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1 Inguinal Hernia Edited
1 Inguinal Hernia Edited
Rajamahendran
Overview:
Definition :
• Hernia is an abnormal protrusion of a part or whole of the viscus through a
normal or abnormal opening through the wall of the cavity that contains it.
HISTORY TAKING
Name
Age
Sex
Occupation :
VIVA Stops:
PRESENTING COMPLAINTS
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5. Relieving Factors :
- By lying down
- Manually by himself
II. COMPLICATIONS
1. Irreducibility :
Reasons for becoming irreducible:
• Crowding of the contents
• Adhesion between sac and contents
• Adhesion between contents
• Adhesion between sac.
2. Obstruction :
Four cardinal features
• Colicky abdominal pain
• Vomiting
• Abdominal distension
• Obstipation (Absolute constipation) - not passing flatus and
feces**
3. Strangulation :
(Obstruction + irreducibility + Arrest of Blood Supply)
• Colicky abdominal pain becomes dull aching continuous pain if
bowel goes for gangrene**
• Sudden increase in size of hernia; becomes tense and tender.
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Viva Stops:
• Weight Lifting is not a risk factor for Hernia from 27th Edition Bailey and Love**
PAST HISTORY :
• H/o. Diabetes mellitus / Hypertension / Ischaemic heart disease / Bronchial
asthma / Tuberculosis
• H/o. Previous Surgery ( Appendicectomy and Hernia surgery in same side or
opposite side)
FAMILY HISTORY :
• H/o. connective tissue disorders in family
PERSONAL HISTORY :
• H/o. Smoking : Smoking leads to chronic bronchitis
• Collagen deficiency occurs in smokers.
GENERAL EXAMINATION :
General Condition
Anemia
Lymph adenopathy
Blood Pressure
Pulse Rate
INSPECTION :
1. Site
2. Size
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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
Viva Stops:
SHAPE :
• Hemispherical – Direct ( Figure 1.1)
• Pyriform – Indirect ( Figure 1.3)
• Retort - Femoral
POSITION :
• Femoral - Below and lateral to public tubercle ( Figure 1.3)
• Inguinal - Above and medial to pubic tubercle
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PALPATION :
1. Temperature
2. Tenderness
3. Site
4. Size
5. Shape
6. Extent
7. Surface
8. Skin Over
9. Consistency
10. Reducibility
11. Get above the swelling
12. Cough impulse
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VIVA Stops:
Can be performed by :
• Making the child cry
• Valsalva manoevre
• Head raising and abdomen contraction
To demonstrate by inspection;
• No need to reduce the content
• Just ask the patient to stand and cough
Inference :
• Swelling increases in size or
• Impulse seen and swelling reappears
To demonstrate by palpation :
• Hold the right side of the root of scrotum with your left thumb and
index finger without reducing the content and ask to cough.
• You will get expansile and propulsive impulse
• In Bubonocele - keep your thumb at deep ring
• Strangulated hernia
• Incarcerated hernia
• Neck of sac becomes blocked by adhesions
Viva Stop:
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Also note:
• Get above the swelling at root of scrotum is a classical feature of hydrocele.
This is absent in Hernia.
VIVA STOP:
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When will you get the swelling even though it is an indirect hernia by deep ring
Occlusion test?
• Pantaloon hernia
• Wide Deep ring (Occlude in such cases with index and middle finger together
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• Only test in Hernia; done in lying position always, and only test never done
in Females
Prerequisite :
• Swelling should be reducible
• Lax of skin should be there for invaginating (so this test could not be done
in females)
Procedure :
o Reduce the swelling.
o For Right side, invaginate with right little finger into the superficial ring.
o Rotate the little finger medially so that the pulp faces medially.
o Note the direction of entry and site of impulse.
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What are the things you will look for in Finger Invagination test:
1. Strength of superficial ring: Normal ring admits only the tip
2. Direction of Canal:
• Direct hernia - Directly backwards
• Indirect - Goes upwards, backwards and Laterally
3. Site of impulse :
• Pulp - Direct
• Tip - Indirect
4. Strength of posterior wall
5. To find early cases of hernia, impulse felt at tip.
PERCUSSION :
o Enterocele : Resonant
o Omentum : Dull
AUSCULTATION:
• Peristaltic sounds occasionally heard.
OTHERS :
• Testis: `Traction Test' to find whether the inguinal swelling is an Encysted
Hydrocele of Cord, Also look for Normal or atrophied testis.
• Epididymis :
• Penis : Look for 3P’s in Penis
▪ Phimosis
▪ Penile strictures
▪ Pinhole meatus
• Regional Nodes
• Opposite Groin
PERRECTAL EXAMINATION :
(not needed to do for Final year students- but you must say you will do PR to look
for following)
• Benign Prostate hypertrophy - Micturition difficulty
• Malignant anal or rectal Obstruction
• Chronic fissure - constipation
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CARDIOVASCULAR SYSTEM :
ABDOMEN :
o Mass abdomen
o Malgaigne’s Bulgings
o Ascites
VIVA Stops:
What are these MALGAIGNE'S BULGINGS?
• Oval, longitudinal, bilateral bulging produced on straining, in inguinal region or
above it; and are parallel to medial half of inguinal ligament.
• Present in Direct hernia
• Indicates poor muscle tone
• Signifies Hernioplasty is the treatment.
3. Inguinal - Femoral
4. Complete / Incomplete
5. Complicated / Uncomplicated
Classification of Hernia:
European Hernia Society Classification:
• Primary or Recurrent ( P or R)
• Lateral, Medial or Femoral ( L, M or F)
• Defect size in Finger Breadths assumed by be 1.5 cm
Type I- Indirect hernia with Normal deep ring Type 1 - Small, indirect
Type II - Indirect hernia with Dilated deep ring Type 2 - Medium, indirect
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Type 7 - Femoral
Reducibility Compressibility
After reducing the swelling opposite force Opposite force is not required for
is required to make the swelling reappear reappearing. It appears slowly to its
original size
Swelling can be completely reduced Swelling cannot be completed reduced
Eg : Hernia Eg : Hemangioma
Procedure : Flex the knee, Adduct and internally rotate the hip
* With the thumb and fingers hold the sac; guide with other
hand at superficial ring*
Complications of Taxis:
• Bowel injury
• Reduction en mass-Reducing the sac with the constriction being present at the
neck; thereby making the hernia with obstruction to go into the abdomen.
• Sac may rupture at its neck and the contents may be reduced extra peritoneally.
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ROUTINE
• Haemoglobin
• Bleeding Time / Clotting time
• Total count, differential count, ESR
• Urine - Albumin, Sugar, deposits
• Blood - urea, sugar
• Blood grouping/typing - for irreducible hernia / huge hernia
ANAESTHETIC PURPOSE
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Conservative management is indicated only in cases of very old unfit man with Direct
hernia; since there is no chance of obstruction. Otherwise SURGERY is the Gold standard
treatment for Hernias.
• Old age : Where muscles are weak : HERNIOPLASTY under spinal anaesthesia/
Local anesthesia
Recent Trend : HERNIOPLASTY using Meshes is the GOLD Standard procedure and
Repairs by using Only suture materials is OBSOLETE. ( not followed)
• VAGINAL (COMPLETE) - descends upto scrotum base, Testis not felt (separately).
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Other names :
• Inguinal ligament - Poupart's.
• Lacunar ligament - Gimbernat's
• Iliopectineal ligament - Cooper's
• Saphenous opening- Fossa ovalis
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Lymphatics of testis
Testicular plexus of sympathetic nerves
Genital branch of Genitofemoral N
Vas deferens
Deep ring : Half inch above mid inguinal point (Between Anterior superior iliac spine
and pubic symphysis)
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ANATOMY OF HERNIA
• Sac
• Contents
• Coverings
Sac : 1. Mouth
2. Neck (narrowest past)
3. Body
4. Fundus
Sacless hernia :
Epigastric hernia
INDIRECT HERNIA
o Peritoneum
o Internal spermatic fascia (from fascia transversalis)
o Cremasteric fascia (from internal oblique)
o External spermatic fascia (from external oblique)
o Scrotum
DIRECT HERNIA
o Peritoneum
o Transversalis fascia (from fascia transversalis)
o External spermatic fascia (from external oblique) usually does not
descend into scrotum.
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• Femoral canal is bounded above by femoral ring with extra peritoneal pad of fat;
Below by saphenous opening covered by cribriform fascia.
Author’s Note:
• By answering this far in Examination- Already you are passed and you can be
confident on the questions about to come from Examiner hereafter, because they
are just to give extra marks.
HERNIOTOMY :
Steps in herniotomy:
• Separation of sac from cord structures
• Reducing the content
• Trans fixation and ligation of sac
• Excise the redundant sac.
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(Don't separate the sac beyond pubic tubercle, as we will damage the scrotal blood supply
doing so).
Also Know:
• Herniotomy( transfixation and ligation of the sac) is done only for indirect
inguinal Hernia.
• For direct hernia just push the sac back into abdomen without opening
HERNIORRHAPHY
Steps in Herniorrhaphy:
• Herniotomy
• Narrowing of the deep ring with 2'0 prolene (LYTLE'S REPAIR)
• Approximation of conjoint tendon with inguinal ligament using 1'
polypropylene material.
HERNIOPLASTY
• Silk - Black
• Catgut - Brown
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Herniorrhaphy Types:
Modified Bassini: ( Figure 1.13)
• By using 1’ prolene suture continuously , approximation done between
Conjoint tendon and inguinal ligament, it’s a tension repair. Not done
nowadays in many advanced centres.
• It is followed only in cases of Strangulated hernia surgeries where keeping
a mesh can cause infection.
• TANNER'S MUSCLE SLIDE
o Basically all the herniorrhaphy are tension - repairs.
o To avoid tension in the rhaphy site, the incision made curvilinearly
over the anterior RECTUS SHEATH
o This relaxes the conjoined muscles and thus get approximated with
inguinal ligament without tension.
o This type slide is not done as we are not doing this type Tension
herniorrhaphy procedures nowadays.
Shouldice technique
• He gave additional strength to the posterior wall by double breasting the
fascia transversalis.
• Best among all anatomical repairs (Herniorrhaphy)
• Least recurrence among herniorrhaphy
McVay's Repair :
• Approximated conjoined tendon with iliopectineal ligament of cooper.
• It prevents both inguinal and femoral hernia
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Hernioplasty Procedures:
LICHTENSTEIN HERNIOPLASTY
• Prolene mesh 16 x 10 cm size is taken and fixed in the inguinal canal. ( Figure
1.15)
• First bite taken from periosteum of pubic tubercle; and fix the mesh to a point
beyond the deep ring.
• Fix the mesh with inguinal ligament and conjoined tendon using 1'0 or 2'0 prolene
without tension.
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Lichtensteins tension free mesh repair is used for all types of inguinal hernia nowadays
for its least recurrence. It is the Gold Standard hernia Repair now.
STOPPAS PROCEDURE
• For bilateral direct hernia's, a modified pfannensteil incision made in the lower
abdomen and a huge mesh placed in between the peritoneum and the fascia
transversalis (PREPERITONEAL MESH repair).
Laparoscopic Hernia Repair: Recently becoming the Gold standard and me be the
Procedure of choice in 1 to 2 decades.
• Most surgeons are now getting trained in laparoscopic hernia surgeries
• Though all the hernias can be done by Laparoscopic method, NICE guidelines for
hernia surgery advices the laparoscopic repair is ideal for
1. Recurrent hernias
2. Bilateral hernias
• There are two methods for laparoscopic hernia repair.
• In both the methods a huge mesh is kept pre peritoneal.
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Triangle of Pain:
Lateral- Iliopubic tract
Medial- Gonadal vessels
Inferior- Inferior edge of skin incision
Contents: Femoral Br of GF nerve, Lateral FCN, Anterior FCN of thigh
Lateral to triangle of doom
Stapling here causes neuralgia
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Must know:
• MC nerve injured in Laparoscopic Hernia repair- Lateral Cutaneous Nerve of Thigh* >
Genito femoral nerve*
• MC nerve injured in Open Hernia repair- Ilio Inguinal Nerve*> Genital Branch of
Genito femoral nerve and Ilio hypogastric nerve.
Basic Principle :
Approximate Inguinal Ligament with Cooper's Ligament (Ilio pectineal ligament).
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4. HENRY Procedure:
o Midline Abdominal Extra peritoneal Femoral hernioplasty**
o This doesn’t damage the Transversalis fascial floor and hence reduced risk
for recurrence.
o This is considered as PROCEDURE OF CHOICE nowadays**
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Don't attempt
• Taxis
• Foot end elevation
Steps at operation:
• Paint with povidone iodine from xiphisternum to midthigh (may need
laparotomy for nonviable bowel).
• Inguino scrotal incision made.
• Before separating the sac from cord structures, open the FUNDUS OF SAC
FIRST to release the toxic contents.
• If you push the toxic fluid into the abdomen peritonitis may develop.
• Constriction is usually seen in 50% cases at deep ring and 50% cases at
superficial ring.
• Look for the bowel viability and hold the bowel before releasing the
constriction with HERNIA DIRECTOR (Grooved hernia director)
• Normal bowel is pinkish red; peristalsis seen, glistening.
• In such cases push the bowel inside and do herniorrhaphy.
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Viva Stop:
What will you do in gangrene content?
Non viable bowel:
• Small bowel- end to end resection anastomosis
• Omentum- excise the gangrenous part
Large bowel:
Patients who are unfit for resection and anastomosis the following procedures are done in
emergency.
Hartmann’s operation- Gangrenous Colon is excised and the proximal end is brought out
as colostomy and distal end closed and left inside temporarily. 6 weeks later re
anastomosis is done.
Gangrenous
Bowel
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Sliding Hernia:
Definition
• Part of the posterior wall formed not only by the peritoneum but also by
part of retroperitoneal structures. ( Figure 1.23)
• Eg: Urinary Bladder, caecum, sigmoid or descending colon.
Clinical feature:
1. Incompletely reducible
2. Huge scrotal hernia
3. Appears slowly after reduction
4. Old male.
During Surgery
1. Don't dissect the sac from the retroperitoneal structures, just push part of the sac along
with them.
2. Hernioplasty is ideal.
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Scrotal abdomen:
Very huge hernia, with most of the intestines inside the scrotum.
Clinical feature :
1. Mostly irreducible
2. Cough impulse - negative
During surgery :
1. Assess the respiratory status, because if you suddenly push the whole bowel into
the abdomen he may go for respiratory distress post operatively.
2. Pneumoperitoneum should be created and the patient allowed to work with it for
a few months before surgery.
3. Inguinal incision made as usually and the pneumoperitoneum released; gradually
reduce the content.
4. Do hernioplasty.
• This occurs through spigelian fascia, thin strip of fascia that runs parallel to the
outer border of rectus sheath from tip of 9th costal cartilage to pubic tubercle.
• This fascia contributes to few fibres of anterior rectus sheath and is wide at the
level of ARCUATE LINE, where the hernia occurs and runs in between external
and internal oblique muscles.
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MISCELLANEOUS :
RICHTER'S HERNIA
• A portion of the circumference of the intestine becomes the content of the sac. (
Figure 1.25)
• Strangulation occurs when associated with femoral or obturator hernia.
• Diarrhoea is seen in cases of strangulation.
• Unless more than half of the circumference is involved there is no constipation.
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OGILVIE HERNIA
• Direct hernia 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.
Sportsman’s hernia:
• Severe pain in the groin area extending into the scrotum and upper thigh.
• MC in young men who play football and rugby.
• O/E- Tenderness seen in the inguinal region over the pubic Tubercle and over the
insertion of adductor muscles of thigh.
• Usually no hernia is felt on examination.
• In most cases the pain is due to Orthopaedic injury like Adductor strain, Pubic Symphysis
Diastasis or Muscle tearing like GILMORE Groin* or Posterior wall stretching.
• IOC is MRI .
• Herniography or Laparoscopy is also used.
• Hernia surgery must be the last resort and always warn the patient that failure of pain
relief may happen.
Obturator hernia:
• Hernia Via the obturator foramen.
• MC in females due to wider obturator foramen* following multiparity, old age, Wider
pelvis, malnutrition.
• In females its mc on right side and in males its common on the left side*
• MC presenting feature is intestinal obstruction.
• Howship Romberg sign- referred pain in medial side of knee is seen due to compression
of Obturator nerve. Pathognomonic of incarcerated hernia.
• Hannington Kiff Sign- Absent Obturator reflex due to obturator nerve compression.
• Operation is indicated- Posterior approach is done**
Umbilical hernia:
• Umbilical hernia in infants are congenital
• Most of them closes spontaneously by 2 years*
• Complications are unusual- so surgery is done at 5 years age*
• Surgery- Anatomical repair for small defects and defects> 3cm need mesh repair.
• Mayo’s repair: Vest over pant type repair in which the superior layer and inferior layers
are imbricated. This is not performed nowadays because of high tension and recurrence**
• Howship Romberg Sign**- Obstructed Obturator hernia Causing Pain referred to knee.
• Peterson Hernia- Hernia behind Roux Limb
• Stammers Hernia- Hernia behind Transverse mesocolon.
• Laugier’s Hernia- Via defect in Lacunar ligament.
• Littre hernia- Meckel’s diverticulum containing hernia
• Amyand hernia- Appendix containing hernia
• Berger’s Hernia- hernia into Pouch of Doughals
• Grynfelt Hernia- Superior lumbar hernia
• Petit Hernia- Inferior lumbar hernia.
• Narath hernia- hernia seen in congenital Dislocation of hip
• Maydl’s hernia- W’ shaped loop in hernial sac. Retrograde strangulation occurs
• Cloquet’s hernia is one in which the sac lies under the fascia covering the pectineus muscle.
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CONSOLIDATION
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