436ff125.pptx

ANATOMY OF INGUINAL CANAL
 Oblique passage in the lower part of the anterior
abdominal wall , situated just above the medial
half of the inguinal ligament.
 Length and direction : About 4 cm(1.5 inches)
long directed downwards , forwards, and
medially.
 It extends from the deep inguinal ring to the
superficial inguinal ring.

SUPERFICIAL INGUINAL RING
 Opening in external oblique aponeurosis.
 It lies 1.25 cm above the pubic tubercle.
 Bounded by the superomedial and inferolateral crura.
 Normally it does not admit tip of little finger.
DEEP INGUINAL RING
shaped condensation of fascia transversalis.
1.25 cm above inguinal ligament midway between pubic
symphysis and anterior superior iliac spine(mid inguinal point).

DEVELOPMENT
 It represents the passage of GUBERNACULUM through
the abdominal wall.
 It extends from the caudal end of developing gonad(in
the lumbar region) to the labioscrotal swelling.
 In the early life, the canal is very short.
 As the pelvis increases in width, the deep inguinal ring is
shifted laterally and the adult dimension of canal is
attained .

BOUNDARIES
ANTERIOR WALL
In its whole extent
 skin
 superficial fascia
 ext. oblique aponeurosis
In its lateral one third
Fleshy fibres of the internal oblique muscle
ROOF
 Arched fibres of the internal oblique and transverses abdominis muscle.
FLOOR
 Grooved upper surface of the inguinal ligament and at the medial end by
the lacunar ligament.

POSTERIOR WALL
 In its whole extent
 fascia transversalis
extra peritoneal tissue
parietal peritoneum
 In its medial two thirds
The conjoint tendon
Reflected part of inguinal ligament
 In its lateral one third
By interfoveolar ligament extending b/w lower border of
transversus abdominis and sup ramus of pubis.

STRUCTURES PASSING THROUGH THE
CANAL
 Spermatic cord in males and round ligament of uterus in
females
 Ilioinguinal nerve

COVERINGS OF SPERMATIC CORD
 FROM WITHIN OUTWARDS
 Internal spermatic fascia: Fascia transversalis: covers the
whole extent.
 Cremasteric fascia: Internal oblique and transversus abdominis
muscle: covers below the level of these muscles.
 External spermatic fascia: Ext.oblique aponeurosis: covers
below the superficial inguinal ring.

 It is an osseo-myo-aponeurotic tunnel. It is through this
tunnel all groin hernias occur.
 It is bounded:
 Medially by the lateral border of the rectus sheath.
 Above by the arched fi bres of internal oblique and transversus
abdominis muscle.
 Laterally by the illiopsoas muscle.
 Below by the pectin pubis and fascia covering it
FRUCHAUD’S MYOPECTINEAL ORIFICE

MECHANISM OF INGUINAL CANAL
The presence of the inguinal canal is a cause of weakness of lower part of
ant abdominal wall. This weakness is compensated by the following
factors:
 Obliquity of the inguinal canal-Flap valve mechanism
 The sup inguinal ring is guarded-from behind by the conjoint tendon and
by the reflected part of inguinal ligament
 The deep inguinal ring is guarded from the front by the fibres of internal
oblique.
 Shutter mechanism of internal oblique-triple relatn of the muscle
 Contraction of the cremaster helps the spermatic cord to plug the
sup inguinal ring(ball valve mech).
 Contraction of the ext oblique results in the approximation of two
crura(slit valve mech).

HERNIA
 DEFINITION
Abnormal protrusion of a viscous or a part of viscous through
an opening natural or artificial with a sac covering it
 PARTS OF HERNIA
 COVERING
 SAC
 CONTENT

COVERING
LAYERS OF ABDOMINAL WALL
SAC
DIVERTICULUM OF PERITONEUM WITH
MOUTH, NECK, BODY AND FUNDUS
CONTENTS
OMENTOCELE
ENTEROCELE
CYSTOCELE
RICHTER′S HERNIA
LITTRE′S HERNIA
OVARY WITH FALLOPIAN TUBE

IN ENTEROCELE
 First part is difficult to reduce
but last part is easier. There
will be gurgling sound on
reduction .
 Resonant on percussion.
 Peristalsis is seen.
 Bowel sounds may be heard.
IN OMENTOCELE
(EPIPLOECELE)
 First part is easier to reduce
but last part is difficult. Has a
doughy feeling.
 Dull on percussion.
 No peristalsis.
 Bowel sounds not heard.

CLASSIFICATION OF HERNIA
 CLINICAL





REDUCIBLE
IRREDUCIBLE
OBSTRUCTED
INFLAMED
STRANGULATED
 CONGENITAL/ACQUIRED
 ACCORDING TO CONTENTS
 OMENTOCELE
 ENTEROCELE
 CYSTOCELE
 RICHTER′S HERNIA
 LITTRE′S HERNIA -Meckel’s diverticulum
 MAYDL’S HERNIA
 SLIDING HERNIA

Richter’s hernia
Richter’s hernia is a hernia in which the sac contains only a portion of the
circumference of the intestine (usually small intestine). It usually complicates
femoral and, rarely, obturator hernias.
Sliding hernia
Here posterior wall of the sac is not only formed by the parietal peritoneum,
but also by sigmoid colon with its mesentery on left side; caecum on right side
and often with portion of the bladder.
Maydl’s hernia (Hernia-in-W)
Here a loop of bowel in the form of ‘W’lies in the hernial sac and the centre
portion of the ‘W’loop is strangulated and lies within the abdominal cavity.

INGUINAL HERNIA
CLASSIFICATION
 Anatomical classification
 Indirect hernia
It come out through the internal ring along with the cord .Sac
is lat. to the inf epigastric artery.
 Direct hernia
It occurs through the Hasselbach’s triangle. Sac is medial to
the inf. epigastric artery.

GILBERT’S CLASSIFICATION
 Type 1 Indirect inguinal hernia(IIH)-tight deep ring
 Type 2 IIH deep ring admit 1 finger but less than 2 finger breadth
 Type 3 IIH deep ring more than 2 finger breadth
 Type 4 Direct hernia –entire posterior wall is defective
 Type 5 direct hernia-punched out hole/defect in transversalis
fascia
 Type 6 Pantaloon/double hernia
 Type 7 Femoral hernia
 Type 6 & 7 are Robbin’s modification

NYHUS CLASSIFICATION
 Type I-indirect hernia with normal deep ring
 Type II-indirect hernia with dilated deep ring without
impengement on the floor of the inguinal canal
 Type III-post wall defect
 direct
 pantaloon hernia
 femoral hernia
 Type IV –recurrent hernia

INDIRECT INGUINAL HERNIA DIRECT INGUINAL HERNIA
 Can occur in any age from
childhood to adult.
 Occurs in a pre-existing sac.
 Protrusion through the deep ring;
herniation occurs later
 Pyriform/oval in shape; descends
obliquely and downwards.
 Can become complete by
descend down in to scrotum.
 Sac is anterolateral to cord.
 Commonly u/l but can be b/l .
 Sac should be opened in surgery
.
 Common in elderly
 Always acquired
 Herniation through posterior
wall of the inguinal canal
 Globular/round in shape;
descends directly forward bulge.
 Descent down in to scrotum is
rare
 Sac is posterior to the cord.
 Commonly b/l.
 It is not necessarily opened.

ACCORDING TO THE EXTENT - INDIRECT
IH
 Incomplete
Bubonocele-sac is confined to the inguinal canal
Funiclar-here the sac crosses the sup inguinal ring but does not
reach the bottom of the scrotum
 Complete
Sac descend to the bottom of the scrotum

PRECIPITATING CAUSES
 STRAINING
 CHRONIC CONSTIPATION
 RESPIRATORY CAUSES
 SMOKING
 OBESITY
 ASCITES
 PREVIOUS SURGERY LIKE APPENDICECTOMY
 URINARY PROBLEMS LIKE BPH , URETHRAL
STRICTURE
 MULTIPLE PREGNANCIES

• Old appendicectomy scar with direct inguinal hernia. It
is due to injury to ilioinguinal nerve during
appendicectomy.

COVERINGS
INDIRECT HERNIA
 Extra peritoneal tissue
 Internal spermatic fascia
 Cremastric fascia
 External spermatic fascia
 Skin
DIRECT HERNIA
 Extra peritoneal tissue
 Fascia transversalis
 Conjoint tendon
 External spermatic fascia
 Skin

CLINICAL FEATURES
 More common in males(20:1)
 Pat. presents with dragging pain and swelling in the groin which is better
seen while coughing and standing.
 Contents are either small bowel, ,large bowel, omentum or its
combination.
 Usually reducible but can go for irreducibility ,inflammation,
obstruction or strangulation.
 Other symptoms –colicky abd. pain, vomiting, abd. distention and
constipation.
 Should ask h/o chronic bronchitis, frequency or urgency of
micturation,enlargment of prostate
Past history
 Any past surgical history: Appendicectomy
 Previous h/o hernia repair on the same or opp. side

Local examination
 Should be exposed from umbilicus up to the mid thigh.
Examine first in standing position then in the supine position.
INSPECTION
Swelling-
osize and shape
o position and extent
o visible peristalsis
Skin over the swelling
Impulse on coughing
Position of the penis

PALPATION
Temp. tenderness
Position and extent
Get above the swelling(scrotal & inguino scrotal swelling)
The root of scrotum is held between the thumb infront and other fingers
behind in an attempt to reach above swelling. Inguinoscrotal Hernia –cannot get
above the swelling
Consistency(doughy & granular omentum elastic-intestine)
Relation of the swelling to the testis and sprmatic cord
Impulse on coughing(Zieman’s technique ): Three finger test

Fig. 18.23: Zieman’s test: Index finger on deep ring; middle finger on superficial
ring and ring finger over saphenous opening—are placed after reducing the
content. Patient is asked to cough and impulse is felt in finger corresponding to
the existing hernia.

Reducibility-taxis
A method of reducing hernia. Here pt is asked to flex the thigh of the affected
side and to adduct and rotate it internally .The fundus of the sac is gently held
with one hand and pressure is applied to squeeze contents while other hand will
guide the contents through supf. ring.
Invagination test
Done after reduction of hernia. Using little finger skin of the scrotum is
invaginated from bottom up to pubic tubercle. The finger is then rotated and
pushed up into the supf ing ring.the pt is asked to cough and if the impulse felt
on the pulp of finger –direct ; if on tip- indirect.
Ring occlusion test
Done after reduction of hernia
This is a confirmatory test to differentiate an IIH from DIH
A Thumb is pressed on the deep ing ring (1/2 inch above mid-inguinal
point).Ask the pt to stand. the pt is asked to cough .
A direct hernia will show a bulge medial to the occluding finger but an indirect
hernia will not.

PERCUSSION
Resonant-enterocele
Dull-omentocele
AUSCULTATION
Peristaltic sound
Examine the testis ,epididymis and spermatic cord
Examine the other side
Examine the tone of abdominal muscles –head or leg rising test or by
valsalva maneouvre
MALGAIGNE BULGINGS -it indicate pure tone of oblique muscles
 PRE-PROSATE ENLARGMENT

DIFFERENTIAL DIAGNOSIS
 Hydrocele
 Undescended testes
 Femoral hernia
 Lipoma of cord
 Inguinal lymph node enlargement
 Groin abscess

INVESTIGATIONS
Usual pre op investigations
Chest X-Ray
USG abdomen

COMPLICATIONS OF HERNIA
 Irreducibility
 Obstruction
 Strangulation
 Inflammation
 Incarceration

TREATMENT
 INDIRECT HERNIA
Always surgery
IN INFANTS:
Herniotomy
IN ADULTS:
Herniotomy[excision of hernial sac]+Herniorrhaphy/
Hernioplasty[strengthening of the posterior wall of inguinal
canal either by repair or mesh]

REPAIR MAY BE:
• Shouldice,Mac
Vay,Modified bassini
PURE
TISSUE
REPAIR
• Lichtenstein,Rives,Gilbe
rt,Stopa,TEP,TAPP
PROSTHE
TI-C
REPAIR

REPAIR CAN ALSO BE:
• Through anterior inguinal
approach
• Bassinis, Shouldice,Mac Vay,
Lichtenstein, Rives peritoneal
repair
Anterior
Repair
• Through Supra Inguinal Pre
peritoneal Approach
• Nyhus repair, Stoppas, TEP,
TAPP, Kugel’s Repair
Posterior
Repair

HERNIOTOMY
 Anesthesia-spinal or GA
 After cleaning and draping, skin is incised-1.25 cm above
and parellel to the medial 2/3 of inguinal ligament.
 Sup fascia(camper’s and scarpa’s fascia)are incised.
 Ext oblique aponeurosis is incised.
 Visualize the inguinal ligament.
 Illio inguinal nerve is safeguarded.
 Cremasteric muscle is opened, cord structures are dissected.
 Sac which is ant and lat to the cord is identified and its pearly
white in colour.

 Dissection usually starts from the fundus and extented towards the
neck which is identified by extra peritoneal fat
 Finger is passed to release any adhesions
 Sac is twisted and transfixed using absorbable suture and is
excised distally

BASSININI´S HERNIORRHAPHY
 Strengthening of posterior wall of inguinal canal by approximation
of conjoint tendon to inguinal ligament.
 Monofilament non-absorbable suture material.
 Commonly used suture material is either polypropylene[blue] or
poly ethylene[black]
 Always interrupted sutures.

Fig. 18.36: Modified Bassini’s repair
It is approximation of inguinal ligament to conjoint tendon using
interrupted non absorbable monofilament sutures.

Complications of Herniorrhaphy
 Haemorrhage
 Haematoma, seroma
 Infection—1-5%
 Haematocele
 Post-herniorrhaphy hydrocele, lymphocele
Hyperaesthesia over the medial side of inguinal canal
due to injury to iliiohypogastric nerve—neuralgia (15%)
 Recurrence—10-15%
 Osteitis pubis
 Injury to urinary bladder/bowel
 Testicular atrophy, penile oedema rarely can occur

SHOULDICE REPAIR
 Multilayered Repair
TRANSVERSALIS FASCIA INSCISED ALONG THE LINE OF WOUND
FROM DEEP RING TO PUBIC TUBERCLE.
LOWER FLAP SUTURED TO POSTERIOR PART OF UPPER FLAP
UPPER FLAP SUTURED TO INGUINAL LIGAMENT.
CONJOINT TENDON AND INGUINAL LIGAMENT APPROXIMATED BY
TWO LAYERS OF CONTINUOUS SUTURES
EXTERNAL OBLIQUE APONEUROSIS SUTURED IN 2 LAYERS IN
FRONT OF THE CORD

SIX LAYERS:
First two layers – trasversalis fascia
Next two layers – conjoint tendon & ing ligmt
Last two layers – external oblique aponeurosis
SUTURE MATERIAL:
Fine steel wire of 34 gauge.
OR
Polypropylene / polyethylene

LYTLE’S REPAIR
OFTEN INTERNAL RING IS NARROWED BY PLACING
INTERRUPTED SUTURES OVER THE MEDIAL SIDE OF THE
RING TO THE TRANSVERSALIS FASCIA USING EITHER
THREAD OR SILK (TO NARROW THE RING AND PUSH THE
CORD LATERALLY).

Tanner Slide Operation
To reduce the tension in the repair area, relaxing incision is placed
over the lower rectus sheath so that conjoined tendon is allowed to
slide downward

HERNIOPLASTY
Strengthening of posterior inguinal wall in case of inguinal hernia or
in any large hernia with weak abdominal wall using a supportive
material. This allows and supports good fibroblast proliferation.
MATERIALS USED:
o Synthetic: Prolene mesh, Dacron mesh, Morlex mesh, mersiline
sheath.
o Biological: Tensor fascia lata, temporal fascia and skin. Not well
accepted.

INDICATIONS:
Direct hernia
Recurrent hernia
Incisional hernia
Old age
Hernia with weak abdominal muscle tone.
Sliding hernia
COMPLICATIONS:
Infection
Mesh extrusion
Foreign body reaction
Mesh inguinodynia – hyperaesthesia and pain along the
distribution of ilioinguinal or iliohypogasrtric nerve
Mesh erosion into bowel ,bladder or vessels.

PRINCIPLE:
Size of mesh should be bigger than size of defect.
Mesh should be fixed above and below to conjoint tendon and inguinal
ligament or abdominal wall using interrupted non absorbable sutures.
Absolute hemostasis and control of infection.
TYPES OF MESH REPAIR:
On lay repair
Lichtenstein tension free onlay mesh repair
In lay repair
Under lay repair
Gilbert patch and plug repair / Gilbert’s PHS repair(on lay + sub lay)
Nyhus preperitoneal mesh repair.
Kugel groin hernia mesh repair
Modified Rives preperitoneal mesh repair
TEP
TAPP

Fig. 18.43: Hernioplasty: Mesh repair—Lichtenstein’s method
(done under local anaesthesia).
 Mesh is fixed inferiorly to lacunar & inguinal ligaments,
medially to overlap rectus sheath & fixed to fascia over the pubic
bone
 Laterally an artificial deep ring is created by crossing of both upper
and lower leaf of mesh, superiorly it is fixed to conjoint tendon.

DIRECT HERNIA-TREATMENT
Surgery
 The principles of repair of direct hernias are the same as
those of an indirect hernia ,with the exception that the hernia
sac is not opened.
 This reconstruction of the posterior wall of the inguinal
canal should be undertaken by the Shouldice repair or by
using a mesh implant according to the Lichtenstein
technique.
 Ideally hernioplasty (mesh repair) is done.

LAPAROSCOPIC HERNIORRHAPHY
TAPP approach
 In large indirect hernia or irreducible inguinal hernia.
 10 umbilical port for laproscope
 5mm ports-each side on pararectal point above the level of
umbilicus
 Contents of hernia reduced,sac dissected in preperitoneal plane
 Vas, gonadal vessels, pubic bone, inferior epigastric vessels
identified
 Prolene mesh placed in preperitoneal space & fixed to pubic
bone using tacks.
 Peritoneum closed with continuous prolene sutures.

TEP REPAIR USING LAPROSCOPE
 Through subumbilical incision 10mm extraperitoneal space is
reached.
 After CO2 insufflation- 5mm port 4cm below first,-5mm in same
line
 Dissection carried out downward then medially upto pubic
tubercle, iliopectineal ligament, laterally to iliac vessels,& inferior
epigastric vessels.
 Mesh placed & sutured to iliopectineal ligament

Ports used for TEP and for TAPP Port incisions in TEP

COMPLICATIONS IN TEP
 Cord or vas injury
 Inadvertent opening of the sac or peritoneum and creation of
pneumoperitoneum.
 Injury to major structures like iliac vessels.
 Displacement of mesh or erosion into structures like bladder.
 Nerve injury
 Seroma / hematoma
 Infection
 Recurrence

ADVANTAGES
 Approach is totally extraperitoneal
 Small incision
 Proper placement of mesh in preperitoneal space
 Peritoneal cavity is intact and not opened
 CONTRAINDICATIONS
 Obstructed/strangulated hernia
 Ascites
 Bleeding disorders

COMPLICATIONS OF OPEN HERNIA
SURGERY
 Infection
 Groin pain
 Ischemic orchitis
 Injury to vas
 Injury to viscera
 Recurrence
 Hydrocele
 Seroma
 Hematoma
 Inguinodynia
 Dysejaculation

oCONSERVATIVE MEASURES
CONSERVATIVE MEASURES SHOULD BE AVOIDED IN HERNIAAS MUCH
AS POSSIBLE
TAXIS –TRIAL REDUCTION
TRUSS: A RAT TAILED SPRUNG TRUSS WITH A PERINEAL BAND TO
PREVENT THE TRUSS FROM SLIPPING AWAY
Hernia truss: It is used only when patient is not fit for surgery. It may precipitate
strangulation. Before placing truss, contents of the hernia should be reduced
completely a properly fitting truss must control the hernia when the patient stands
with leg apart, stoops & cough violently.

RECURRENT HERNIA
Recurrence: within 3 years – early ; after 3 years – late
PREDISPOSING FACTORS:
 PREOPERATIVE
 smoking
 chronic cough
 constipation
 old age
 anemia
 hypoproteinaemia
 straining
 increased intra abdominal pressure
 ascites

 OPERATIVE

 tension in the sutures
weak anterior abdominal wall
 POSTOPERATIVE



Infection
Hematoma
Straining
RECURRENCE RATE:
 Bassini’s repair - 10%
Shouldice repair - 1%

 Hernioplasty
 Other methods
- 1 – 3%
- 1 – 5%
More likely to go in for strangulation.
TREATMENT:
Treat the cause and later hernioplasty.
TEP/TAPP is better.

STRANGULATED HERNIA
Most serious Complication of hernia. Most common in IIH
A hernia becomes strangulated when the blood supply of its contents is
seriously impaired, rendering the contents ischaemic.
PATHOLOGY
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

Clinical Features of Strangulated Hernia
 Sudden severe pain, initially over a pre-existing hernia which later
becomes generalized over the abdomen.
 Persistent vomiting, constipation and distension of the abdomen.
 Hernia is tense, severely tender, irreducible and without any
expansile impulse on coughing. Rebound tenderness is diagnostic.
 Features of toxicity and dehydration & shock
 Electrolyte imbalance.
 Abdominal distension with guarding and rigidity.
 Oliguria
 3% in incidence.
In strangulated omentum features of obstruction are not
present (i.e. vomiting, constipation)

 Investigations
 Plain X-ray abdomen in erect posture shows multiple air-fluid
levels.
 Serum electrolytes.
 Blood urea and serumc reatinine.
 Total count is increased.
 U/S abdomen.
 Treatment of Strangulated Hernia
 The patient is admitted.
 Ryle’s tube aspiration.
 Intravenous fluids to correct dehydration and electrolyte
imbalance.
 Antibiotics.
 Catheterisation to maintain adequate urine output.
 Emergency surgery

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