1 Inguinal Hernia Edited

Long cases in Surgery- Dr.
Rajamahendran
Case 1: INGUINAL HERNIA
Overview:
History Taking Anatomy

Examination Surgeries
Diagnosis Strangulated Hernia
Investigations Sliding Hernia
Treatment Miscellaneous
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:
• M/c hernia in females - Indirect Inguinal hernia

• M/c hernia in males - Indirect
• Femoral hernia m/c among - Females
• Young Age : Indirect
• Old Age : Direct
• Direct hernia never occurs in females and children
PRESENTING COMPLAINTS
I. About the Hernia

II. Due to Hernia (Complications)
III. Precipitating Factors
1
Long cases in Surgery- Dr.Rajamahendran
I. ABOUT THE HERNIA

1. Duration
2. Onset - Suddenly / gradually
3. Site of Start - From groin to scrotum (hernia)
From scrotum to groin (hydrocele & varicocele)
4. Aggravating Factors :
- On straining
- On standing
- On coughing
5. Relieving Factors :
- By lying down
- Manually by himself
6. Associated with Pain : Usually painless
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.
III. H/O. PRECIPITATING FACTORS

• Chronic Bronchitis / Asthma / TB
• Difficulty in micturition
• Difficulty in defecation
2
Viva Stops:
• Why are you asking about H/o. Open Appendicectomy ?

- Ilioinguinal or ilio hypogastric nerve if damaged by grid iron incision or during
keeping the drain; DIRECT HERNIA OCCUR**.
• What will happen if you cut IlioInguinal or Iliohypogastric nerve in Inguinal

Canal?
- If ilio inguinal nerve is cut in the inguinal canal direct hernia never occurs.
Because the nerve supplies the abdominal muscles before entering the canal.
Only sensory supply is lost in Root of penis and anterior third Scrotum in
males , Labia majora and Clitoris area in females.
• Where is the Pain in Inguinal hernia usually?

- Pain in inguinal hernia is usually in the region of the umbilicus due to drag in
the root of mesentry as bowel enters the sac.
• 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
LOCAL EXAMINATION OF INGUINAL REGION:
INSPECTION :
Patient in standing position
1. Site
2. Size
3
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
Figure 1.1 Direct hernia ( Hemispherical shape)
4
Figure 1.2 Indirect Hernia ( Pyriform shaped)
Figure 1.3 . Femoral hernia ( Obstructed)
PALPATION :
In standing and Lying position
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
5
13. Invagination test

14. Deep Ring occlusion test
15. Ziemann's Three finger technique
VIVA Stops:
What is Cough impulse?

• `Propulsive and Expansile Impulse on Coughing'
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
ABSENT COUGH IMPULSE :
• Strangulated hernia
• Incarcerated hernia
• Neck of sac becomes blocked by adhesions
Where else you see cough impulse :
• Varicocele-Expansile and thrill like not propulsive

• Morrisey's cough impulse - In case of varicose veins, expansile impulse at
sapheno - femoral junction.
• Laryngocele
Viva Stop:
How will you say -the content of hernia?
On testing the reducibility :

• Intestine:Last part is easy to reduce; Initial part is difficult to reduce; gets
6
reduced with gurgling sound.

• Omentum:First part easy to reduce ,last part is difficult because omentum
adheres to fundus of sac.
On testing for Consistency :

• Soft Elastic - Intestine
• Doughy granular – Omentum
Also note:
• Get above the swelling at root of scrotum is a classical feature of hydrocele.
This is absent in Hernia.
VIVA STOP:
How will you do the following Tests:
Test 1: Ziemann's Technique : ( Figure 1.4 a and 1.4 b)
For Right side inguinal hernia,

• Place the Right hand ( No hard and fast rules to keep fingers- Whichever is
comfortable you keep in such a way and write the impulse felt at which
opening)
Index finger over deep ring
Middle finger over superficial ring
Ring finger over saphenous opening
See where the impulse is felt

Direct hernia - superficial ring
Indirect hernia - Deep ring
Femoral hernia - Saphenous opening
Figure 1.4.a. Ziemann’s Technique
7
Figure 1.4 b. Ziemann’s Technique
Test 2: Deep Ring Occlusion Test: ( Figure 1.5)

After reducing the contents, patient in standing position, occlude the deep ring
with thumb. Ask the patient to cough.
If swelling appears - Direct
Doesn’t appear - Indirect
Figure 1.5. Deep Ring Occlusion test
Fallacy of Deep ring occlusion Test
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
Test 3: Ring Invagination Test ( Figure 1.6 a and b)
8
• 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.
Figure 1.6.a. Finger Invagination test.
9
Figure 1.6 b. Finger Invagination test
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
10
CARDIOVASCULAR SYSTEM :
RESPIRATORY SYSTEM : Respiratory Infections
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.
Final Diagnosis: 6 points
1. Side - Right / Left
2. Type - Indirect / Direct
3. Inguinal - Femoral
4. Complete / Incomplete
5. Complicated / Uncomplicated
6. Content - Enterocele / Omentocele
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
So PL2 means- Primary, Lateral and Defect size 3 cm**
NYHUS CLASSIFICATION OF HERNIA Gilbert Classification
Type I- Indirect hernia with Normal deep ring Type 1 - Small, indirect
Type II - Indirect hernia with Dilated deep ring Type 2 - Medium, indirect
Type III - Posterior wall defect Type 3 - Large, indirect

A. Direct
B. Pantaloon Type 4 - Entire floor, direct
C. Femoral
11
Type IV - Recurrent Type 5 - Diverticular, direct
Type 6 - Combined, pantaloon
Type 7 - Femoral
Post Presentation Examiner’s Rapid Shots:
1. Tell the difference between Reducibility and Compressibility:
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
2. How will you demonstrate Hernia in very small children?

GORNALL'S TEST
* Child held from back by both hands of clinician on its abdomen
* Abdomen is pressed and child is lifted up
* Hernia appears due to increase in the abdominal pressure exerted.
3. What is Taxis?( Do Not mention unless asked by the examiner)

Method of reducing the inguinal hernia
Procedure : Flex the knee, Adduct and internally rotate the hip
Relaxes the abdominal muscles
* 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.
12
4. Name the DIFFERENTIAL DIAGNOSIS of the swelling in Inguinal region:
Inguinal Swelling Inguinoscrotal Swelling Femoral Hernia

1. Enlarged lymph nodes 1. Encysted hydrocele of cord 1. Inguinal hernia
2. Undescended testis 2. Varicocele 2. Saphena varix
3. Lipoma 3. Lymph varix 3. Cloquet's node
4. Femoral hernia 4. Diffuse lipoma of cord 4. Lipoma
5. Saphena varix 5. Inflammatory thickening of 5. Femoral aneurysm
Cord
6. Psoas abscess 6. Psoas abscess
7. Femoral aneurysm
5. List out the investigations done for Hernia:
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
• X-ray Chest ( Chronic TB, Asthma- precipitate hernia)

• ECG all leads
USG ABDOMEN AND PELVIS

• In old age group - to find benign prostate hyperplasia , calculate post voidal
residual urine. If >100ml post voidal residual urine is present- it is significant
• To find any mass.
6. What is TRUSS? ( Fig 1.7)

TRUSS – Hernia Belts:
* Truss is not curative for hernia.
o It is 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 in cases of irreducible hernia, undescended testis, associated
huge hydrocele, unintelligent people.
* Don't say in exams as the treatment unless the examiner asks you.
13
Fig 1.7. Truss for Inguinal hernia
7. How will you treat your case of Hernia?

Treat the precipitating cause of hernia first
• Benign prostate hypertrophy
• Tuberculosis
• Stop smoking
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.
Exam point of view: Surgical Management:
• Age Group < 8 - 10 years : HERNIOTOMY itself is enough
• Young adults: HERNIORRHAPHY/ HERNIOPLASTY under spinal anaesthesia/

Local anesthesia.
• 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)
ANATOMY OF INGUINAL HERNIA

(Author’s warning: Friends don’t go to examination hall without knowing anatomy of
inguinal canal. Most of the students are failed only because of not answering the anatomy
properly).
TYPES OF HERNIA : Figure 1.8
• VAGINAL (COMPLETE) - descends upto scrotum base, Testis not felt (separately).
• FUNICULAR - Testis felt separately, processus vaginalis closed above epididymis.
• BUBONOCELE - Inguinal swelling only.
14
Figure 1.8 Types of Hernia
BOUNDARIES OF INGUINAL CANAL :

• Anterior Wall :External oblique aponeurosis, arched fibres of internal oblique
laterally.
• Posterior Wall: Fascia transversalis, conjoint muscles (tendon) in medial half.
• Floor :Grooved part of external oblique aponeurosis; Medial end there is lacunar
ligament.
• Roof: Conjoint muscles (Internal oblique and transversus abdominis)
INGUINAL CANAL : (House of Bassini)

• 3.75 cm length
• Extends from deep ring to superficial ring
• Deep ring is a semioval opening in the fascia transversalis
• Superficial ring is a triangular opening in the external oblique aponeurosis,
guarded by two crura of muscle fibres.
Other names :
• Inguinal ligament - Poupart's.
• Lacunar ligament - Gimbernat's
• Iliopectineal ligament - Cooper's
• Saphenous opening- Fossa ovalis
CONTENTS OF INGUINAL CANAL

• Ilioinguinal nerve
• Spermatic cord in Male, Round ligament in Female
CONTENTS OF SPERMATIC CORD
Arteries : Testicular Artery

Artery of Vas
Artery to Cremaster
Veins : Pampiniform plexus of veins

Veins corresponding to Arteries
15
Lymphatics of testis
Testicular plexus of sympathetic nerves
Genital branch of Genitofemoral N
Vas deferens
Extra Edge Question:

How does Ilio - inguinal nerve enter the inguinal canal?
• Does not enter through deep ring; but enters through the intermuscular plane
between internal oblique and transverse abdominis and supplies anterior
scrotum, medial side of thigh, root of penis in males, labia majora, and clitoris in
females.
Anatomical landmarks of all the openings ( Figure 1.9)
Deep ring : Half inch above mid inguinal point (Between Anterior superior iliac spine
and pubic symphysis)
(Remember here: Femoral artery is palpated at Midpoint of inguinal

ligament- between ASIS and Pubic tubercle)
Superficial ring : Just above pubic tubercle
Saphenous opening : 4 cm below and lateral to pubic tubercle
Figure: 1.9. Landmarks of openings in Hernia
Mechanisms that Prevent Hernia when abdominal pressure rises.

• Shutter mechanism-Arched fibres of internal oblique
• Flap valve mechanism- Oblique canal; approximation of anterior and posterior
wall.
• Ball valve mechanism- Cremaster contracts, thereby superficial ring plugged by
spermatic cord.
16
• Slit valve mechanism - Crura of the superficial ring.
On internal examination during surgery: ( Figure 1.10)

• Indirect hernia sac is seen lateral to inferior Epigastric Artery via Deep ring
• Direct hernia sac is seen medial to inferior epigastric artery via Hesselbach
triangle.
• Femoral hernia is seen coming below the inguinal ligament in Saphenous opening
Figure :1.10. Identification of types of hernia
HESSEL BACH TRIANGLE ( Figure 1.11)

Weak spot in anterior abdominal wall through which direct hernia appears.
• Medial : Outer border of rectus abdominis.
• Lateral : Inferior epigastric vessels
• Below : Medial part of inguinal ligament
• Floor : Fascia transversalis
• Traversed by medial umbilical fold; (Obliterated Umbilical Artery)
Figure: 1.11.Hesselbach Triangle Boundaries
17
ANATOMY OF HERNIA
• Sac
• Contents
• Coverings
Sac : 1. Mouth
2. Neck (narrowest past)
3. Body
4. Fundus
Sac that lacks neck :

1. Direct hernia
2. Incisional hernia
Sacless hernia :
Epigastric hernia
How can you identify the neck of the sac?

• Narrowest part
• Extraperitoneal pad of fat will be present
• Inferior epigastric vessels will be on medial side
What is the color of sac?

• Sac of hernia is PEARLY WHITE
• Sac of hydrocele is BLUISH
What is the relation of sac with cord :

• Direct Sac: Postero medial to the cord
• Indirect Sac: Antero lateral to the cord.
COVERINGS OF INGUINAL 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.
FEMORAL HERNIA : ANATOMY

Femoral Canal : 2 x 2 cm size , Medial compartment of femoral sheath ( Figure 1.12)
Base : Femoral ring

Bounded
18
Anteriorly - Inguinal ligament

Posteriorly - Cooper's ligament
Medially - Lacunar ligament
Laterally - femoral vein
Contents : Cloquet's node

Lymphatics
Areolar tissue
Figure:1.12 Anatomical Boundaries of Femoral Canal
• Femoral canal is bounded above by femoral ring with extra peritoneal pad of fat;
Below by saphenous opening covered by cribriform fascia.
• Femoral hernia is Retort shaped : because as it goes down through saphenous

opening Holden's Line prevents the contents going further down. Hence the
contents turns up and enters inguinal canal.
• Holden's Line - Fascia scarpa (deep membranous layer of superficial fascia)

attaches firmly with Deep fascia of thigh (fascia lata)
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.
EXTRA Edge Points for Exams:
Surgeries for Hernia:
HERNIOTOMY :
Steps in herniotomy:
• Separation of sac from cord structures
• Reducing the content
• Trans fixation and ligation of sac
• Excise the redundant sac.
19
(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
There is already weakness of abdominal wall muscles, so no approximation can be done.

Hence we use PROLENE MESH to bridge the gap between inguinal ligament and conjoint
tendon.
Pass or Fail- Table:
Colour of Suture Materials :
• Prolene( poly propylene - Dark blue
• Vicryl( poly glycolic acid) - Violet
• Silk - Black
• Catgut - Brown
• Prolene mesh - White
Increasing order of size of materials :
• 3'0 < 2'0 < 1'0 < 1' < 2'
Types of Hernia Surgeries:

Herniorrhaphy Hernioplasty
1. Original bassini ( Obsolete) 1. Lichtensteins
2. Modified bassini 2. Gilbert's plug
20
3. Mc Vay's 3. Prolene hernia system

4. Shouldice 4. Laparoscopic mesh repair
5. Darning Herniorrhaphy
5. Stoppas repair
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.
Figure 1.13. Herniorrhaphy
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
21
DARNING herniorrhaphy: ( Fig 1.14)

• A type of herniorrhaphy which is done by suturing the conjoined tendon with
inguinal ligament using 1 prolene without tension in a zig zag manner multiple
times.
• The suture material appears like mesh due to multiple crossings. It is yet followed
in places where there is risk of keeping a mesh or in places where mesh is not
available.
Figure:1.14 Darning procedure
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.
22
Figure:1.15 Hernioplasty repair
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.
GILBERT'S PLUG REPAIR

• A plug mesh is kept in the deep ring and also to reinforce the posterior wall.
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.
TAPP- Trans Abdominal Preperitoneal TEP- Total Extra peritoneal Repair

repair (Fig 1.16) ( Fig 1.17)
Approach: Peritoneal cavity is not entered, we create
By entering the peritoneal cavity extra peritoneal space by using balloon or
direct inflation to reach the preperitoneal
space of lower abdomen.
Advantages;
• Easy for the beginners • As we go totally extraperitoneal no
• Can be done for those people who chance of intra abdominal visceral
had open prostatectomy (where injuries
extra peritoneal space is not • Easy recovery
available)
Disadvantage:
• Chance of visceral injuries more • Difficult training course. Needs lot
than TEP of training
23
Figure: 1.16. TAPP repair
Figure :1.17. TEP repair
Laparoscopic Anatomy of hernia: PG Standard:

Laparoscopic anatomy of Hernia ( Fig 1.18)
Triangle of DOOM:
 Lateral- Gonadal vessels
 Medial- Vas deferns
 Apex- Deep inguinal ring
 Content- External Iliac vessels
 Dangerous bleeding occurs if you put staples inside this triangle
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
24
Circle of Death ( Corona Mortis)

• Vascular connection between Obturator artery and External Iliac Artery
• Aberrant Obturator Artery*** may arise from Inferior epigastric artery and arches over
the Coopers ligament and joins the normal Obturator artery.
• Significant haemorrhage can occur if accidentally cut during surgery
Fig 1.18.Laparoscopic Hernia Anatomy:
Operations not to be mentioned in exam unless the examiner asks you

Kuntz operation Hamilton Bailey operation
• Orchidectomy is done along with the • Cord is removed from the inguinal
removal of the entire cord and testis. canal by ligating at the external and
• Posterior inguinal canal repaired internal ring.
• Done in old age patients with • Testis is retained for psychological
recurrent hernias reasons.
• Inguinal canal is repaired
• Testis derives its blood supply from
the scrotal vessels and survives
25
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.
FEMORAL HERNIA SURGERY
Basic Principle :
Approximate Inguinal Ligament with Cooper's Ligament (Ilio pectineal ligament).
Four named Approaches :
1. Lothiessen's inguinal approach:

- Inguinal incision made similar to inguinal hernia.
- Fascia transversalis opened.
- Approximate inguinal ligament with iliopectineal and also conjoint tendon
with Inguinal ligament.
- Prevents inguinal hernia also.
2. High approach of Mc Evedy : ( Fig 1.19)

- Vertical incision made over the femoral canal continued above to inguinal
ligament.
- Very useful for irreducible and strangulated hernia.
26
Figure. 1.19. Mc Evedy vertical incision approach
3. Low operation of Lock wood :

- Groin crease incision.
- Indicated in uncomplicated femoral hernia only.
- Just approximate inguinal ligament and iliopectineal ligament.
- Not prevents inguinal hernia.
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**
Operative Steps : VIVA: Hernia surgery:

Under spinal anaesthesia :
* An incision made half inch above and parallel to the medial 2/3 of the inguinal
ligament.
* Superficial vessels identified and ligated.
* Superficial ring identified as a opening in the external oblique aponeurosis.
* External oblique aponeurosis laid open from superficial ring to the level of deep
ring.
* Ilioinguinal nerve and Iliohypogastric nerve may be seen on opening the
external oblique aponeunosis - preserve them.
* Cremasteric muscle along with cord structures seen.
* Cremasteric muscle and fascia opened.
* Cord structures identified and they are separated from the sac.
* Indirect Hernia- Sac separated upto the deep ring, transfixation
and ligation done at deep ring. Herniotomy done.
* Direct Hernia - Just push back the direct sac into the abdomen
and strengthen the posterior wall defect approximating
27
fascia transversalis with 2'0 prolene.

LYTLE'S REPAIR : Narrow the deep ring with 2'0 prolene.
* Herniorrhaphy started after LATERALISING THE CORD.
* First bite taken from the periosteum of pubic tubercle and completed at deep
ring.
* Assuring complete hemostasis cord kept back and layers closed.
Extra Edge Questions:
Strangulated hernia: (Fig 1.20)

Management :
1. Resuscitation : Nasal oxygen, Intravenous fluids.
2. Parenteral antibiotics.
3. Delay should not be made for operation.
`Danger is in delay not in operation'
Don't attempt
• Taxis
• Foot end elevation
Take the patient to operation theatre,

Under General Anaesthesia
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.
If bowel is not viable (Gangrenous, lustureless, no peristalsis)Figure 1.20

1. Keep a warm pad over the bowel.
2. 100% oxygen given nasal.
3. Wait for 10 - minutes
4. If viable put it back in the abdomen
5. If nonviable; abdomen opened through midline incision.
28
Figure 1.20. Strangulated bowel
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
Figure: 1.21. Hartman’s operation
29
Strangulation in Maydl's Hernia.
• Maydl's hernia (Retrograde strangulation) `W' shaped hernia. (Figure 1.22)

• Gangrene in the obstructed bowel starts first at the neck of sac; then
immediately at the antimesentric border distally.
• Therefore in Maydl's hernia; the distal anti mesentric border is inside the
abdomen; which goes for strangulation first
• Hence look for the full length of intestine by pulling out the loop inside the
abdomen.
Figure:1.22. Maydl’s hernia
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.
30
Figure 1.23. Sliding hernia with Retroperitoneal contents
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.
Spigelian hernia: ( Figure 1.24)
• *Type of interstitial (Hernia that comes inbetween the layers of anterior

abdominal wall muscles).
• 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.
31
Figure 1.24. Spigelian Hernia
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.
Figure:1.25. Obstructed Richter’s hernia -relieved from Obstruction
Dual Hernia:(PANTALOON / SADDLE BAG)

• Has two sac- Both Indirect and Direct
• Actually a posterior wall defect in which sac comes through
• Hesselbach's triangle and deep ring.
• Isthmus behind is inferior epigastric vessels.
32
• If one sac is not treated properly recurrence will occur.

• Ring occlusion test : Not significant.
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**
Other named hernias:
• 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.
33
• Gibbon’s hernia- Hernia with hydrocele

• Beclard’s hernia- Femoral hernia via opening in Saphenous Vein
CONSOLIDATION
Factors S.No. Direct Indirect

Age 1. Older Young
Sex 2. Never occur in female M : F = 20:1
3. Reduced on lying down Reduced by manipulation
History
4. Mostly Bilateral Usually unilteral to start
5. Hemispherical shape Pyriform shape
Inspection 6. Malgaigne's bulge (+) No malgaigne's bulge
7. Incomplete variety Complete / Incomplete
8. Deep ring occlusion - Swelling not appears
swelling appears
9. Finger invagination - Impulse at tip of finger
Palpation impulse felt at pulp of little
finger
10. Ziemann's technique - Impulse at deep ring
impulse at superficial ring
Complication 11. Strangulation very rare Common
During surgery 12. Sac is postero medial to Sac is antero lateral to cord.
cord
Sac is medial to inferior Lateral to inferior epigastric
epigastric vessels vessels
Comes through Comes through deep ring
Hesselbach's triangle
Hernioplasty must be done Hernioplasty / Herniorrhaphy
34

1 Inguinal Hernia Edited

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

1 Inguinal Hernia Edited

Uploaded by

Copyright:

Available Formats

Long cases in Surgery- Dr.

Case 1: INGUINAL HERNIA

History Taking Anatomy

• M/c hernia in females - Indirect Inguinal hernia

I. About the Hernia

I. ABOUT THE HERNIA

6. Associated with Pain : Usually painless

III. H/O. PRECIPITATING FACTORS

• Why are you asking about H/o. Open Appendicectomy ?

• What will happen if you cut IlioInguinal or Iliohypogastric nerve in Inguinal

• Where is the Pain in Inguinal hernia usually?

LOCAL EXAMINATION OF INGUINAL REGION:

Patient in standing position

Figure 1.1 Direct hernia ( Hemispherical shape)

Figure 1.2 Indirect Hernia ( Pyriform shaped)

Figure 1.3 . Femoral hernia ( Obstructed)

In standing and Lying position

13. Invagination test

What is Cough impulse?

ABSENT COUGH IMPULSE :

Where else you see cough impulse :

• Varicocele-Expansile and thrill like not propulsive

How will you say -the content of hernia?

On testing the reducibility :

reduced with gurgling sound.

On testing for Consistency :

How will you do the following Tests:

Test 1: Ziemann's Technique : ( Figure 1.4 a and 1.4 b)

For Right side inguinal hernia,

See where the impulse is felt

Figure 1.4.a. Ziemann’s Technique

Figure 1.4 b. Ziemann’s Technique

Test 2: Deep Ring Occlusion Test: ( Figure 1.5)

Figure 1.5. Deep Ring Occlusion test

Fallacy of Deep ring occlusion Test

Test 3: Ring Invagination Test ( Figure 1.6 a and b)

Figure 1.6.a. Finger Invagination test.

Figure 1.6 b. Finger Invagination test

RESPIRATORY SYSTEM : Respiratory Infections

Final Diagnosis: 6 points

1. Side - Right / Left

2. Type - Indirect / Direct

6. Content - Enterocele / Omentocele

So PL2 means- Primary, Lateral and Defect size 3 cm**

NYHUS CLASSIFICATION OF HERNIA Gilbert Classification

Type III - Posterior wall defect Type 3 - Large, indirect

Type IV - Recurrent Type 5 - Diverticular, direct

Type 6 - Combined, pantaloon

Post Presentation Examiner’s Rapid Shots:

1. Tell the difference between Reducibility and Compressibility:

2. How will you demonstrate Hernia in very small children?

3. What is Taxis?( Do Not mention unless asked by the examiner)

Relaxes the abdominal muscles

4. Name the DIFFERENTIAL DIAGNOSIS of the swelling in Inguinal region:

Inguinal Swelling Inguinoscrotal Swelling Femoral Hernia

5. List out the investigations done for Hernia:

• X-ray Chest ( Chronic TB, Asthma- precipitate hernia)

USG ABDOMEN AND PELVIS

6. What is TRUSS? ( Fig 1.7)

Fig 1.7. Truss for Inguinal hernia

7. How will you treat your case of Hernia?

Exam point of view: Surgical Management:

• Age Group < 8 - 10 years : HERNIOTOMY itself is enough

• Young adults: HERNIORRHAPHY/ HERNIOPLASTY under spinal anaesthesia/