This document discusses hernias, including their anatomy, types, causes, diagnosis, and treatment options. It provides details on the layers of the abdominal wall and inguinal canal. There are two main types of hernias - indirect and direct. Treatment options include open repair techniques like Shouldice repair as well as laparoscopic techniques like TAPP and TEP which involve placing a mesh to reinforce the abdominal wall. Complications of hernia repair can include recurrence, chronic pain, infection, and injury to surrounding structures.

1. Dr.P.Viswakumar.,M.S
Assistant professor,
Dept of General surgery,
PSGIMSR.

2. The term “hernia” is derived from
the Greek word hernios, which
means “budding.”
Hernia – Protrusion of visceral contents
through the Abdominal wall.
Two key components
Defect Hernial Sac

3. • Erect Human posture – Vulnerability between
abdominal muscle wall & hard pelvic bones.
• Passage of various structure from trunk to
extremities (Femoral nerve,Iliac vessels and
Spermatic cord).
• So Adult hernia is in part results from weakness of
inner envelope of Abdominal wall (Transversalis
fascia).
• Weakest points – Inguinal, Femoral and Umblical.

4. Why ?
“ No disease of human body belonging to the
province of the surgeon requires in its treatment a
better combination of accurate knowledge with
surgical skill than hernia in all its varities”
- Sir Astley paston cooper ;1804

5. • Layers of Abdominal wall ??
- 9 layers
1) Skin
2) Camper’s fascia
3) Scarpa’s fascia
4) External oblique muscle & aponeurosis.
5) Internal oblique muscle & aponeurosis.
6) Transverse abdominus & aponeurosis.
7) Transversalis fascia
8) Preperitoneal fat.
9) Peritoneum.

7. Ligament of henle/Falx inguinalis :
• Lateral vertical expansion of the rectus sheath that inserts
on the pecten of the pubis.
• In one-third to one-half of patients and is fused with the
transversus aponeurosis and fascia

8. Conjoint tendon:
• By definition, the fusion of lower fibers of the internal
oblique aponeurosis with similar fibers from the
aponeurosis of the transversus abdominis where they
insert on the pubic tubercle and superior ramus of the
pubis.
• The trouble is that the anatomic configuration thus
described is extremely rare (3 – 5%).
• The distinction between falx inguinalis and
conjoined tendon is one of anatomic nicety and
admittedly of little practical significance in the
operating room provided that the distinction is
understood.
• The term conjoined area can be applied correctly
to that region that contains the ligament of Henle

10. Ligament of Gimbernat (Lacunar Ligament):
• Triangular extension of the inguinal ligament before its
insertion upon the pubic tubercle.

11. Cooper’s or Pectineal ligament:
• The periosteum of the superior ramus of the pubis,
strongly reinforced by endoabdominal fascia
(transversalis fascia), with more reinforcement by the
transversus abdominis aponeurosis and the iliopubic
tract medially
Iliopubic tract :
• Aponeurotic band formed by transversus abdominis
muscle and aponeurosis and the transversalis
fascia.
• Begins near the anterior superior iliac spine
extends medially to attach to Cooper's ligament

13. • The inguinal canal is formed in relation to the relocation
of the testis during fetal development.
• The inguinal canal in adults is an oblique passage
approximately 4 cm long directed inferomedially.
• The main occupant is the spermatic cord in males and
the round ligament of the uterus in females.
• The deep (internal) inguinal ring defect in fascia
transversalis.
• The superficial ring is a split that occurs in the diagonal,
otherwise parallel fibers of the external oblique
aponeurosis. The lateral crus attaches to the pubic
tubercle, and the medial crus attaches to the pubic crest.

14. • Anterior wall: external oblique aponeurosis throughout the
length of the canal; its lateral part is reinforced by muscle
fibers of the internal oblique.
• Posterior wall: transversalis fascia; its medial part is
reinforced by pubic attachments of the internal oblique and
transversus abdominis aponeuroses that frequently merge to
variable extents into a common tendon—the inguinal falx
(conjoint tendon)—and the reflected inguinal ligament.
• Roof: laterally by the transversalis fascia, centrally by
musculoaponeurotic arches of the internal oblique and
transversus abdominis, and medially by the medial crus of the
external oblique aponeurosis.
• Floor: laterally by the iliopubic tract, centrally by gutter formed
by the infolded inguinal ligament, and medially by the lacunar
ligament.

18. • The laparoscopic anatomy of the inguinal area based on
Myopectineal orifice of Fruchaud.
• Superior: Arch of internal oblique muscle and transversus
abdominis muscle
• Lateral: Iliopsoas muscle
• Medial: Lateral border of rectus muscle and its anterior
lamina
• Inferior: Pubic pecten

26. Preperitoneal space:
Space of Retzius- Retropubic space
Space of Bogros – Lateral extension of space of
retzius
Contains inferior epigastric artery

27. Types :
Anatomical types:
• According to Extent
i) Bubonocele
ii) Incomplete
iii) Complete

28. According to its site of Exit :
i) Indirect hernia.
ii) Direct hernia.
Indirect(oblique) Hernia :
• 80 % of cases
• Almost all pediatric and women cases comprise this
group
• Often a complete variety
• Two forms Congenital and Acquired
Congenital
1) Congenital vaginal(complete)
2) congenital funicular
Acquired
Differentiated from above by as it wont
form complete hernia

29. According to its contents:
1) Enterocele
2) Epiplocele or Omentocele
3) Cystocele
Clinical types:
i) Reducible
ii) Irreducible
iii) Obstructed or Incarcerated (irreducibility + obstruction)
iv) Strangulated
v) Inflammed

31. Rare varieties of Hernia :
• Hernia-en-glissade or Sliding hernia.
Extraperitoneal bowel
Part of sac wall

32. • Richter’s hernia

33. Littre’s hernia

34. Maydl’s hernia ( Hernia-en-W)
Strangulated
intraabdominal part
Bowel within sac

36. Coughing
Chronic obstructive pulmonary disease
Obesity
 Straining
 Constipation
 Prostatism
Pregnancy
Birthweight <1500 g
Family history of a hernia
Valsalva's maneuvers

37. Ascites
Upright position
Congenital connective tissue disorders
Defective collagen synthesis
Previous right lower quadrant incision
Arterial aneurysms
Cigarette smoking
Heavy lifting
Physical exertion (?)

38. Gilbert Classification :
Type 1 : Small, indirect
Type 2 : Medium, indirect
Type 3 : Large, indirect
Type 4 : Entire floor, direct
Type 5 : Diverticular, direct
Type 6 : Combined (pantaloon)
Type 7 : Femoral

39. Nyhus classification :
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

40. • History
• Physical examination
• Imaging
Differential diagnosis :
Malignancy
Lymphoma
Retroperitoneal sarcoma
Metastasis
Testicular tumor

41. Primary testicular
Varicocele
Epididymitis
Testicular torsion
Hydrocele
Ectopic testicle
Undescended testicle
Femoral artery aneurysm or pseudoaneurysm
Lymph node
Sebaceous cyst
Hidradenitis
Cyst of the canal of Nuck (female)
Saphenous varix
Psoas abscess
Hematoma
Ascites

43. Open Repair
Anterior Repairs, Nonprosthetic
i) Bassini’s repair
ii) Shouldice Repair
iii) McVay Repair
iv) Moloney darn
Anterior Repairs, Prosthetic
i) Lichtenstein tension free Hernioplasty
ii) Mesh plug and patch
iii) Read-Rives
iv) Kugel
v) Nyhus-Condon
vi) Wantz, Stoppa, and Rives

49. • Recurrence
• Chronic groin pain
• Nociceptive
• Neuropathic
• Cord and testicular
• Hematoma
• Ischemic orchitis
• Testicular atrophy
• Injury to vas deferens
• Hydrocele
• Testicular descent
• Bowel and bladder injury

50. • Osteitis pubis
• Prosthetic complications
• Contraction
• Erosion
• Infection
• Rejection
• Fracture
• Miscellaneous complications
• Seroma
• Hematoma
• Wound infection
• General complications

51. 1) TAPP (Transabdominal preperitoneal repair)
2) TEP ( Total extraperitoneal repair)