.
 Anaesthesia- spinal or local infiltration block (general anaesthesia in case of
uncooperative patients)
 Incision- oblique and parallel to the inguinal ligament and above it (3-4 cm)
 Opening of the subcutaneous fat along the line of the incision
 Opening of the Scarpa fascia down to the external oblique aponeurosis and
visualization of the external inguinal ring and the lower border of the
inguinal ligament

63.  Division of the external oblique aponeurosis from the external ring
laterally for up to 5 cm, safeguarding the ilioinguinal nerve
 Mobilization of the spermatic cord, along with the cremaster,
including the ilioinguinal nerve, the genitofemoral nerve, and the
spermatic vessels; all of these structures may then be encircled in a
Penrose drain or tape
 Opening of the coverings of the spermatic cord and identification
and isolation of the hernia sac
 Inversion, division, resection, or ligation of the sac, as indicated

64.  A sheet of proline or vipro mesh is fashioned to fit the inguinal canal.
 A slit is made in the lateral aspect of the mesh, and the spermatic cord is
placed between the two tails of the mesh.
 The spermatic cord is retracted in the cephalad direction.
 The medial aspect of the mesh overlaps the pubic bone by approximately 2
cm.
 The mesh is secured to the APONEUROTIC TISSUE OVER PUBIC TUBERCLE
nonabsorbable monofilament material.
 The suture is continued laterally to the shelving edge of the inguinal
ligament to a point just lateral to the internal inguinal ring.

67. • A second suture is placed at the level of the pubic tubercle and
continued laterally suturing the internal oblique aponeurosis
• The lower edges of the two tails are sutured to the shelving edge of
the inguinal ligament to create a new internal ring made of mesh.
• The spermatic cord structures are placed within the inguinal canal
overlying the mesh. In males, gentle pulling of the testes back down
to their normal scrotal position
• Closure of spermatic cord layers, the external oblique aponeurosis,
subcutaneous tissue, and the skin

69. Post-operative care
 IV fluids- initially isotonic fluids are given and changed to 0.45%
saline with dextrose.
 Pulse, blood pressure and respiration should be monitored
 Wound care and regular dressing
 Adequate pain relief and continuation of antibiotics
 Sutures removed after 10 days.

70. COMPLICATIONS
 Recurrence
 Chronic groin pain
 Nerve damage- iliohypogastric
ilioinguinal
genitofemoral
 Cord and testicular- hematoma
ischaemic orchitis
testicular atrophy
dysejaculation
hydrocele
 Wound hematoma and infection

71.  Prosthetic complications- erosion
rejection
infection
 Laparoscopic- visceral injury
gas embolism
 Miscellaneous- nausea and vomiting
respiratory insufficiency

72. Thank you