Prof C M K Reddy
A TRIBUTE TO A GREAT TEACHER
AND SOCIAL WORKER - Prof RNR
Prof R Nanjunda Rao
CME Program for
Undergraduates
INGUINAL HERNIA
Prof R Nanjunda Rao
&
A S I – Chennai City Branch
Prof D Nagarajan, President
Dr G Chandrasekar, Secretary
Dr Ravindran Kumeran, Treasurer
BY
Prof C M K REDDY
DSc (Hon) FRCS (Glas) FRCS (Ire)
Emeritus Professor, TN Dr MGR Med University
General & Vascular Surgeon
Apollo Hospitals & Halsted Surgical Clinic
CHENNAI
President
TN Medical Practitioners’ Association (TAMPA)
Indian Chapter, Royal College of Surgeons in
Ireland
Core Committee for Hosp. Waste Mgmt. of
Chennai
Formerly
Medical 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 Eminent
Medical 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 HERNIA
PROLAPSE 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 HERNIA
HESSELBACH’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
EXTERNAL DISSECTION
HESSELBACH’S
TRIANGLE
Laparoscopic view
from inside
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 HERNIA
Laparoscopic Anatomy
INDIRECT
DIRECT
FEMORAL
INFERIOR
EPIGAST
VESSELS
INGUINAL HERNIA
Myopectineal Orifice of Fruchaud
Boundaries
Medial :
Rectus muscle
Lateral :
Iliopsoas
Superior :
Conjoint tendon
Inferior :
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 HERNIA
INDIRECT 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 HERNIA
Bubonocele Funicular
Complete
INGUINAL HERNIA
BILATERAL 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 RIGHT
INGUINAL
INTERSTITIAL
HERNIA
INGUINAL HERNIA
RIGHT
INGUINAL
INTERSTITIAL
HERNIA
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 UROPATHY
BPH 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 HERNIA
BUBONOCELE, LEFT
INGUINAL HERNIA
LARGE 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 HERNIA
EXT 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
INGUINAL
Vs
FEMORAL
HERNIA
INGUINAL HERNIA
DD : Testicular descent
INGUINAL HERNIA
DD : 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
VAGINAL
HYDROCELE
LEFT
INGUINAL HERNIA
Diff 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 ELDERLY
INDIVIDUALS
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 HERNIA
LEG RAISING (CARNETT) TEST
TO LOOK FOR MALGAIGNE BULGES
INGUINAL HERNIA
MAYDL’S HERNIA (HERNIA-en-W)
‘NORMAL’ LOOKING
LOOPS
MAYDL’S HERNIA
HERNIA-en-W
or
RETROGRADE
STRNGULATION
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
HERNIOGRAPHY
CONTRAST STUDY
OF THE
PERITONEAL SAC
(RARELY DONE)
SLIDING HERNIA WITH BLADDER
(SCROTAL CYSTOCELE)
PELVIC
PART
URINARY
BLADDER
SCROTAL
PART
INGUINAL HERNIA
TREATMENT
NO MEDICAL TREATMENT
ONLY FOR PREOPERATIVE OPTIMIZATION
TRUSS SHOULD NOT BE PRESCRIBED
SURGERY IS THE ONLY TREATMENT
INGUINAL HERNIA
TRUSS 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 HERNIA
Not 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 HERNIA
Very Large, reaching the Knees
NOTE THE SUPRAPUBIC
POLYTHENE TUBE TO
CREATE 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 HERNIA
LICHTENSTEIN’S MESH REPAIR
INGUINAL HERNIA
TRILAMINAR HERNIA SYSTEM (PROLENE)
INGUINAL HERNIA
LAPAROSCOPIC
SURGERY
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 HERNIA
SURGERY 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 HERNIA
Gangrenous loops of bowel due to
Strangulation (delayed)
INGUINAL HERNA
CAUSES OF RECURRENCE
PREOPERATIVE
OPERATIVE
POSTOPERATIVE
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 CHAPTERS
800 PAGES
1000 PICTURES
CHARLES DARWIN
1809 - 82
“It is not the strongest nor the most intelligent
species that survives, but only the one
capable of adopting to the
changed environment”
Prof R Nanjunda Rao
&
A S I – Chennai City Branch
Prof D Nagarajan, President
Dr G Chandrasekar, Secretary
Dr Ravindran Kumeran, Treasurer
IF I COVER
TOO MUCH
YOU MAY
LOSE
INTEREST
C M K Reddy