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Hernia

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hernia inguinal clinical surgery

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Hernia

  1. 1. HERNIA SURGERY TONY 2010 MBBS
  2. 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. 3. HERNIA COMMON INGUINAL INCISIONAL FEMORAL UMBILICAL EPIGASTRIC RARE OBTURATOR SPIGELIAN GLUTEAL LUMBAR DIAPHRAGMATIC TONY 2010 MBBS
  4. 4. TONY 2010 MBBS
  5. 5. TONY 2010 MBBS
  6. 6. HISTORY TONY 2010 MBBS
  7. 7. HISTORY • AGE : YOUNG •INDIRECT OLD AGE (weak musculature) •DIRECT TONY 2010 MBBS
  8. 8. HISTORY • OCCUPATION =STRENOUS STRENOUS WORK PERSISTENT PROCESSUS VAGINALIS WEAK ABDOMINAL WALL HERNIATION TONY 2010 MBBS
  9. 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
  10. 10. PRESENTING COMPLAINTS TONY 2010 MBBS
  11. 11. • ABOUT LUMP • COMPLICATIONS • ETIOLOGY (PRECIPITATING FACTORS) TONY 2010 MBBS
  12. 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. 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. 14. PAIN • PAIN= DRAGGING & ACHING TYPE Appears b4 the swelling Increase with time Subsides when it is fully formed TONY 2010 MBBS
  15. 15. PAIN Acute pain around umbilicus tenderness strangulation Due to drag on mesentry TONY 2010 MBBS
  16. 16. PAIN • In strangulation due to drag on mesentry pain all over the abdomen TONY 2010 MBBS
  17. 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. 18. acquired } small initially ↑ size gradually • REDUCIBILITY Reduces on lying down DIRECT Does not reduce on lying down INDIRECT TONY 2010 MBBS
  19. 19. • SYMPTOMS OF OBSTRUCTION COLICKY ABDOMINAL PAIN VOMITING •BILIOUS •FAECAL (USUALLY) ABDOMINAL DISTENSION ABSOLUTE CONSTIPATION TONY 2010 MBBS
  20. 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. 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. 22. FAMILY HISTORY • CONNECTIVE TISSUE DISORDERS TONY 2010 MBBS
  23. 23. PERSONAL HISTORY • History of Smoking: • Smoking leads to chronic bronchitis • Collagen deficiency occurs in smokers. TONY 2010 MBBS
  24. 24. LOCAL EXAMINATION TONY 2010 MBBS
  25. 25. INSPECTION TONY 2010 MBBS
  26. 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. 27. INSPECTION • EXPOSE 4M UMBILICUSMID THIGH POSITION OF PATIENT STANDING Inguinal, lumbar, femoral, epigastric, obturator, gluteal, spigelian SUPINE TONY 2010 MBBS
  28. 28. SWELLING shape spherical femoral direct pyriform indirect TONY 2010 MBBS
  29. 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. 30. POSITION & EXTENT • Femoral hernia  starts below the inginal ligament and ascend over it TONY 2010 MBBS
  31. 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. 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. 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. 34. POSITION OF PENIS • Deviation of penis to opposite side= in large complete inguinal hernia TONY 2010 MBBS
  35. 35. PALPATION TONY 2010 MBBS
  36. 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. 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. 38. HOW TO IDENTIFY PUBIC TUBERCLE TONY 2010 MBBS
  39. 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. 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
  41. 41. TONY 2010 MBBS
  42. 42. TONY 2010 MBBS
  43. 43. CONSISTENCY • DOUGHY & GRANULAR} OMENTUM=OMENTOCELE • ELASTIC} INTESTINE=ENTEROCELE • TENSE & TENDER} STRANGULATED HERNIA TONY 2010 MBBS
  44. 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. 45. CLASSICAL SIGNS OF AN UNCOMPLICATED HERNIA TONY 2010 MBBS
  46. 46. EXPANSILE IMPULSE ON COUGHING • STANDING POSITION • ABSENT IN CASE OF STRANGULATED & INCARCERATED HERNIA 1. MOMENTARY BULGE IN SUPERFICIAL RING ON COUGHUING 2. ROOT OF SCROTUM B/W INDEX FINGER & THUMB IS SEPARATED ON COUGHING TONY 2010 MBBS
  47. 47. TONY 2010 MBBS
  48. 48. EXPANSILE IMPULSE IS ALSO PRESENT IN • Meningocele • Laryngocele • Empyema necessitans TONY 2010 MBBS
  49. 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. 50. ZEIMANN’S TECHNIQUE Impulse on Index finger Middle finger Ring finger Indirect inguinal hernia Direct inguinal hernia Femoral hernia TONY 2010 MBBS
  51. 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. 52. HOW TO IDENTIFY DEEP RING TONY 2010 MBBS
  53. 53. HOW TO IDENTIFY DEEP RING TONY 2010 MBBS
  54. 54. TONY 2010 MBBS
  55. 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
  56. 56. REDUCIBILITY TONY 2010 MBBS
  57. 57. INVAGINATION TEST • After reduction of hernia in recumbent position • Using little finger  rt. Hand side for rt. Side lt. hand side for lt. side • Invaginate skin 4m the bottom of scrotum & the little finger is pushed to palpate pubic tubercle • Finger is then rotated & pushed further up in to superficial inguinal ring • Nail will be against spermatic cord pulp will feel walls of ring • Normal ring transmits only tip of finger ,>1 finger}abnormally large TONY 2010 MBBS
  58. 58. INVAGINATION TEST TONY 2010 MBBS
  59. 59. INVAGINATION TEST TONY 2010 MBBS
  60. 60. INVAGINATION TEST Finger goes directly backward=direct hernia TONY 2010 MBBS
  61. 61. INVAGINATION TEST Finger goes upwards, backwards, outwards= indirect TONY 2010 MBBS
  62. 62. INVAGINATION TEST Impulse on coughing Pulp of finger direct tip indirect TONY 2010 MBBS
  63. 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. 64. RING OCCLUSION TEST • Swelling appears even when deep ring is occluded=direct hernia • No swelling when deep ring is occluded = indirect hernia TONY 2010 MBBS
  65. 65. TONY 2010 MBBS
  66. 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. 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. 68. AUSCULTATION • Peristaltic sounds=enterocele TONY 2010 MBBS
  69. 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. 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. 71. ABDOMINAL MUSCLE STRENGTH TONY 2010 MBBS
  72. 72. MALGAGNES BULGING • Head or leg raising test: to test for abdominal muscle tone & malgaignes bulging TONY 2010 MBBS
  73. 73. SYSTEMIC EXAMINATION • RESPIRATORY SYSTEM • R/O • C/C BRONCHITIS ,TB • ABDOMEN • MASS • ASCITES TONY 2010 MBBS
  74. 74. • Abdominal examination • Respiratory system • Urinary systems • Per rectal examination TONY 2010 MBBS
  75. 75. PER-RECTAL EXAMINATION • 1. Benign Prostate hypertrophy—micturition difficulty • 2.Malignant obstruction • 3. Chronic fissure—constipation TONY 2010 MBBS
  76. 76. • Diagnosis • • Side—right/left • • Type—indirect/direct • • Inguinal—femoral • • Complete/Incomplete • • Complicated/Uncomplicated • • Content—enterocele/omentocele TONY 2010 MBBS
  77. 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. 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
  79. 79. MANAGEMENT TONY 2010 MBBS
  80. 80. • Investigations • Treatment TONY 2010 MBBS
  81. 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. 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. 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. 84. TAXIS • Supine hip & knee flexed hip internally rotated • Contents are pushed with one hand directed with the other TONY 2010 MBBS
  85. 85. TREATMENT • Surgery= treatment of choice • Under LA/GA/spinal/epidural surgery Hernioplasty herniorraphy TONY 2010 MBBS
  86. 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. 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. 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
  89. 89. TONY 2010 MBBS
  90. 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. 91. PROCEDURE • Cremasteric muscle is opened TONY 2010 MBBS
  92. 92. • Herniotomy = ligation & excision of sac only • Herniorraphy = herniotomy + repair of posterior wall • Hernioplasty= herniotomy + reconstruction of posterior wall with prosthetics TONY 2010 MBBS
  93. 93. HERNIORRAPHY TONY 2010 MBBS
  94. 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. 95. BASSINI REPAIR • Is frequently used for indirect inguinal hernias and small direct hernias • The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament TONY 2010 MBBS
  96. 96. TONY 2010 MBBS
  97. 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. 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. 99. MODIFIED BASSINIS REPAIR TONY 2010 MBBS
  100. 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. 101. MC VAYS REPAIR TONY 2010 MBBS
  102. 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. 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. 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. 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. 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
  107. 107. TONY 2010 MBBS
  108. 108. TONY 2010 MBBS
  109. 109. TONY 2010 MBBS
  110. 110. TONY 2010 MBBS
  111. 111. TONY 2010 MBBS Tanner's muscle slide
  112. 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. 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. 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. 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. 116. COMPLICATION • Mesh extrusion • Foreign body reaction • infection TONY 2010 MBBS
  117. 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. 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
  119. 119. TONY 2010 MBBS
  120. 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. 121. INLAY MESH METHOD • mesh deep to conjoint tendon TONY 2010 MBBS
  122. 122. NYHUS PREPERITONEAL MESH REPAIR • Broad mesh is kept in the preperitoneal space in b/l direct or recurrent hernia TONY 2010 MBBS
  123. 123. LICHTENSTEIN TENSION FREE MESH REPAIR • Less recurrence • Cord is covered with mesh and is sutured as in onlay method TONY 2010 MBBS
  124. 124. LICHENSTEIN TENSION FREE REPAIR TONY 2010 MBBS
  125. 125. TENSION – FREE REPAIR TONY 2010 MBBS
  126. 126. TENSION – FREE REPAIR TONY 2010 MBBS
  127. 127. LICHTENSTEIN TENSION-FREE REPAIR TONY 2010 MBBS
  128. 128. PROLENE HERNIA SYSTEM TONY 2010 MBBS
  129. 129. PROLENE HERNIAL SYSTEM TONY 2010 MBBS
  130. 130. TONY 2010 MBBS
  131. 131. STOPPAS REPAIR • GPRVS (Giant Prosthesis for Reinforcement of Visceral Sac) • OVER FRICHAUDS MYOPECTINEAL ORIFICE TONY 2010 MBBS
  132. 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. 133. LAPAROSCOPIC HERNIA REPAIR • Transabdominal Preperitoneal Procedure (TAPP) • Totally Extraperitoneal (TEP) Repair • Indications include bilateral inguinal hernia, recurring hernia, need for early recovery TONY 2010 MBBS
  134. 134. TONY 2010 MBBS
  135. 135. TEP TONY 2010 MBBS
  136. 136. TEP TONY 2010 MBBS
  137. 137. TAPP TONY 2010 MBBS
  138. 138. COMPLICATIONS OF HERNIA REPAIR IMMEDIATE 1. Injury to the blood vessels (inferior epigastric and femoral) 2. Injury to bowel and bladder 3. Injury to ilioinguinal and iliohypogastric nerves 4. Injury to cord structures EARLY 1. Urine retention 2. Hematoma 3. Infection 4. Periostitis of pubic tubercle (as the stitch is taken from periosteum) 5. Postherniorrhaphy hydrocele (due to obstruction of lymphatics At deep ring when narrowed tightly) LATE 1. Recurrence 2. Numbness over the local region if the nerve was cut during surgery TONY 2010 MBBS
  139. 139. DISCUSSION TONY 2010 MBBS
  140. 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. 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
  142. 142. TONY 2010 MBBS
  143. 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. 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. 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.
  146. 146. TONY 2010 MBBS
  147. 147. TONY 2010 MBBS
  148. 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. 149. CONTENTS OF INGUINALCANAL TONY 2010 MBBS
  150. 150. COVERING OF SPERMATIC CORD TONY 2010 MBBS
  151. 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. 152. FRICHAUDS MYOPECTINEAL ORIFICE The MPO is divided anteriorly by the inguinal ligament, and posteriorly by the iliopubic tract. It is bounded medially by the lateral border of the rectus muscle, superiorly by the arching fibers of the transversus abdominus and the internal oblique muscles, laterally by the iliopsoas muscle and inferiorly by the Cooper ligament. ALL HERNOA ARE THROGH THI ORIFICE TONY 2010 MBBS
  153. 153. TONY 2010 MBBS
  154. 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. 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. 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. 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. 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. 159. PARTS OF A HERNIA • SAC • COVERING OF SAC • CONTENTS OF SAC TONY 2010 MBBS
  160. 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. 161. COVERING OF SAC • LAYERS OF ABDOMINAL WALL TONY 2010 MBBS
  162. 162. CONTENTS OF SAC • OMENTOCELE: omentum….easy to reduce initially,…but difficult later • ENTEROCELE: usuaslly SI,….difficult to reduce initially…easy later • RICHTERS HERNIA :a portion of circumference of bowel • LITTRE’S HERNIA: meckels diverticulum • CYSTOCELE :bladder • Ovary,fallopian tube • Fluid :ascitic, blood from strangulated hernia, from congested bowel TONY 2010 MBBS
  163. 163. TONY 2010 MBBS
  164. 164. CLINICAL CLASSIFICATION HERNIA REDUCIBLE HERNIA IRREDUCIBLE HERNIA OBSTRUCTED HERNIA INCARCERATED HERNIA STRANGULATED HERNIA INFLAMMED HERNIA TONY 2010 MBBS
  165. 165. CLINICAL CLASSIFICATION • REDUCIBLE HERNIA contents can be reduced by the patient or surgeon expansile impulse on coughing TONY 2010 MBBS
  166. 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. 167.  OBSTRUCTED HERNIA : bowel is obstructed…but blood supply is good TONY 2010 MBBS
  168. 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. 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. 170. • INFLAMMED HERNIA inflammation of contents of hernia sac appendicitis,salpingitis TONY 2010 MBBS
  171. 171. CLASSIFICATION hernia congenital acquired TONY 2010 MBBS
  172. 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. 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
  174. 174. TONY 2010 MBBS
  175. 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. 176. INDIRECT INGUINAL HERNIA • Commonest more in males • Thin sac • Narrow neck • Lateral to inferior epigastric vessels TONY 2010 MBBS
  177. 177. TONY 2010 MBBS
  178. 178. CLASSIFICATION( BASED ON EXTENT) Inguinal hernia incomplete bubonocele funicular complete Sac is confined to inguinalcanal Sac crosses superficial ring but not reaches bottom of scrotum Reaches bottom of scrotum TONY 2010 MBBS
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  181. 181. TONY 2010 MBBS
  182. 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. 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. 184. Direct hernia medial lateral TONY 2010 MBBS
  185. 185. TONY 2010 MBBS
  186. 186. 2 CLASSICAL SIGNS OF UNCOMPLICATED HERNIA • Impulse on coughing • Reducibility TONY 2010 MBBS
  187. 187. COMPLICATIONS OF HERNIA • Irreducibility • Obstructed hernia • Strangulated hernia • Inflammation • Incarceration TONY 2010 MBBS
  188. 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. 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. 190. INCARCERATED HERNIA • When it contains a portion of colon with faeces  indenting with fingers putty like feeling TONY 2010 MBBS
  191. 191. STRANGULATED HERNIA • Irredudicibility + intestinal obstruction + arrest of blood supply • Due to constriction at the neck TONY 2010 MBBS
  192. 192. SIGNS OF STRANGULATED HERNIA • Tense • Tender • No impulse on coughing • irreducible • Recent increase in size TONY 2010 MBBS
  193. 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. 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. 195. FEMORAL HERNIA Femoral canal Saphenous opening TONY 2010 MBBS
  196. 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
  197. 197. TONY 2010 MBBS
  198. 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
  199. 199. ANATOMY TONY 2010 MBBS
  200. 200. COURSE OF FEMORAL HERNIA TONY 2010 MBBS
  201. 201. COVERINGS • Skin • Superficial fascia • Cribriform fscia • Anterior layer of femoral sheath • Fatty content of femoral canal • Femoral septum • peritoneum TONY 2010 MBBS
  202. 202. • Increased chance of strangulation • F>M • Uncommon in children • Symptoms • Pain • Swelling TONY 2010 MBBS
  203. 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. 204. • Position • Zeimanns test • Impulse on ring finger • Invagination test • Empty inguinal canal • Ring occlusion of saphenous opening TONY 2010 MBBS
  205. 205. DD • Saphena varix • Aneurysm • Psoas abscess • Undescended ectopic testis • Lipoma • Psoas bursa • Hydrocele of femoral hernia sac TONY 2010 MBBS
  206. 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. 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. 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. 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. 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. 211. SPIGELIAN HERNIA • Lateral ventral hernia • Herniate b/w muscles of abdomen • At or blw arcuate line due to absence of posterior rectus sheath(half way b/w umbilicus & inguinal ligament) • High risk of strangulation • Rectus abdominis medially & arcuate line laterally TONY 2010 MBBS
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  215. 215. LUMBAR HERNIA TONY 2010 MBBS
  216. 216. UMBILICAL HERNIA Umbilical hernia Exomphalos Umbilical hernia in infants & children Para umbilical hernia of adults TONY 2010 MBBS
  217. 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
  218. 218. TONY 2010 MBBS
  219. 219. EXOMPHALOS MAJOR • Umbilical cord attached to inferior aspect of large swelling • Contains SI… LI & part of liver TONY 2010 MBBS
  220. 220. • Exomphalos major may burst • So emergency Sx is needed TONY 2010 MBBS
  221. 221. EXOMPHALOS MINOR • Sac is small • Umbilical cord is attached to its summit TONY 2010 MBBS
  222. 222. TONY 2010 MBBS
  223. 223. UMBILICAL HERNIA IN INFANTS & CHILDRENS • Through umbilical cicatrix • Spherical in shape • Increase in size in crying TONY 2010 MBBS
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  225. 225. PARAUMBILICAL HERNIA OF ADULTS • Not through umbilical cicatrix but through linea alba • Above (supraumbilical) • Below (infraumbilical) TONY 2010 MBBS
  226. 226. INTERSTITIAL HERNIA • Hernial sac lies between muscle layers of abdominal wall • Preperitoneal/intraparietal • Interparietal • Extraparietal TONY 2010 MBBS
  227. 227. LITTRE’S HERNIA • Meckels diverticulum is the content TONY 2010 MBBS
  228. 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. 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. 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. 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

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