Prof C M K Reddy

A TRIBUTE TO A GREAT TEACHERAND SOCIAL WORKER - Prof RNR

Prof R Nanjunda RaoCME Program forUndergraduates

INGUINAL HERNIA

ACKNOWLEDGEMENTS

Prof R Nanjunda Rao&

A S I – Chennai City Branch

Prof D Nagarajan, PresidentDr G Chandrasekar, Secretary

Dr Ravindran Kumeran, Treasurer

BY

Prof C M K REDDYDSc (Hon) FRCS (Glas) FRCS (Ire)

Emeritus Professor, TN Dr MGR Med University

General & Vascular Surgeon

Apollo Hospitals & Halsted Surgical Clinic

C H E N N A I

President

TN Medical Practitioners’ Association

(TAMPA)

Indian Chapter, Royal College of

Surgeons in

Ireland

Core Committee for Hosp. Waste Mgmt.

of

Chennai

FormerlyMedical Director, Sri Jayendra

Saraswathi Inst of Med Sciences

Honorary Professor of Surgery Stanley Medical College

President, Tamil Nadu Medical Council

Receiving Dr B C Roy National Award as EminentMedical Teacher from the President of India (2000)

Honorary Doctorate (DSc) conferred by the TN Dr MGR Medical University (2007)

INGUINAL HERNIA

HERNIA IS DEFINED AS AN ABNORMAL PROTRUSION OF A VISCUS THROUGH NORMAL OR ABNORMAL OPENING LINED BY A SAC

IF A VISCUS FORMS A PART OF THE SAC, IT IS CALLED A SLIDING HERNIA

IF THERE IS NO SAC, IT IS A PROLAPSE

SLIDING HERNIA(Hernie-en-glissade)

PROPLASE RECTUM & UTERUS

INGUINAL HERNIAPROLAPSE OF BOWEL (TRAUMA)

INGUINAL HERNIA

GROIN

IS A COLLOQUIAL TERM TO INCLUDE THE FOLLOWING REGIONS :

INGUINAL

FEMORAL

ROOT OF SCROTUM or LABIA MAJORA

WHILE DESCRIBING A MASS, THE PARTICULAR AREA TO BE SPECIFIED

INGUINAL HERNIA

ANATOMY OF INGUINAL CANAL

IT IS AN OBLIQUE CANAL, 6cm LONG, EXTENDS FROM DEEP TO SUPERFICIAL RING

PARALLEL TO THE MEDIAL HALF OF THE INGUINAL (POUPART) LIGAMENT

INGUINAL ANATOMY

INGUINAL HERNIA

EXTERNAL (SUPERFICIAL) RING

A TRIANGULAR OPENING IN THE EXTERNAL OBLIQUE APONEUROSIS

2cm ABOVE & MEDIAL TO PUBIC TUBERCLE

IT DOESN’T NORMALLY ADMIT TIP OF A FINGER. FORCIBLE ATTEMPT IS RESISTED DUE TO DISCOMFORT

INGUINAL HERNIA

INTERNAL (DEEP) INGUINAL RING

IT IS A ‘U’ SHAPED DEFECT IN THE TRANSVERSALIS FASCIA, 2cm ABOVE THE MIDPOINT OF INGUINAL LIGT

(MIDWAY BETWEEN ANT SUP ILIAC SPINE & PUBIC TUBERCLE)

INGUINAL HERNIA

BOUNDARIES OF ING CANAL

FLOOR : INGUINAL LIGT

POST WALL : TRANSVERSALIS FASCIA & MEDIALLY CONJOINT TENDON

ROOF : ARCHING FIBRES OF CONJOINT TENDON

ANT WALL : EXT OBLIQ APONEUROSIS &

INT OBLIQ MUSCLE LATERALLY

INGUINAL HERNIAHESSELBACH’S TRIANGLE

WEAK AREA IN POSTERIOR WALL THROUGH WHICH DIR HERNIA PRESENTS

BOUNDARIES

LATERAL : INF EPIGASTRIC VESSELS

RAISING LATERAL UMBILICAL LIGT (FOLD)

MEDIAL : LATERAL BORDER OF RECTUS

INFERIOR : MEDIAL THIRD OF ING LIGT

FLOOR BISECTED BY MEDIAL UMB LIGT, FORMED BY OBLITERATED UMB ARTERY

INGUINAL HERNIA

HESSELBACH’S TRIANGLE

Laparoscopic viewfrom inside

EXTERNAL DISSECTION

INGUINAL HERNIA

• AS WE GO FROM OUTSIDE

• SKIN

• TWO LAYERS OF SUPERFICIAL FASCIA SUPERFICIAL (FATTY) : CAMPER’S FASCIA

DEEP (MEMBRANOUS) : SCARPA’S FASCIA

A THIN AREOLAR LAYER IMMEDIATELY OVER THE EXT OBLIQ APONEUROSIS :

FASCIA INNOMINATUM (OF GALLAUDET)

EXT OBLIQ APONEUROSIS & EXT RING

INGUINAL CANAL & SPERMATIC CORD

INGUINAL HERNIALaparoscopic Anatomy

FEMORAL

DIRECT

INDIRECT INFERIOREPIGASTVESSELS

INGUINAL HERNIAMyopectineal Orifice of Fruchaud

BoundariesMedial : Rectus muscleLateral : IliopsoasSuperior : Conjoint tendonInferior : Pectin pubis

INGUINAL HERNIA

INGUINAL HERNIA MAY BE

DIRECT – THRO’ THE H’ TRIANGLE

INDIRECT – THRO’ THE INT RING

SADDLE or PANTALOON (ROMBERG)

WITH BOTH COMPONENTS SADDLED BY INF EPIGAST VESSELS

• ALL OF THEM ULTIMATELY COME OUT THRO’ THE EXTERNAL RING

INGUINAL HERNIA

DIRECT TYPE

ACQUIRED

SAC LIES SEPARATE FROM AND POSTERIOMEDIAL TO THE CORD

STRANGULATION IS RARE SINCE THE NECK OF THE SAC IS WIDE

IT IS GLOBULAR AND DOESN’T READILY DESCEND INTO SCROTUM

INGUINAL HERNIAINDIRECT TYPE

CONSIDERED TO BE CONGENITAL

DUE TO IMPERFECT OBLITERATION OF PROCESSUS VAGINALIS

COMES OUT THRO’ BOTH RINGS

RETORT SHAPED

DESCENDS READILY INTO SCROTUM

DUE TO THE ‘READY MADE’ SAC

SAC LIES WITH IN AND ANTEROSUPERIOR TO THE CORD STRUCTURES

Diff between Ind. & Dir. Ing Hernia

INGUINAL HERNIA

HOW DO WE SAY IF AN IRREDUCIBLE HERNIA IS DIRECT OR

INDIRECT ?

SHAPE

WHETHER DESCENDED INTO SCROTUM

THE FACT IT IS IRREDUCIBLE, IS IN FAVOR OF INDIRECT HERNIA

BUT IT IS ONLY OF ACADEMIC INTEREST, SINCE EARLY SURGERY IS NECESSARY & IT COULD BE DECIDED AT THAT TIME

INGUINAL HERNIA

TOPOGRAPHIC TYPES

BUBONOCELE (Boubon : Groin)

FUNICULAR TYPE

(UPTO THE TOP OF TESTIS)

COMPLETE or CONGENITAL

ENTIRE PROCESSUS IS PATENT TESTIS BECOMES A CONTENT

OF THE HERNIAL SAC

INGUINAL HERNIABubonocele Funicular Complete

INGUINAL HERNIABILATERAL BUBONOCELES

INGUINAL HERNIA

GIBBON’S HERNIA

LARGE INGUINAL HERNIA PRODUCING SECONDARY HYDROCELE, DUE TO COMPRESSION OF VENOUS AND

LYMPHATIC CHANNELS

INGUINAL HERNIA

INTERPARIETAL or INTERSTITIAL TYPE

DOWN’S or PRUNE BELLY SYND

UNDESCENDED TESTIS

SAC DISSECTS INTO THE LAYERS OF ABDOMINAL WALL

PREPERITONEAL

INTERPARIETAL or INTERMUSCULAR

(COMMONEST)

EXTRAPARIETAL or

INGUINO-SUPERFICIAL

LARGE RIGHTINGUINAL

INTERSTITIALHERNIA

INGUINAL HERNIA

RIGHT INGUINAL

INTERSTITIALHERNIA

INGUINAL HERNIA

CLASSIFICATION

REDUCIBLE (UNCOMPLICATED)

IRREDUCIBLE

OBSTRUCTED

STRANGULATED

INFLAMED

INGUINAL HERNIA

COMPRESSIBLE Vs REDUCIBLE

COMPRESSIBLE SWELLING REFILLS IMMEDIATELY (SPONTANEOUSLY) AS SOON AS THE PRESSURE IS RELEASED

Eg : HEMANGIOMA, LYMPHANGIOMA,

ANEURYSM, MENINGOCELE ETC

REDUCIBLE SWELLING MAY REQUIRE SOME MANEUVERING TO BRING IT OUT AFTER REDUCTION

INGUINAL HERNIA

PREDISPOSING / PRECIPITATING FACTORS

CHRONIC COUGH / COPD (SMOKING)

CHRONIC CONSTIPTION

OBSTRUCTIVE UROPATHYBPH or STRICTURE URETHRA

STRENUOUS PHYSICAL ACTIVITY

PREVIOUS SURGERY

INGUINAL HERNIA

HISTORY OF PREVIOUS SURGERY

IN LINE WITH ILIOHYPOGASTRIC & ILIOINGUINAL (L-1) NERVES

APPENDECTOMY THRO’ McBURNEY’S

DRAINAGE OF PSOAS ABSCESS

LUMBAR SYMPATHECTOMY

URETERIC or RENAL SURGERY

EXTENDED PFANNENSTEIL INCN

INGUINAL HERNIA

SYMPTOMS

ASYMPTOMATIC, MAY BE DISCOVERED DURING ROUTINE EXAM

A MASS APPEARING / DISAPPEARING

VAGUE LOCAL DISCOMFORT

IRREDUCIBLE or PAINFUL LUMP

FEATURES OF INTEST OBSTRUCTION

FEATURES OF SEPTICEMIA (LATE CASES OF STRANGULATION)

INGUINAL HERNIA

SIGNS

SHOULD BE EXAMINED BOTH IN

STANDING & SUPINE POSITIONS

TWO CLASSICAL SIGNS OF UNCOMPLICATED HERNIA :

EXPANSILE COUGH IMPULSE

& REDUCIBILITY

INGUINAL HERNIA

WHY SHOULD IT BE EXAMINED

IN ERECT POSITION ?

IN SUPINE POSITION, NORMAL PROTECTIVE MECHANISMS

COME TO PLAY BEFORE THE VISCERA ENTER THE DEEP RING

INGUINAL HERNIA

SIGNS …..

POSITION

SCROTAL or INGUINOSCROTAL

COUGH IMPULSE (EXPANSILE)

CONSISTENCY (DOUGHY or ELASTIC)

REDUCIBILITY

OMENTOCELE : INITIALLY EASY

ENTEROCELE : INITIALLY DIFFICULT &

REDUCES WITH A GURGLE

INGUINAL HERNIABUBONOCELE, LEFT

INGUINAL HERNIALARGE LEFT INGUINAL HERNIA IN A CHILD

INGUINAL HERNIA

SIGNS ….

INTERNAL RING OCCLUSION TEST

2cm ABOVE THE MIDPOINT OF ING LIGT

DON’T SAY POSITIVE or NEGATIVE

THIS TEST IS NOT POSSIBLE IF THE HERNIA IS IRREDUCIBLE

INGUINAL HERNIA

SIGNS ….

EXTERNAL RING INVAGINATION TEST

NORMLLY PAINFUL

SIZE OF EXTERNAL RING (IMPORTANT)

STRENGTH OF POSTERIOR WALL

IMPULSE TOUCHING THE TIP or PULP OF THE FINGER (UNRELIABLE)

INGUINAL HERNIAEXT RING INVAGINATION TEST

NOTE : PATIENT EXPERIENCS DISCOMFORT

INGUINAL HERNIA

EXT RING INVAGINATION IS

NOT POSSIBLE IN

WOMEN

ASSOCIATED WITH LARGE HYDROCELE or FILARIAL SCROTUM

IRREDUCIBLE HERNIA

INGUINAL HERNIA

SIGNS ….

THREE FINGER TEST (ZIEMAN’S)

DIFFICULT TO ELICIT

NEVER DONE BY SENIORS

BETTER TO EXAMINE INDIVIDUAL AREAS FOR COUGH IMPULSE

INGUINAL HERNIA DIFF DIAGNOSIS (COMMON CONDITIONS)

HYDROCELE– VAGINAL– ENCYSTED– INFANTILE– BILOCULAR– OF CANAL OF NUCK (in females) RARE

FEMORAL HERNIA

VARICOCELE

CANALICULAR (UNDESCENDED) TESTIS

DIFFUSE LIPOMA OF THE CORD

INGUINAL HERNIA DD : Types of Hydrocele

Vaginal Congenital Infantile Encysted (communicating) YOU MAY NOT GET ABOVE THE SWELLING IN B, C & D TYPES and BILOCULAR TYPE

INGUINAL HERNIA

INGUINALVs

FEMORALHERNIA

INGUINAL HERNIADD : Testicular descent

INGUINAL HERNIADD : Varcocele, left

INGUINAL HERNIA

DIFF DIAGNOSIS (RARE)FUNCULITIS

LYMPH VARIX

PSOAS ABSCESS

INGUINAL HERNIA

HOW TO DIFFERENTIATE

A LARGE SCROTAL HERNIA FROM

A HYDROCELE

INGUINAL HERNIA

VAGINALHYDROCELE

LEFT

INGUINAL HERNIADiff between Hydrocele & Scrotal Hernia

NOTE : BOTH CONDITIONS MAY COEXIST

INGUINAL HERNIA

IS IT CONGENITAL (COMMUNICATING)

HYDEROCELE OR

CONGENITAL HERNIA ?

DEPENDS UPON THE SIZE OF

THE NECK OF THE SAC

WHETHER IT ALLOWS ONLY FLUID

OR VISCERA

INGUINAL HERNIA

HERNIA OF A HYDROCELE

LOCALIZED THINNING OF TUNICA LEADING TO PSEUDOPODIUM-LIKE PROJECTION, USUALLY SEEN WHEN THE SAC IS THICK AND FLUID IS UNDER TENSION

INGUINAL HERNIA

HYDROCELE OF A HERNIA

FLUID SEQUESTRATION IN A LOCULUS OF THE HERNIAL SAC, RESEMBLING HYDROCELE. THIS IS SEEN IN LONG STANDING CASES WITH ADHESIONS WITHIN THE SAC

MORE COMMON IN VENTRAL HERNIA CONTAING OMENTUM

INGUINAL HERNIA

MALGAIGNE BULGING

IT IS A PHANTOM HERNIA, LOCATED

JUST ABOVE THE INGUINAL LIGT, MEDIAL TO ANT SUP ILIAC SPINE

MAY BE SEEN IN NORMAL THIN ELDERLYINDIVIDUALS

DENOTES LOSS OF TONE OF CONJOINT TENDON (WHICH IS MORE MUSCULAR)

INGUINAL HERNIA

MALGAIGNE BULGES ….

SEEN IN STANDING POSITION or

HEAD RISING (CARNETT’S) MANEUVER

VALSALVA MANEUVER

THEY ARE NOT DIAGNOSTIC OF HERNIA THEIR PRESENCE DOES NOT IMPLY A GOOD HERNIORRHAPHY CAN’T BE DONE

INGUINAL HERNIALEG RAISING (CARNETT) TEST

TO LOOK FOR MALGAIGNE BULGES

INGUINAL HERNIAMAYDL’S HERNIA (HERNIA-en-W)

MAYDL’S HERNIAHERNIA-en-W

orRETROGRADE STRNGULATION

‘NORMAL’ LOOKINGLOOPS

NECROZED LOOP

INGUINAL HERNIA

INVESTIGATIONS

NO SPECIFIC INVESTIGATIONS REQUIRED FOR THE DIAGNOSIS

ONLY TO ASSESS THE FITNESS FOR ANESTHESIA / SURGERY

SCREEN PRECIPITATING CONDITIONS

COPD, BPH, COLORECTAL LESIONS

INGUINAL HERNIA

INVESTIGATIONS - BASIC

ROUTINE BLOOD, URINE, CXR, ECG

IN AN ELDERLY PATIENT

USG ABDOMEN IF BPH IS SUSPECTED

COLONOSCOPY IF COLORECTAL LESION IS SUSPECTED

HERNIOGRAPHYCONTRAST STUDY

OF THE PERITONEAL SAC(RARELY DONE)

SLIDING HERNIA WITH BLADDER(SCROTAL CYSTOCELE)

PELVIC PART

URINARYBLADDER

SCROTAL PART

INGUINAL HERNIA

TREATMENT

NO MEDICAL TREATMENT

ONLY FOR PREOPERATIVE OPTIMIZATION

TRUSS SHOULD NOT BE PRESCRIBED

SURGERY IS THE ONLY TREATMENT

INGUINAL HERNIATRUSS SHOULD NOT BE ADVISED

INGUINAL HERNIA

TREATMENT

TREAT THE PREDISPOSING CONDITIONS BEFORE ELECTIVE SURGERY

STOP SMOKING (AT LEAST 10 DAYS)

TREATMENT OF CHRONIC COUGH

IF BPH WITH SIGNIFICANT OUTFLOW OBSTRUCTION PRESENT, IT SHOULD BE APPROPRIATELY TREATED

CONSTIPATION SHOULD BE CORRECTED

INGUINAL HERNIANot only it can cause hernia, it may increase its postoperative morbidity

INGUINAL HERNIA

SURGERY

HERNIOTOMY

HERNIORRHAPHY

HERNIOPLASTY

OPEN (CONVENTIONAL)

LAPAROSCOPIC

CARDINAL PRINCIPLES

NO TENSION

NONABSORBABLE SUTURES

INGUINAL HERNIA

HERNIOTOMY

HIGH LIGATION IS IMPORTANT

IN CHILDREN AS THE ONLY PROCEDURE

DONE BEFORE OTHER PROCEDURES

DIRECT SAC MAY BE INVERTED BY

A PURSE-STRING SUTURE

INGUINAL HERNIA

HERNIORRHAPHY

BASSINI REPAIR (& MODIFICATION)

HALSTED REPAIR

SHOULDICE REPAIR

WILLI MEYER REPAIR (& MODIFICATION)

LA ROQUE REPAIR (FOR SLIDING TYPE)

INGUINAL HERNIA

ADJUVANT PROCEDURES

RELAXING INCISION (TANNER)

RESECTION OF SPER CORD (KOONTZ)

ORCHIDECTOMY

OMENTECTOMY

ARTIFICIAL TENSION

PNEUMOPERITONEUM

INGUINAL HERNIAVery Large, reaching the Knees

NOTE THE SUPRAPUBICPOLYTHENE TUBE TOCREATE ARTIFICIAL

PNEUMOPERITONEUM

INGUINAL HERNIA

HERNIOPLASTY

AUTOLOGOUS TISSUE

SYNTHETIC MESH (MORE COMMON)

POLYPROPYLENE (PROLENE)

(MOST COMMON)

PTFE (GORE-TEX)

MARLEX

DACRON

INGUINAL HERNIA

HERNIOPLASTY ……

OPEN :

LICHTENSTEIN REPAIR (TENSION-FREE)

LAPAROSCOPIC : (ALWAYS MESH USED)

TRANS ABDOMINAL PRE PERITONEAL

(TAPP)

TOTALLY EXTRA PERITONEAL (TEP)

INGUINAL HERNIALICHTENSTEIN’S MESH REPAIR

INGUINAL HERNIATRILAMINAR HERNIA SYSTEM (PROLENE)

INGUINAL HERNIA

LAPAROSCOPICSURGERY

INGUINAL HERNIA

STRANGULATION

IS IT OBSTRUCTED or STRANGULATED SYMPTOMS

IRREDUCIBILITY

LOCAL PAIN

FEATURES OF INT OBSTRUCTION

VOMITING (EVEN IN OMENTOCELE)

ABDOMINAL DISTENTION

COLICKY ABD PAIN

ABSOLUTE CONSTIPATION

INGUINAL HERNIA

SIGNS OF STRANGLATION

INGUINO-SCROTAL SWELLING

TENSELY CYSTIC IN CONSISTENCY

IRREDUCIBLE

NO COUGH IMPULSE

MAY BE SIGNS OF INT OBSTRUCTION

IN LATE CASES

SIGNS OF PERITONITIS

FEATURES OF SEPTICEMIA

INGUINAL HERNIA

STRANGULATION ……

URGENT SURGERY

ONLY ESSENTIAL INVESTIGATIONS

IF FEATURES OF INT OBSTRUCTION

IV FLUIDS

ANTIBIOTICS

NASOGASTRIC ASPIRATIONS

INGUINAL HERNIASURGERY FOR STRANGULATION

INGUINO-SCROTAL INCISION

OPEN THE SAC FIRST (BEFORE CUTTING THE EXT RING)

SUCK OUT THE TOXIC FLUID

HAVE A HOLD ON THE BOWEL LOOP

THEN DIVIDE THE CONSTRICTING BAND DRAW MORE BOWEL LOOPS INTO THE FIELD

ASCERTAIN THE VIABILITY OF THE LOOP BEFORE REDUCTION

INGUINAL HERNIA

SURGERY FOR STRANGULATION ……

IF THE BOWEL IS VIABLE :

REST OF THE PROCEDURE IS SIMILAR TO AN ELECTIVE CASE

IF THE BOWEL IS NONVIABLE :

BOWEL RESECTION & ANASTOMOSIS

CONTINUE IV FLUIDS, ANTIBIOTICS &

NG ASPIRATIONS, TILL THE RETURN OF BOWEL ACTIVITY (48-72 HRS)

AVOID MESH PLASTY- FEAR OF INFECTION

INGUINAL HERNIAGangrenous loops of bowel due to

Strangulation (delayed)

INGUINAL HERNA

CAUSES OF RECURRENCE

PREOPERATIVE

OPERATIVEPOSTOPERATIVE

COMMON CAUSES

INFECTION

TECHNICAL REASONS

UNRESOLVED PREDISPOSING FACTORS

EARLY RETURN TO ACTIVITY

INGUINAL HERNIA

WHAT TO DO IF

AFTER GOOD COUNSELING

THE PATIENT REFUSES SURGERY ?

LET HIM GO TO

130 CHAPTERS800 PAGES

1000 PICTURES

CHARLES DARWIN1809 - 82

“It is not the strongest nor the most intelligent species that survives, but only the one

capable of adopting to the changed environment”

ACKNOWLEDGEMENTS

Prof R Nanjunda Rao&

A S I – Chennai City Branch

Prof D Nagarajan, PresidentDr G Chandrasekar, Secretary

Dr Ravindran Kumeran, Treasurer

IF I COVERTOO MUCH YOU MAY

LOSE INTEREST

C M K Reddy