HERNIA

Defined as an abnormal protrusion of viscera or a part of viscera through

an opening, artificial or natural with a sac covering it.
 AETIOLOGY
• Straining
• Lifting heavy weights
• Chronic cough
• Chronic constipation
• Uriniary causes: BPH, Ca prostate, stricture, meatal
stenosis, phimosis
• Obesity
• Pregnancy
• Smoking
• Ascites
• Appendectomy through McBurney’s incision
 CLASSIFICATION OF HERNIA

1. Clinical:
• Reducible hernia- gets reduced on its own
• Irreducible hernia- contents cannot be returned to
abdomen due to narrow neck, adhesions, overcrowding
• Obstructed hernia- irreducible hernia with obstruction
but blood supply is not interfered
• Inflammed hernia- inflammation of contents of sac
(appendicitis, salpingitis)
• Strangulated hernia- irreducible hernia with obstructed
blood flow. Swelling is tense, tender, absent cough
impulse, features of intestinal obstruction
• Occult hernia- swelling not clinically detectable but
presents with groin pain. Cough impulse may be absent
2. ACCORDING TO CONTENTS
• Omentocele- omentum
• Enterocele- intestine

• Cystocele- urinary bladder

• Littre’s hernia- meckel’s diverticulum

• Richter’s hernia- part of bowel wall

• Amyand’s hernia- appendix

3. Congenital and acquired hernias

3. BASED ON SITE
• Inguinal hernia • Lumbar hernia
• Femoral hernia • Spigellian hernia
• Obturator hernia • Umbilical hernia
• Diaphragmatic hernia • Epigastric hernia
 INGUINAL HERNIA
• Occurs in inguinal canal
• Most common hernia because the muscular
anatomy in inguinal region is weak and due to
presence of natural weaknesses like deep ring and
cord structures.
CLASSIFICATION OF INGUINAL HERNIA

Indirect hernia: Direct hernia:

• Comes out through deep ring • Comes through hasselbach’s
• Is lateral to inferior epigastric triangle in the posterior wallof
artery inguinal canal
• Is medial to inferior epigastric
artery
Incomplete:
• Sac confined to inguinal Complete:
canal- bubonocele • Sac descends to bottom of the
• Sac crosses superficial ring- scrotum
funicular
NYHUS CLASSIFICATION
• Type I: indirect hernia with normal deep ring
• Type II: indirect hernia with dilated deep ring
• Type III: posterior wall defect (direct, pantaloon,
femoral)
• Type IV: recurrent
INDIRECT INGUINAL HERNIA
• The most common type of hernia
• More common in younger ages
• Sac is thin, neck is narrow and lies lateral to
inferior epigastric artery
• Coverings- extraperitoneal tissue, internal
spermatic fascia, cremasteric fascia, external
spermatic fascia, skin
CLINICAL FEATURES
• Dragging pain, swelling in groin which is better
seen on coughing and standing
• In complete hernia, cannot get above he swelling
• On deep ring occlusion test, swelling does not
appear on coughing after occluding the deep ring
• On Zieman test, impulse felt at the index finger
DIRECT INGUINAL HERNIA
• It is due to weakening of posterior wallof inguinal
canal
• Sac is medial to inferior epigastric artery. Sac is
thick
• Rarely descends into scrotum and strangulation is
less common due to wide neck
MANAGEMENT
• Herniotomy: sac is cut and hernia is reduced
• Hernia repair/ herniorrhaphy:

Pure tissue repair- Bassini, MacVay, Shouldice,

Desarda’s repair
Prosthetic repair: lichtenstein, Stoppa, TAP, TEP
HERNIOTOMY
• Incision taken 1.25 cm abovemedial 2/3 of inguinal
ligament and deepened in layers.
• External aponeurosisincised along itslong axis parallel to
the line of skin incision, medially extended to cut the
margins of superficial ring.
• Cremasteric muscle and fascia is opened.
• Cord structures are dissected, sac is identified, opened at the
fundus.
• Sac is twisted to prevent any content from coming back,
transfixed and excised.
• Direct sac is not opened unless it shows adhesions and
obstruction
LICHTENSTEIN HERNIOPLASTY
• After herniotomy a suitable mesh is placed deep to the
cord structures and sutured to inguinal ligament.
• Medially, should overlap 2-2.5 cm over pubic tubercle.
Laterally mesh is slit into 2 tails and cord is passed in
between the tails. Both tails are overlapped and sutured
into inguinal ligament at level of deep ring.
• Laterally spread upto ASIS for 6 cm.
• Above and medially fixed to conjoint tendon.
• It is a tension free repair.
TISSUE REPAIRS
• Modified bassini repair: conjoint tendon and inguinal
ligament are approximated using interrupted sutures
• Desarda’s repair: live external oblique tissue flap
reconstruction of posterior wall of inguinal canal
• Shouldice repair: double breasting of transversalis
fascia.
• McVay repair. Interrupted sutures between edge of
transverse abdominis and coopers ligament
COMPLICATIONS OF HERNIORRHAPHY
• Haemorrhage, hematoma, hematocele
• Infection
• Hyperaesrthesia over medial side of inguinal
canal due to injury to ilioinguinal or
iliohypogastric nerve
• Recurrence
• Injury to bladder or bowel
TRIANGLE OF PAIN
TRIANGLE OF DOOM
TRANSABDOMINAL PREPERITONEAL MESH REPAIR

• 10mm umbilical port, 5mm ports placed on each

side on pararectal point at or above level of
umbilicus.
• Contents of sac reduced, sac dissected in
preperitoneal plane.
• Mesh is placed in preperitoneal space, fixed to
pubic bone with tacs.
• Peritoneum closed with continuous prolene
sutures
TOTAL EXTRAPERITONEAL REPAIR
• Though a subumbilical incision 10mm, extraperitoneal
space is reached.
• A 5mm port inserted 4cm below first port in midline
• Third 5mm port inserted in same line 4cm below or in
RIF
• Space created, mesh is placed, spread and sutured
 • Contraindications for
• Indications for TEP TEP:
• Recurrent hernia, B/L • Obstructed/ strangulation
hernia, indirect, femoral or hernia, ascites, bleeding
direct hernia disorders
ADVANTAGES OF TEP REPAIR
• Approach is completely extra peritoneal
• Small incision
• Peritoneum is intact
STRANGULATION HERNIA
• Obstruction
• ↓
• Initially venous return is impaired
• ↓
• Congestion of the bowel
• ↓
• Further dilatation of the bowel which becomes purple coloured
• ↓
• Fluid collects in the sac
• ↓
• Eventually arterial blood supply is impaired
• ↓
• Bowel becomes dark, brownish black coloured with flabby and friable wall
• ↓
• Bacteria migrate transerosally and multiply in fluid of the sac ↓
• Perforation occurs at the site of constriction ring
• ↓
• Peritonitis occurs.
CAUSES OF STRANGULATION
• Narrow neck
• Adhesions
• Irreducibility
• Long time, large hernia with adhesions
LOCKWOOD LOW
• Sac is approached from below the inguinal
ligament through groin crease incision so that
funds sac is dissected by direct vision and repair
is done from below.
• Inguinal ligament is sutured to Cooper’s ligament
MCEVEDY HIGH OPERATION
• Incision over femoral canal extending vertically
above inguinal ligament.
• Sac dissected from below, neck from above and
repair is done from above
• Gives good exposure and is done in strangulated
hernia
LOTHEISSEN’S OPERATION
• It is through inguinal canal approach
• Transversalis fascia is opened, neck of the sac is
identified in femoral ring and dissected from
above.
• Neck is lighted and repair is done
• Conjoined tendon sutured to iliopectineal line
• Complications: bleeding hematoma, abscess
THA. THANK YOU