This document provides information about hernia surgery. It describes the different types of hernias including inguinal, incisional, femoral, umbilical, and epigastric hernias. It discusses the common presenting complaints of a hernia such as a lump or pain and precipitating factors. The document outlines the process of examining a patient for a hernia including inspection, palpation, and tests like the cough impulse and Zeimann's technique to determine the type of hernia. It also provides guidance on examining other related areas like abdominal muscles and performing a full systemic examination of the patient.
7. HISTORY
⢠AGE :
YOUNG
â˘INDIRECT
OLD AGE (weak musculature)
â˘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)ď¨ 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 ď
OBLITERATEDď 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:
⢠â On straining
⢠â On standing
⢠â On coughing
⢠5. Relieving factors:
⢠â By lying down
⢠â Manuallybyhimself
⢠6. Associated with pain: Usually painless
TONY 2010 MBBS
13. PRESENTING COMPLAINTS
LUMP
⢠Onset : coughing
lifting weight
⢠Site: groin ď 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 ď 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 initiallyď â 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
â˘BILIOUS
â˘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
â˘Damage to ilioinguinal nerve
ď¨ weak abdominal wallď
DIRECT hernia
APPENDICECTOMY
â˘Same side
â˘Opposite side
RECURRENT HERNIA
TONY 2010 MBBS
29. POSITION & EXTENT
⢠Inguinal hernia ď¨ 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 ď¨ starts below the inginal ligament and ascend over it
TONY 2010 MBBS
31. VISIBLE PERISTALSIS
⢠Invisible = femoral hernia
⢠Visible in case of inguinal herniaď when skin is thin ď¨as in case of recurrent
hernia
TONY 2010 MBBS
32. SKIN OVER THE SWELLING
⢠Uncomplicated=normal
⢠Strangulated=reddened
⢠Truss 4 long time=discolouration,ď¨ due to deposition of hemosiderin
streaks,
⢠Scar=recurrence
⢠Wide irregular puckered=wound infectionď¨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
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
44. RELATION OF THE SWELLING TO
THE TESTIS & SPERMATIC CORD
INGUINAL HERNIA
â˘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
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. ZEIMANNâS 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 ď¨deep inguinal ring (1/2 â above mid inguinal point)
Middle finger ď¨superficial inguinal ring (superomedial to pubic tubercle)
Ring finger ď¨saphenous opening (4cm blw & lateral 2 pubic tubercle)
Hold the nose & blow or cough
TONY 2010 MBBS
50. ZEIMANNâS TECHNIQUE
Impulse on
Index finger
Middle finger
Ring finger
Indirect inguinal hernia
Direct inguinal hernia
Femoral hernia
TONY 2010 MBBS
51. ZEIMANNâS TECHNIQUE
⢠In presence of swelling ď coughing ď expansile impulse on coughing
ďśMovement 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
55. REDUCIBILITY
⢠Reduces on lying down ď¨ direct hernia
⢠Using TAXIS
⢠Flexes the thigh
⢠Adduct the thigh
⢠Rotate internally
Relaxes
superficial
inguinal ring +
oblique muscles
⢠Reduces with gurgling=>ENTEROCELE ď¨ Difficult to reduce initially but last
part slips of easily
⢠First part reduces easily last part difficultď¨omentocele
TONY 2010 MBBS
57. INVAGINATION TEST
⢠After reduction of hernia in recumbent position
⢠Using little finger ď 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
63. RING OCCLUSION TEST
⢠Standing position after reduction of swelling
⢠Using thumb pressure over the deep inguinal ring (1/2 â 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
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
⢠Inspectionď¨protrusion of lower abdominal wall
⢠Malgaigneâs bulging:
⢠oval shaped b/l bulge on straining above & parallel to medial half of inguinal
ligament
⢠ď¨weakness of abdominal wall
⢠DIRECT HERNIA
⢠HERNIOPLASTY IS REQUIRED
TONY 2010 MBBS
78. DIFFERENTIAL DIAGNOSIS
In males
⢠Hydrocele â
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 â
this is the most common dif-ferential
diagnostic problem
⢠femoral hernia.
TONY 2010 MBBS
81. INVESTIGATIONS
⢠I. Routine
⢠⢠Hemoglobin
⢠⢠Bleeding time/Clotting time
⢠⢠Total count, differential count, ESR
⢠⢠Urineâalbumin, sugar deposits
⢠⢠Bloodâurea, sugar
⢠⢠Blood grouping/typingâfor irreducible hernia/huge hernia
⢠II. Anesthetic Purpose
⢠⢠X-ray chest (Chronic TB, Asthmaâprecipitate hernia)
⢠⢠ECG all leads
⢠III. USG Abdomen and Pelvis
⢠⢠In old age groupâto 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. McVayâs
⢠4. Shouldice
Hernioplasty (prosthetic
repair )
⢠1. Lichtenstein
⢠2. Gilbertâs 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 1â
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 âŚâŚTHERE 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
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 ď adequate tensile strength for about 6 months
⢠Monofilamentď polyfilament has crevices=infn
⢠Interrupted ď continuous suture= decrease blood supply interfere with
healing
TONY 2010 MBBS
100. MCVAY REPAIR
⢠inguinal and
femoral canal
defects
⢠The conjoined
tendon is sutured to
Cooperâs ligament
from the pubic
cubicle laterally
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
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. Lichtensteinâs method
⢠7. TAPP
⢠8. TEP
TONY 2010 MBBS
120. ONLAY MESH METHOD:
⢠repair by placing mesh in frontâŚ..using monofilament non absorbable suture
materialâŚ.above to conjoint tendon & below to inguinal ligament
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
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
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. FRUCHAUDâS 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
ďśC/C CONSTIPATION (HABITUAL,STRICTURE)
ďśURINARY PROBLEMS
ďą OLD AGE =BPH, Ca prostate
ďą YOUNG AGE=STRICTURE URETHRA
ďą VERY YOUNG=PHIMOSIS,MEATAL STENOSIS
ďśLIFTING OF HEAVY WEIGHT
⢠C/C COUGH =T.B, B.A, C/C BRONCHITIS
⢠OBESITY
⢠PREGNANCY
⢠SMOKING
⢠ASCITES
TONY 2010 MBBS
158. ETIOLOGY
⢠APPENDICECTOMY ď DESTROY ILIO INGUINAL Nď 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
ďą MOUTH
ďą NECK
ďą BODY
ďą 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: omentumâŚ.easy to reduce initially,âŚbut difficult later
⢠ENTEROCELE: usuaslly SI,âŚ.difficult to reduce initiallyâŚeasy later
⢠RICHTERS HERNIA :a portion of circumference of bowel
⢠LITTREâS HERNIA: meckels diverticulum
⢠CYSTOCELE :bladder
⢠Ovary,fallopian tube
⢠Fluid :ascitic, blood from strangulated hernia, from congested bowel
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 canât be reduced âŚdue to adhesions b/w contents
and sacâŚor due to crowding
irreducibility + no other symptoms}OMENTOCELE
Irreducibility predisposes to strangulation
TONY 2010 MBBS
167. ďś OBSTRUCTED HERNIA : bowel is obstructedâŚbut blood supply is good
TONY 2010 MBBS
168. ďś 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. ďśSTRANGULATED HERNIA blood supply is impairedď ISCHAEMIAď GANGRENE
OF INTESTINE
TENDERNESSâŚ. 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
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.Ziemanâs 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 AâD 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 TRIANGLEâŚ.. HESSELBACHS TRIANGLE IS DIVIDED IN
TO LATERAL & MEDIAL HALVES BY OBLITERATED UMBILICAL ARTERY(LATERAL
UMBILICAL LIGAMENT) ď DIRECT HERNIA CAN BE DIVIDED IN TO LATERAL AND
MEDIAL BASED UPON THIS LIGAMENT
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 ď 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 (gravityď redn of hernia)
⢠Ice bag applin ď 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 bowelâend to end resection anastomosis
⢠Omentumâexcise 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
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. MAYDLâS HERNIA
⢠Bowel loop = W SHAPE (HERNIA IN W)
⢠CENTRAL PART CAN GET STRANGULATED
(INTRA ABDOMINAL)
⢠NO LOCAL TENDERNESS AS IN OTHER CASES
OF STRANGULATION
ď¨PERITONITIS
TONY 2010 MBBS
208. RICHTERâS 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 âen-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
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
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
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