HERNIA

SURGERY
HERNIA
PROTRUSION OF A VISCUS OR A PART OF VISCUS THROUGH A NORMAL OR
ABNORMAL OPENING IN THE WALLS OF ITS CONTAINING CAVITY
HERNIA
COMMON
INGUINAL
INCISIONAL
FEMORAL
UMBILICAL
EPIGASTRIC
RARE
OBTURATOR
SPIGELIAN
GLUTEAL
LUMBAR
DIAPHRAGMATIC
HISTORY
HISTORY
AGE :
YOUNG
INDIRECT
OLD AGE (weak musculature)
DIRECT
HISTORY
OCCUPATION =STRENOUS
STRENOUS
WORK
PERSISTENT
PROCESSUS
VAGINALIS
WEAK
ABDOMINAL
WALL
HERNIATION
PRESENTING COMPLAINTS
PRESENTING COMPLAINTS
PAIN= DRAGGING & ACHING TYPE
Appears b4
the swelling
Increase
with time
Subsides
when it is
fully formed
PRESENTING COMPLAINTS
Acute pain tenderness strangulation
Due to drag
on mesentry
PRESENTING COMPLAINTS
In strangulation due to drag on mesentry pain all over the abdomen
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
acquired } small initially size

REDUCIBILITY





Reduces on lying down
DIRECT
Does not reduce on lying
down
INDIRECT
SYMPTOMS OF OBSTRUCTION
COLICKY ABDOMINAL PAIN
VOMITING
BILIOUS
FAECAL (USUALLY)
ABDOMINAL DISTENSION
ABSOLUTE CONSTIPATION
OTHER COMPLAINTS
C/C COUGH=TB ,BA,C/C BRONCHITIS
CONSTIPATION
FREQUENCY OF MICTURITION
URGENCY OF BENIGN ENLARGEMENT OF PROSTATE
PAST HISTORY
PREVIOUS SURGERY

Damage to ilioinguinal
nerve ==> weak
abdominal wallhernia
APPENDICECTOMY
Same side
Opposite side
RECURRENT HERNIA
LOCAL EXAMINATION
INSPECTION
INSPECTION
EXPOSE 4M UMBILICUSMID THIGH
POSITION


POSITION
STANDING
Inguinal, lumbar,
femoral,
epigastric,
obturator, gluteal,
spigelian
SUPINE
SWELLING
shape
spherical
femoral
direct
pyriform
indirect
POSITION & EXTENT
Inguinal hernia above the inner part of inguinal ligament
Inguinal
hernia
Congenital
(complete)
Extend in to
scrotum
acquired
(funicular)
Sops above
testis
POSITION & EXTENT
Femoral hernia starts below the inginal ligament and ascend over it
VISIBLE PERISTALSIS
Invisible = femoral hernia



Visible in case of inguinal hernia when skin is thin as in case of recurrent
hernia
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 infectionrecurrence

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
POSITION OF PENIS
Deviation of penis to opposite side= in large complete inguinal hernia
PALPATION
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
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

GET ABOVE THE SWELLING
INGUINAL HERNIA
NOT ABLE TO GET ABOVE THE
SWELLING
SCROTAL SWELLING
ABLE TO GET SBOVE THE SWELLING
CONSISTENCY
DOUGHY & GRANULAR} OMENTUM=OMENTOCELE


ELASTIC} INTESTINE=ENTEROCELE


TENSE & TENDER} STRANGULATED HERNIA
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
CLASSICAL SIGNS OF AN UNCOMPLICATED
HERNIA
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
ZEIMANNS 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
ZEIMANNS TECHNIQUE
I
m
p
u
l
s
e

o
n

Index finger
Middle finger
Ring finger
Direct inguinal hernia
Indirect inguinal hernia
Femoral hernia
ZEIMANNS 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
REDUCIBILITY
Reduces on lying down direct hernia

Flexes the thigh
Adduct the thigh
Rotate internally


Using taxis
Reduces with gurgling=>ENTEROCELE Difficult to reduce initially but last
part slips of easily
First part reduces easily last part difficultomentocele

Relaxes
superficial
inguinal ring +
oblique muscles

INVAGINATION TEST
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
INVAGINATION TEST
Finger goes
directly
backward=direct
hernia
INVAGINATION TEST

Finger goes upwards,
backwards,
outwards= indirect
INVAGINATION TEST
Impulse on
coughing
Pulp of
finger
direct
tip indirect
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
RING OCCLUSION TEST
Swelling appears even when deep ring is occluded=direct hernia

No swelling when deep ring is occluded = indirect hernia
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
PERCUSSION
Resonant=enterocele
Dull =omentum/extraperitoneal fatty tissue
Diff b/w a/c epididymitis
a/c filalrial funiclitis &
strangulated hernia
AUSCULTATION
Peristaltic sounds=enterocele
EXAMINATION OF TESTIS
,SPERMATIC CORDS & EPIDIDYMIS
Testis traction test: pull testis downwards
encysted hydrocele}descends slightly & become fixed
inguinal hernia}cant be fixed
EXAMINATION OF TONE OF
ABDOMINAL MUSCLES
Inspectionprotrusion of lower abdominal wall
Malgaignes bulging:oval shaped b/l bulge on straining above & parallel to
medial half of inguinal ligamentweakness of abdominal wall
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



ETIOLOGY
APPENDICECTOMY DESTROY ILIO INGUINAL NDIRECT INGUINALHERNIA
McBURNEYS INCISION

FAMILIAL COLLAGEN DISORDER
CONGENITAL PREFORMED SAC (REMAINS OF PROCESSUS VAGINALIS)
PARTS OF A HERNIA
SAC
COVERING OF SAC
CONTENTS OF SAC
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)


COVERING OF SAC
LAYERS OF ABDOMINAL WALL
CONTENTS OF SAC
OMENTOCELE: omentum.easy to reduce initially,but difficult later
ENTEROCELE: usuaslly SI,.difficult to reduce initiallyeasy later
RICHTERS HERNIA :a portion of circumference of bowel
LITTRES HERNIA: meckels diverticulum
CYSTOCELE :bladder
Ovary,fallopian tube
Fluid :ascitic, blood from strangulated hernia, from congested bowel
CLINICAL CLASSIFICATION
H
E
R
N
I
A

REDUCIBLE
HERNIA
IRREDUCIBLE
HERNIA
OBSTRUCTED
HERNIA
INCARCERATED
HERNIA
STRANGULATED
HERNIA
INFLAMMED
HERNIA
CLINICAL CLASSIFICATION

REDUCIBLE HERNIA contents can be reduced by the patient or surgeon
expansile impulse on coughing

Enterocele Omentocele
Resonant on percussion Dull on percussion
Bowel sounds++ Bowel sounds--
Perstalsis++ Peristalsis--
Gurgling sound on reduction No sound,doughy feel
1
st
more difficult to reduce than
last
last portion is more difficult to
reduce than first
IRREDUCIBLE HERNIA cant be reduced due to adhesions b/w contents
and sacor due to crowding
irreducibility + no other symptoms}OMENTOCELE
Irreducibility predisposes to strangulation
OBSTRUCTED HERNIA : bowel is obstructedbut blood supply is good

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 nger, 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.
STRANGULATED HERNIA blood supply is impaired ISCHAEMIAGANGRENE
OF INTESTINE
TENDERNESS. TENSE SAC
NO IMPULSE ON COUGHING
FEATURES OF INTESTINAL OBSTRUCTION

INFLAMMED HERNIA
inflammation of contents of hernia sac
appendicitis,salpingitis

CLASSIFICATION
hernia
congenital
acquired
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
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.
Inguinal canal
:It is an oblique passage in lower part of abdominal wall, 4 cm long, situated
above the medial of inguinal ligament,
extending from deep inguinal ring to superficial inguinal ring.
BOUNDARIES
Anteriorly: external oblique muscle
fleshy fibres of internal oblique lateral 1/3
rd

skin & superficial fascia
Posteriorly: transversalis fascia
conjoint tendon
reflected part of inguinal ligament
Floor inguinal ligament
Roof fibres of internal oblique

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


CONTENTS OF INGUINALCANAL
COVERING OF SPERMATIC CORD
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
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
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.Ziemans 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

12.Sac should be
opened during surgery

12.Sac is not necessarily
opened unless obstruction
is present
INDIRECT HERNIA
Deep ring
Whole of
inguinal canal
Superficial ring
DIRECT HERNIA
Weak post wall of
inguinal canal
(hesselbachs triangle)
Part of inguinal canal
Superficial ring
INDIRECT INGUINAL HERNIA
Commonest more in males
Thin sac
Narrow neck
Lateral to inferior epigastric vessels
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
ETIOLOGY
CLINICAL FEATURES
P.C: SWELLIING IN GROIN,
DRAGGING PAIN
VISIBLE MORE ON COUGHING
EXPANSILE IMPULSE ON COUGH
USUALLY REDUCIBLE BUT CAN UNDERGO OBSTRUCTION,STRANGULATION
DEEP RING OCCLUSION TEST : after reduction of hernia deep ring is occluded
with thumb..if swelling appears medial to thumb it is direct hernia.if no
swelling appears and appears on coughing after release of thumb it is
indirect



Ring invagination test: After reduction of hernia, the
little finger/index finger of the examiner is
invaginated from the bottom of the scrotum, gradually
pushed up and rotated to enter the superficial
inguinal ring. The impulse on coughing is felt at the
tip of the invaginated finger.
ZEIMANNS TEST
After reduction
Index finger = deep ring
Middle =superficial inguinal ring
Ring finger=saphenous opening
Impulse on coughing on deep ring =indirect inguinal hernia
Head or leg raising test: to test for abdominal muscle tone & malgaignes
bulging
Abdominal examination
Respiratory system
Urinary systems
Per rectal examination

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.

INVESTIGATIONS
Blood routine examination
Chest x ray for TB
Usg abdomen
Other test

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 AD are sometimes added, which correspond TO
INDIRECT, DIRECT, FEMORAL, AND MIXED, RESPECTIVELY
TREATMENT
Surgery= treatment of choice
Under LA/GA/spinal/epidural

surgery
herniotomy
herniorraphy
HERNIOTOMY
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
RINGA ARE SUPERIMPOSED THERE FORE NO NEED OF REPAIR
HENCE DONE ALONE IN CHILDREN,ADOLESCENT
In indirect inguinal hernia
PROCEDURE
ANAESTHESIA: spinal or G/A
Incision is made parallel to medial 2/3
rd
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


PROCEDURE
Cremasteric muscle is opened
REPAIR OF HERNIA
A SIMPLE REPAIR OF POSTERIOR WALL IS ALONE IS DONE (HERNIORRAPHY)
SHOULDICE REPAIR
Mac vays repair
Modified BASSINIS REPAIR
PROSTHETIC REPAIR: STOPPAS,RIVES,LICHTENSTEINS,GILBERT,TEP,TAPP
(HERNIOPLASTY)

SHOULDICE REPAIR

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
Monofilamentpolyfilament has crevices=infn
Interrupted continuous suture= decrease blood supply interfere with
healing


MODIFIED BASSINIS REPAIR

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
INDICATION FOR HERNIOPLASTY
Direct hernia,
Recurrent hernia
Re-recurrent hernia
Incisional hernia
Old age
Sliding hernia
Hernia with weak abdominal muscle tone
COMPLICATION
Mesh extrusion
Foreign body reaction
infection
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

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. Lichtensteins method
7. TAPP
8. TEP
TYPES OF OPEN REPAIR
Repairing the floor of the inguinal canal :
Bassini repair
Shouldice repair
Tension free mesh repair
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.
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.
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 2
nd
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.
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.
SHOULDICE REPAIR
The cord is replaced within the inguinal canal, and the external inguinal
aponeurosis is reapproximated with continuous 2-0 absorbable sutures
TENSION FREE REPAIR
There are several options for placement of mesh during anterior inguinal
herniorrhaphy, including
The Lichtenstein approach
The plug-and-patch technique
The sandwich technique with both an anterior and preperitoneal piece of mesh.
TENSION FREE REPAIR
TENSION FREE REPAIR
PROLENE HERNIAL SYSTEM
OPEN APPROACH
OPEN APPROACH

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

MCVAY REPAIR
inguinal and
femoral canal
defects
The conjoined
tendon is sutured to
Coopers ligament
from the pubic
cubicle laterally

SHOULDICE REPAIR
ANTERIOR REPAIR
PROSTHETIC
Inguinal hernia
LICHTENSTEIN
TENSION-FREE REPAIR
LAPAROSCOPIC
HERNIA REPAIR
Transabdominal Preperitoneal Procedure (TAPP)
Totally Extraperitoneal (TEP) Repair


Indications include bilateral inguinal hernia, recurring
hernia, need for early recovery
RECURRENCE
Around 1% for Shouldice repair
Most recurrences are of the same type as the
original hernia

Recurrence Factors
Patient
Technical
Tissue
RECURRENCE
Patient factors
malnutrition, immunosuppression, diabetes, steroid
use, and smoking.
Technical factors
mesh size, prosthesis fixation, and technical
proficiency of the surgeon.
Tissue factors
wound infection, tissue ischemia, and increased
tension within the surgical repair
COMPLICATIONS
The overall risk of complications of inguinal hernia
repair is low.

Common Complications
Pain, injury to the spermatic cord and testes, wound
infection, seroma, hematoma, bladder injury, osteitis
pubis, and urinary retention
ONLAY MESH METHOD:
repair by placing mesh in front..using monofilament non absorbable suture
material.above to conjoint tendon & below to inguinal ligament

INLAY MESH METHOD
mesh deep to conjoint tendon

NYHUS PREPERITONEAL MESH
REPAIR

LICHTENSTEIN TENSION FREE MESH
REPAIR
Less recurrence
Cord is covered with mesh and is sutured as in onlay method
LICHENSTEIN TENSION FREE REPAIR
PROLENE HERNIA SYSTEM
LICHENSTEIN TENSION FREE REPAIR
STOPPAS REPAIR
GPRVS (Giant Prosthesis for Reinforcement of Visceral Sac)
OVER FRICHAUDS MYOPECTINEAL ORIFICE


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.

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

CONSERVATIVE TREATMENT
Use of TRUSS: when surgery is contraindicated/ is refused
Used only for reducible hernia
After reducing the hernia (applied before the patient gets up and when it is
reduced), rat tailed spring truss with perineal band (to prevent slipping ) to
prevent small or moderate sized hernia
Increased risk of strangulation
Not used in INFANT HERNIAINFANT HERNIA if strangulated treated surgically
if noncomplicated it is done after 3 months

TRUSS
TAXIS
Supine hip & knee flexed hip internally rotated
Contents are pushed with one hand directed with the other

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
Direct
hernia
medial
lateral
ETIOLOGY
MALGAIGNE BULGINGS:
on leg raising test, weak soft supple swellings poor abdominal muscle tone
indication for mesh repair
Prominent in direct hernia
Do not descent down in to scrotum, less prone for strangulation but can
occur in long standing cases

FEMORAL HERNIA
Femoral
canal
Saphenous
opening
ANATOMY

FRUCHAUDS 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.
MAYDLS 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


RICHERS HERNIA
A portion of circumference of bowel
Usually ANTIMESENTERIC BORDER
ISCHEMIA IN HERNIATED PART
NO OBSTRUCTION AS LUMEN NOT INVOLVED
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



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

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
LUMBAR HERNIA
UMBILICAL HERNIA
U
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Exomphalos
Umbilical hernia in
infants & children
Para umbilical
hernia of adults
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
EXOMPHALOS MAJOR
Umbilical cord attached to inferior aspect of large swelling
Contains SI LI & part of liver
Exomphalos major may burst
So emergency Sx is needed
EXOMPHALOS MINOR
Sac is small
Umbilical cord is attached to its summit
UMBILICAL HERNIA IN INFANTS &
CHILDRENS
Through umbilical cicatrix
Spherical in shape
Increase in size in crying

PARAUMBILICAL HERNIA OF
ADULTS
Not through umbilical cicatrix but through linea alba
Above (supraumbilical)
Below (infraumbilical)