1. About the hernia
2. Due to hernia (complications)
3. Precipitating factors.

 

1. Duration
2. Onset—suddenly/gradually
3. Site of start— From groin to scrotum (hernia)
   • From scrotum to groin (hydrocele and varicocele)
4. Aggravating factors:
   • - On straining
   • - On standing
   • - On coughing
5. Relieving factors:
   • - By lying down
   • - Manually by himself
6. Associated with pain: Usually painless

 

1. Irreducibility:
   1. Crowding of the contents
   2. Adhesion between sac and contents
   3. Adhesion between contents
   4. Adhesion between sac.
2. Obstruction:
   Four cardinal features
   1. Colicky abdominal pain
   2. Vomiting
   3. Abdominal distension
   4. Obstipation (absolute constipation)—Not passing flatus and feces.
3. Strangulation:
   (Obstruction + Irreducibility + Arrest of blood supply)3
   1. Colicky abdominal pain if continues and becomes gangrenous pain disappears.
   2. Sudden increase in size of herniae; becomes tense and tender.

 

1. Chronic bronchitis/asthma/TB
2. Difficulty in micturition
3. Difficulty in defecation
4. Weight lifting.

     

H/o smoking

:

Smoking leads to chronic bronchitis collagen deficiency occurs in smokers.

 

• General condition
• Anemia
• Lymphadenopathy
• Blood pressure
• Pulse rate

   

• Mass abdomen
• Malgaigne's bulgings
• Ascites

   

1. Site
2. Size
3. Shape
4. Extent
5. Surface
6. Skin over the swelling
7. Visible peristalsis
8. Cough impulse
9. Draining lymph nodes
10. Penis
11. Urethral meatus
12. Opposite scrotum.

 

1. Temperature
2. Tenderness
3. Site
4. Size
5. Shape

6. Extent
7. Surface
8. Skin over
9. Consistency
10. Reducibility
11. Get above the swelling
12. Cough impulse
13. Invagination test
14. Ring occlusion test
15. Ziemann's technique.

     

• Method of reducing the inguinal hernia

Procedure

• • With the thumb and fingers hold the sac, guide with other hand at superficial ring • Do it slowly.

 

1. Bowel injury
2. Reduction en masse – Reducing the sac with the constriction being present at the neck; thereby making the hernia with obstruction to go into the abdomen.
3. Sac may rupture at its neck and the contents may be reduced extraperitoneally.

 

1. Making the child cry
2. Valsalva manoevre
3. Head raising and abdomen contraction
   To demonstrate by inspection
   • No need to reduce the content
     6
   • Just ask the patient to stand and cough

• Swelling increases in size or
• Impulse seen and swelling reappears

 

Reducibility	Compressibility
• After reducing the swelling opposite force is required to make the swelling reappear	Opposite force is not required for reappearing. It appears slowly to its original size
• Swelling can be completely reduced, e.g.: Hernia	Swelling cannot be completely reduced, e.g.: Hemangioma

 

1. Intestine	:	Last part is easy to reduce; initial part is difficult to reduce; gets reduced with gurgling sound.
2. Omentum	:	First part easy to reduce, last part is difficult because omentum adheres to fundus of sac.

   

• Child held from back by both hands of clinician on its abdomen
• Abdomen is pressed and child is lifted up
• Hernia appears due to increase in the abdominal pressure exerted.

   

• Index finger over deep ring
• Middle finger over superficial ring
• Ring finger over saphenous opening.

 

• Direct hernia - Superficial ring
• Indirect hernia - Deep ring
• Femoral hernia - Saphenous opening.

 

If swelling appears	—	Direct
not appears	—	Indirect

   

1. Swelling should be reducible
   8
2. Lax of skin should be there for invaginating (so this test could not be done in females).

 

1. Reduce the swelling.
2. For right side, invaginate with right little finger into the superficial ring.
3. Rotate the little finger medially so that the pulp faces medially.
4. Note the direction of entry and site of impulse.

 

Enterocele:	Resonant
Omentum:	Dull.

   

1. Testis: ‘Traction test’ to find whether the inguinal swelling is an encysted hydrocele of cord.
2. Epididymis.
3. Penis:
   • Phimosis
   • Penile strictures
   • Pinhole meatus
4. Regional nodes.
5. Opposite groin.

 

to R/o

1. Benign prostate hypertrophy — Micturition difficulty 2. Malignant obstruction 3. Chronic fissure — Constipation

 

Inguinal Swelling	Inguinoscrotal Swelling	Femoral Hernia
1. Enlarged lymph nodes	1. Encysted hydrocele of cord	1. Inguinal hernia
2. Undescended testes	2. Varicocele	2. Saphena varix
3. Lipoma	3. Lymph varix	3. Cloquet's node
4. Femoral hernia	4. Diffuse lipoma of cord	4. Lipoma
5. Saphena varix	5. Inflammatory thickening of cord	5. Femoral aneurysm
6. Psoas abscess		6. Psoas abscess
7. Femoral aneurysm

   

For example:

1. Benign prostate hypertrophy 2. Tuberculosis 3. Stop smoking

 

• Truss is not curative for hernia, with the sole exception of newborn infants.
• Hernia should be reducible.
• Contraindicated in cases of irreducible hernia, undescended testis, associated huge hydrocele, unintelligent people.
• Do not say in exams.

     

1. Vaginal (complete)—Descends upto scrotum base, testis not felt separately.
2. Funicular—Testis felt separately, processus vaginalis closed above epididymis.
3. Bubonocele—Inguinal swelling only.

 

Anterior wall	:	External oblique aponeurosis, arched fibres of internal oblique laterally.
Posterior wall	:	Fascia transversalis, conjoint muscles (tendon) in medial half.
Floor	:	Grooved part of external oblique aponeurosis; medial end there is lacunar ligament.
Roof	:	Conjoint muscles (internal oblique and transversus abdominis).

 

• 3.75 cm length
• Extends from deep ring to superficial ring
• Deep ring is a semioval opening in the fascia transversalis
• Superficial ring is a triangular opening in the external oblique aponeurosis, guarded by two crura of muscle fibres.

 

• Ilioinguinal nerve
• Spermatic cord in male, round ligament in female

   

1. Shutter mechanism	—	Arched fibres of internal oblique.
2. Flap valve mechanism	—	Oblique canal; approximation of anterior and posterior wall.
3. Ball valve mechanism	—	Cremaster contracts, thereby superficial ring plugged by spermatic cord.
4. Slit valve mechanism	—	Crura of the superficial ring.

 

Medial	:	Outer border of rectus abdominis
Lateral	:	Inferior epigastric vessels
Below	:	Medial part of inguinal ligament
Floor	:	Fascia transversalis

   

1. Peritoneum
2. Internal spermatic fascia (from fascia transversalis)
3. Cremasteric fascia (from internal oblique)
4. External spermatic fascia (from external oblique)
5. Scrotum.

 

1. Peritoneum
2. Transversalis fascia (from fascia transversalis)
   14
3. External spermatic fascia (from external oblique) usually does not descend into scrotum.

 

• Narrowest part
• Extraperitoneal pad of fat will be present
• Inferior epigastric vessels will be on medial side
• Sac of hernia is pearly white
• Sac of hydrocele is bluish.

 

• - Does not enter through deep ring; but through the intermuscular plane and supplies anterioscrotum, medial side of thigh, root of penis in males, labia majora, and clitoris in females.

 

• Femoral canal is bounded above by femoral ring with extra peritoneal pad of fat; below by saphenous opening covered by cribriform fascia.
• Femoral hernia is retort shaped : Because as it goes down through saphenous opening Holden's line prevents the contents going further down. Hence the contents turns up and enters inguinal canal. [Holden's Line - Fascia scarpa (deep membranous layer of superficial fascia) attaches firmly with deep fascia (fascia lata)]

   

1. Separation of sac from cord structures
2. Reducing the content
3. Transfixation and ligation of sac
4. Excise the redundant sac.

 

1. Herniotomy
2. Narrowing of the deep ring with 2'0 prolene (LYTLE'S REPAIR)
3. Approximation of conjoint tendon with inguinal ligament using 1' polypropylene material.

 

Herniorrhaphy	Hernioplasty
1. Original bassini	1. Lichtensteins
2. Modified bassini	2. Gilbert's plug
3. McVay's	3. Prolene hernia system
4. Shouldice	4. Laparoscopic mesh repair
	5. Stoppas repair

 

• He gave additional strength to the posterior wall by double breasting the fasciatransversalis.
• Best among all anatomical repairs (Herniorrhaphy)
• Least recurrence among herniorrhaphy

   

• Approximated conjoined tendon with iliopectineal ligament of cooper.
• It prevents both inguinal and femoral hernia

 

• Prolene mesh 16 × 10 cm size is taken and fixed in the inguinal canal.
• First bite taken from periosteum of pubic tubercle; and fix the mesh to a point beyond the deep ring.
• Fix the mesh with inguinal ligament and conjoined tendon using 1’0 or 2’0 prolene without tension.

 

• A plug mesh is kept in the deep ring and also to reinforce the posterior wall.

 

• For bilateral direct hernia's, a modified Pfannenstiel's incision made in the lower abdomen and a huge mesh placed in between the peritoneum and the fascia transversalis (preperitoneal mesh repair).

 

1. Inlay Mesh	—	Approach through the abdomen, mesh kept preperitoneally.
2. Onlay mesh	—	Mesh kept in the inguinal canal in front of deep ring.

 

• Serves multipurpose, combination of inlay and onlay mesh
• Prevent direct and femoral hernia as well
• Push the inlay mesh through the deepring or Hesselbach's triangle.

 

• Man made mesh
• Suturing done with 1' prolene approximating conjoint tendon with inguinal ligament to and fro forming a mesh like pattern without tension

   

• - Old age, recurrent hernia
• - Remove the spermatic cord along with testis at the level of deep ring; and do herniorrhaphy.
• - Doing so there is no content in the inguinal canal, thus the canal gets approximated and no chance of recurrence.

 

• - Funniculectomy within the canal.
• - Cord removed in between the superficial and deep ring leaving the testis in the scrotum.

       

1. Lotheissen's inguinal approach:
   • Inguinal incision made similar to inguinal hernia
   • Fascia transversalis opened
     20
   • Approximate inguinal ligament with iliopectineal and also conjoint tendon with inguinal ligament
   • Prevents inguinal hernia also.
2. High approach of mcevedy:
   • Vertical incision made over the femoral canal continued above to inguinal ligament
   • Very useful for irreducible and strangulated hernia.
3. Low operation of lock wood:
   • Groin crease incision
   • Indicated in uncomplicated femoral hernia only
   • Just approximate inguinal ligament and Iliopectineal ligament
   • Not prevents inguinal hernia.

     

1. Resuscitation: Nasal oxygen, intravenous fluids.
2. Parenteral antibiotics.
3. Delay should not be made for operation
   ‘Danger is in delay not in operation’.

   

1. Taxis
2. Foot end elevation

• Paint with povidone iodine from xiphisternum to midthigh (may need laparotomy for nonviable bowel).

1. Keep a warm pad over the bowel.
2. 100% oxygen given nasal.
3. Wait for 10 minutes.
4. If viable put it back in the abdomen.
5. If nonviable; abdomen opened through midline incision.

 

1. Maydl's hernia (retrograde strangulation) ‘W’ shaped hernia.
2. Gangrene in the obstructed bowel starts first at the neck of sac; then immediately at the antimesenteric border distally.
   

   Fig. 1.5: Maydl's hernia
   23
3. Therefore in Maydl's hernia; the distal antimesenteric border is inside the abdomen; which goes for strangulation first (Fig. 1.5).
4. Hence look for the full length of intestine by pulling out the loop inside the abdomen.

       

1. Incompletely reducible
2. Huge scrotal hernia
3. Appears slowly after reduction
4. Old male.

 

1. Don't dissect the sac from the retroperitoneal structures, just push part of the sac along with them.
2. Hernioplasty is ideal.

       

1. Mostly irreducible
2. Cough impulse — Negative

 

1. Assess the respiratory status, because if you suddenly push the whole bowel into the abdomen he may go for respiratory distress postoperatively.
2. Pneumoperitoneum should be created and the patient allowed to work with it for a few months before surgery.
3. Inguinal incision made as usually and the pneumoperitoneum released; gradually reduce the content.
4. Do hernioplasty.

 

• Type of interstitial hernia (that comes in between the layers of anterior abdominal wall muscles).
• This occurs through spigelian fascia, thin strip of fascia that runs parallel to the outerborder of rectus sheath from tip of 9th costal cartilage to pubic tubercle.
• This fascia contributes to few fibres of anterior rectus sheath and is wide at the level of arcuate line, where the hernia occurs and runs in between external and internal oblique muscles.

   

• A portion of the circumference of the intestine becomes the content of the sac.
• Strangulation occurs when associated with femoral or obturator hernia.
• Diarrhoea is seen in cases of strangulation.
• Unless more than half of the circumference is involved there is no constipation.

 

• Meckel's diverticulum is seen in the sac.

 

• Epigastric hernia of line alba
• Circumference of the bowel seen in the sac.

 

Type I:	Indirect hernia with normal deep ring
Type II:	Indirect hernia with dilated deep ring
Type III:	Posterior wall defect a. Direct b. Pantaloon c. Femoral
Type IV:	Recurrent

 

• Has two sacs
• Actually a posterior wall defect in which sac comes through Hessel-bach's triangle and deep ring
• Isthmus behind is inferior epigastric vessels
• If one sac is not treated properly recurrence will occur
• Ring occlusion test: Not significant.

 

• Direct hernia are always acquired. Indirect may be congenital or acquired
• Only congenital direct hernia is ogilvie hernia; through a rigid circular orifice in the conjoined tendon just lateral to where it inserts into the rectus sheath.

 

Factors	S.No. Direct	Indirect
Age	1. Older	Young
Sex	2. Never occur in female	M: F = 20:1
History	3. Reduced on lying down 4. Mostly bilateral	Reduced by manipulation Usually unilateral to start
Inspection	5. Hemispherical shape 6. Malgaigne's bulge (+) 7. Incomplete variety 8. Deepring occlusion— Swelling appears	Pyriform shape No malgaigne's bulge Complete / Incomplete Swelling not appears
Palpation	9. Finger invagination— Impulse felt at pulp of little finger 10. Ziemann's technique— Impulse at superficial ring	Impulse at tip of finger Impulse at deep ring
Complication	11. Strangulation very rare	Common
During surgery	12. Sac is posteromedial to cord 13. Sac is medial to inferior epigastric vessels 14. Comes through Hesselbach's triangle 15. Hernioplasty must be done	Sac is anterolateral to cord. Lateral to inferior epigastric vessels Comes through deep ring Hernioplasty/Herniorrhaphy