4. Classification of Hernia
Classification I (Clinical)
1. Reducible Hernia
Hernia gets reduced on its own or by the patient or by the
surgeon. Intestine reduces with gurgling and it is difficult
to reduce the first portion. Omentum is doughy, and it is
difficult to reduce the last portion. Expansile impulse on
coughing present.
2. Irreducible Hernia
Here contents cannot be returned to the abdomen due to
narrow neck, adhesions, overcrowding. Irreducibility
predisposes to strangulation.
3. Obstructed Hernia
It is an irreducible hernia with obstruction, but blood supply to
the bowel is not interfered. It eventually leads to strangulation.
5. 4. Inflamed Hernia
It is due to inflammation of the contents of the sac, e.g.
appendicitis, salpingitis. Here hernia is tender but not
tense;
overlying skin is red and oedematous.
5. Strangulated Hernia
x It is an irreducible hernia with obstruction to blood flow.
The swelling is tense, tender, with no impulse on coughing
and with features of intestinal obstruction.
6. Classification II
Congenital—Common
It occurs in a preformed sac/defect. Clinically may present at a
later period due to any of the precipitating causes like in indirect
inguinal hernia.
Acquired
It is secondary to any causes which raise the intra-abdominal
pressure
leading into weakening of the area like in direct inguinal hernia.
Classification III: According
to the Contents
™
. Omentocele—omentum.
™
. Enterocele—intestine.
™
. Cystocele—urinary bladder.
™
. Littre’s hernia—Meckel’s diverticulum.
™
. Amyand’s hernia- Appendix
™
. Sliding hernia- Both Direct & Indirect hernial sac present.
™
. Richter’s hernia—part of the bowel wall.
8. TYPES OF MANAGEMENT FOR
HERNIA
• CONSERVATIVE
• SURGICAL{Surgery is the treatment of choice}
9. CONSERVATIVE
• WATCHFUL WAITING: In elderly people, if the hernia
is asymptomatic, small in size, can be reduced easily
and is not causing anxiety, then observation alone
should be sufficient.
• Small paraumbilical hernias are common and they
cause few symptoms and usually contain fat or
omentum with a very low risk of complications.
• In obese and elderly patients, these risks may
outweigh the benefits of surgery so it is common to
adopt a conservative approach.
10. SURGICAL TREATMENT OF HERNIA
• For any hernia the surgical option comprises 2
components :
– Herniotomy
– Herniorrhaphy or hernioplasty
• It is either :
– Open repair
– Laparoscopic repair
11. INDICATIONS FOR SURGERY
• All cases of femoral hernia should be repaired
surgically as they have higher possibility of
strangulation.
• Any case of irreducible hernia with pain and
tenderness, unless coexisting medical factors place
the patient at very high risk from surgery or
anaesthesia.
• Increasing difficulty in reduction and increasing size.
• In younger adult patients as symptoms and
complications are likely over time.
• acute pain in a hernia and if it is irreducible, should
be offered surgery.
12. SURGICAL APPROACHES TO HERNIA
All surgical repairs follow the same basic principles:
1. Reduction of the hernia content into the
abdominal cavity with removal of any non-viable
tissue and bowel repair if necessary.
2. Excision and closure of a peritoneal sac if present
or replacing it deep to the muscles.
3. Reapproximation of the walls of the neck of the
hernia if possible.
4. Permanent reinforcement of the abdominal wall
defect with sutures or mesh
13. HERNIAL SURGERY IN INFANTS
• Only herniotomy is preferred in infants in both
hernia and hydrocele.
• This surgery is called as “Michaelis plank
operation”
14. HERNIAL SURGERY IN ADULTS
1. HERNIOTOMY – excision of hernial sac
2. HERNIORRHAPHY – herniotomy + posterior
wall strengthening
3. HERNIOPLASTY – herniorraphy with mesh
usage
16. HERNIOTOMY
• Anaesthesia: spinal or G/A or local anaesthesia
• Cleaning and draping ; skin is incised—1.25 cm above & parallel to
the medial two/third of inguinal ligament.
• Superficial fascia & external oblique aponeurosis is incised &
inguinal ligament is exposed.
• Ilioinguinal nerve is safeguarded.
• Cremasteric muscle is opened.
• Cord structures dissected. Sac is identified as pearly white in
colour.
• Sac is opened at the fundus. Finger is passed to release any
adhesions. Sac is twisted so as to prevent the content from
coming back.
• It is transfixed using absorbable suture material (chromic catgut 2-0
or vicryl) and is excised distally.
17. Skin incision—1.25 cm above &
parallel to the medial two/third of
inguinal ligament
Twisting of the sac to prevent the
contents to get in.
19. BASSINI’S HERNIORRHAPHY
1. The conjoined tendon is retracted upward
2. the aponeurosis of the transversus abdominis
muscle is approximated to the iliopubic tract that
lies adjacent to the inguinal ligament with several
interrupted sutures.
3. The second layer of the repair involves suturing
the conjoined tendon to the inguinal ligament
with interrupted sutures.
4. This suture line extends from the pubic tubercle to
the medial border of the internal ring.
20. • Opening the fascia transversalis from pubic tubercle to
deep ring.
• Approximation with interrupted stitches
• Approximation of conjoint tendon & upper leaf of
fascia transversalis with inguinal ligament & lower leaf
of fascia transversalis
21.
22. MODIFIED BASSINI’S HERNIORRHAPHY
Approximation with continuous interlocking stitch with
prolene.
•Sutures are placed between the conjoint tendon above and
the inguinal ligament below, extending from the pubic
tubercle to the deep inguinal ring.
23. LYTLE’S REPAIR
• 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)
24. SHOULDICE REPAIR
• an incision is made in the transversalis fascia.
This incision is extended from the internal ring
to the pubic tubercle.
• The repair involves placing four lines of
sutures.
25. • The first suture line is started at the pubic tubercle
using continuous polypropylene, and the white line
is approximated to the free edge of the inferior
transversalis fascial flap.
26. • The second suture line At the internal ring the suture is
tied and then continued medially by approximating the free
edge of the superior flap to the shelving edge of the
inguinal ligament. When the pubic tubercle is reached, the
suture is tied and divided.
27. • The third suture line is started at the level of the
internal ring where the conjoined tendon is
approximated to the inguinal ligament and tied
when the pubic tubercle is reached.
28. • the fourth suture line (Using the same suture)
attaches these same structures to one another and
is tied at the level of the internal ring.
29. • The cord is replaced within the inguinal canal,
and the external inguinal aponeurosis is
reapproximated with continuous absorbable
sutures
30. Desarda’s repair
• An operation where a 1- to 2-cm strip of external
oblique aponeurosis lying over the inguinal canal
is isolated from the main muscle,
• The continuity with muscle and insertion is kept
intact both medially and laterally.
• It is then sutured to the conjoint tendon and
inguinal ligament, reinforcing the posterior wall
of the inguinal canal.
• As the abdominal muscles contract, this strip of
aponeurosis tightens to add further physiological
support to the posterior wall.
31.
32. Tanner Slide Operation
• To reduce the tension in the repair area, relaxing
incision is placed over the lower rectus sheath after
modified bassini’s surgery so that conjoined tendon
is allowed to slide downward.
33. Darning (Abrahamson Nylon Darning)
• Continuous non absorbable sutures are placed
between : conjoint tendon and inguinal ligament to
give good support to posterior wall of inguinal
hernia.
34. McVay Operation
• It is repair by placing interrupted suture is
applied between transversalis fascia to
copper’s ligament starting from pubic tubercle
medially towards femoral sheath and later
continued as suture repair between
transversalis fascia and iliopubic tract laterally
upto entrance of cord
• Covers all three groin defects- indirect, direct,
and femoral.
35. 1. Andrew’s Operation - It involves overlapping
of the external oblique aponeurosis.
2. Nyhus Iliopubic Repair - Transaponeurotic
arch (transverse abdominis muscle and
transversalis fascia) is sutured below to
Copper’s ligament and iliopubic tract.
3. Wilkinson Method - Transversus abdominis
and internal oblique are sutured to inguinal
ligament with continuous monofi lament
sutures
37. Tension – free repair
• There are several options for placement of
mesh during anterior inguinal herniorrhaphy,
including
– The Lichtenstein approach
– The plug-and-patch technique
– The sandwich technique with both an anterior and
preperitoneal piece of mesh.
38. LICHTENSTEIN’S REPAIR.
• Lichtenstein described a tension-free, simple, flat,
polypropylene mesh repair for inguinal hernia.
• The initial part of the operation is identical to Bassini’s. Once
the hernia sac has been removed and any medial defect
closed, a piece of mesh, measuring 8 × 15 cm, is placed over
the posterior wall, behind the spermatic cord, and is split to
wrap around the spermatic cord at the deep inguinal ring.
• Loose sutures hold the mesh to the inguinal ligament and
conjoint tendon.
• Two major advantages are claimed:
– lowered hernia recurrence rates and
– accelerated postoperative recovery.
40. MESH IN HERNIA REPAIR
• The term ‘mesh’ refers to prosthetic material, either
a net or a flat sheet, which is used to strengthen a
hernia repair. Mesh can be used:
• To bridge a defect: the mesh is simply fixed over the
defect as a tension-free patch;
• To plug a defect: a plug of mesh is pushed into the
defect;
• To augment a repair: the defect is closed with
sutures and the mesh added for reinforcement.
• A well-placed mesh should have good overlap
around all margins of the defect up to 5 cm if
possible.
41. Mesh characteristics
• Woven, knitted or sheet
• Synthetic or biological – mainly synthetic
• Light, medium or heavyweight – lightweight
becoming more popular
• Large pore, small pore – large pore causes less
fibrosis andpain
• Intraperitoneal use or not – non-adhesive mesh
on one side
• Non-absorbable or absorbable – mainly non-
absorbable
42. Synthetic
mesh
• Alloderm
• Acellular porcine
dermis
• Acellular human dermis
• Avoided in infection and
strangulation.
• Eg.
– Prolene
– Polyester
– Vypro (vicryl+prolene)
– PTFE(polytetrafluoroethylene)
Biological
mesh
• Can be used where there is
infection.
• Eg:
44. PROPERTIES OF IDEAL MESH
• Possess good handling characteristics in the OR
• Invoke a favorable host response
• Be strong enough to prevent recurrence
• Place no restrictions on post implantation function
• Perform well in the presence of infection
• Resist shrinkage or degradation over time
• Make no restrictions on future access
• Block transmission of infectious disease
• Be inexpensive
• Be easy to manufacture
48. SUBLAY
BETWEEN FASCIAL LAYERS IN THE ABDOMINAL WALL
(INTRAPARIETAL OR SUBLAY);IMMEDIATELY EXTRAPERITONEALLY,
AGAINST MUSCLE OR FASCIA(ALSO SUBLAY);
50. COMPLICATIONS OF MESHPLASTY
• Mesh plug can form a dense ‘meshoma’ of plug and
collagen.
• Seroma’s develop with any mesh type but those with larger
pores may be less likely to do so.
• Migration, erosion into adjacent organs.
• Fistula formation
• Chronic pain
• Materials such as PTFE have a good profile for adhesion risk
but a high risk of infection.
• In contrast, polypropylene meshes are durable and have a
low infection risk but they have little flexibility and a high
adhesion risk.
54. • ‘Deep’ repair of inguinal hernia deals with the
issue from the ‘point of origin’ rather than the
‘point of presentation’.
• This exercise has two important final results.
– Firstly, the ‘inlay/ posterior’ mesh placement
provides a mechanical edge on the ‘onlay/ anterior’
mesh placement.
– Secondly covering the entire ‘Myopectineal orifice
(of Fruchaud’) the ‘deep’ repair handles all the
potential sites in danger
55. MYOPECTINEAL ORIFICE OF FRUCHAUD
• In 1956, Henry Fruchaud espoused the theory that all
groin (inguinofemoral) hernia and obturator originate
in a single weak area called the Myopectineal orifice.
This oval, funnel like, ‘potential’ orifice formed by the
following structures, forms the ‘Myopectineal orifice of
Fruchaud’.
1. Superiorly Internal oblique and transverses
abdominis muscles.
2. Inferiorly Superior pubic ramus.
3. Medially Rectus muscle sheath.
4. Laterally Iliopsoas muscle.
56.
57. THE PERITONEAL LANDMARKS
• Since the growth and development of the
laparoscopic method for treating groin hernia an
increased attention is being paid to ‘pure anatomy’
issues such as the infraumbilical fossae. These types
of fossae have two important roles-
– The fossae delineate the websites of groin herniation.
– They are an essential landmark for orientation during
hernia repairs.
• The fossae are created by the presence of
peritoneal folds, which radiate from the umbilicus
or umbilical area.
58. Median Umbilical Ligament
This ligament ascends within the
median plane in the apex of the
bladder towards the umbilicus. It
represents the obliterated allantoic
duct and its lower part may be the site
from the unusual urachal cyst.
Medial Umbilical Ligament
This ligament symbolizes the
obliterated umbilical artery on both
sides and can be traced down to the
internal iliac artery.
Lateral Umbilical Ligament
It's the ridge of peritoneum, which is
raised by the Inferior Epigastric artery
and its companion two veins because
they course around the medial border
from the internal inguinal ring after
which pass upwards into the posterior
rectus sheath.
59. • Supravesical fossae: The infra-umbilical area between
the median and medial umbilical structures. This is
actually the site for that source of the supravesical
hernia.
• Medial Umbilical fossae: The infra-umbilical area
between the medial and lateral umbilical ligaments. This
is the site for the ori- gin of the femoral and direct
inguinal hernia.
• Lateral Umbilical fossae: The infra-umbilical area
horizontal towards the lateral umbilical ligament. This is
actually the site for the origins of the indirect inguinal
hernia.
68. Operations for inguinal hernia
Herniotomy
TENSION REPAIR
Open suture repair
• Bassini
• Shouldice
• Desarda
Tension-free Repair
1. Open flat mesh repair
• Lichtenstein
2. Open complex mesh repair
• Plugs
• Hernia systems
3. Open preperitoneal repair
• Stoppa
4. Laparoscopic repair
• TEP
• TAPP
69.
70. OPERATIONS FOR FEMORAL HERNIA
OPEN LAPROSCOPIC
HIGH APPROACH
(Above inguinal ligament)
McEVEDY
LOW APPROACH
LOCKWOOD
TEP TAPP
Inguinal approach
LOTHEISSEN
71. LOW APPROACH (LOCKWOOD)
• This is the simplest operation for a femoral hernia but
suitable only when there is no risk of bowel resection.
• It can easily be performed under local anaesthesia.
• A transverse incision is made over the hernia. The sac of
the hernia is opened and its contents reduced.
• The sac is also reduced and non-absorbable sutures are
placed between the inguinal ligament above and the fascia
overlying the bone below.
• A small incision can be made in the medial lacunar ligament
to aid reduction but there may be an abnormal branch of
the obturator artery just deep to it, which can bleed. The
femoral vein, lateral to the hernia, needs to be protected.
72. THE INGUINAL APPROACH
(LOTHEISSEN)
• The initial incision is identical to that of Bassini’s or
Lichtenstein’s operation into the inguinal canal.
• The spermatic cord (or round ligament) is mobilised and
the transversalis fascia opened from deep inguinal ring to
the pubic tubercle.
• A femoral hernia lies immediately below this incision and
can be reduced by a combination of pulling from above and
pushing from below.
• Once reduced, the neck of the hernia is closed with sutures
or a mesh plug, protecting the iliac vein throughout.
• The layers are closed as for inguinal hernia and the surgeon
may place a mesh into the inguinal canal to protect against
development of an inguinal hernia.
73. HIGH APPROACH (McEVEDY)
• This more complex operation is ideal in the emergency situation where the
risk of bowel strangulation is high.
• It requires regional or general anaesthesia.
1. A horizontal incision (classically vertical) is made in the lower abdomen
centred at the lateral edge of the rectus muscle.
2. The anterior rectus sheath is incised and the rectus muscle displaced
medially. The surgeon proceeds deep to the muscle in the preperitoneal
space.
3. The femoral hernia is reduced and the sac opened to allow careful
inspection of the bowel, and a decision made regarding the need for
bowel resection if necessary.
4. In dubious cases, the bowel is replaced into the peritoneal cavity for 5
minutes and then re-examined. The femoral defect is then closed with
sutures, mesh or plug.
This approach allows a generous incision to be made in the
peritoneum,which aids inspection of the bowel and facilitates bowel
resection.
75. UMBLICAL HERNIA
Very small defect
(1-2cm)
Mayo’s repair
(herniorraphy)
Defects up to 2 cm in diameter may be
sutured primarily with minimal tension,
although, the larger the defect,the
more tension and the more likely it is
that mesh reinforcement will be
beneficial. The classic repair was
described by Mayo.
OPEN
Large defects
Meshplasty
LAPROSCOPIC
INTRAPERITONEAL ONLAY REPAIR
Approximation of the musculofascial layers
should be done with minimal tension and
prosthetic mesh should be used to reduce
the risk of recurrence.
76. UMBLICAL HERNIA
• CONSERVATIVE MANAGEMENT (2-3 YEARS)
• IF PERSIST PROCEED WITH SURGICAL REPAIR
PARAUMBLICAL HERNIA
• DEFECT USUALLY SUPERIOR AND RIGHT SIDE
• SEEN IN OBESE FEMALE PT’S.
• SURGERY AS SOON AS POSSIBLE
77. LUMBER HERNIA
• Management can be by open or laproscopic surgery
• The Dowd-Ponka technique involves making an incision
over the hernia site, reducing the sac, and placement of
a prosthetic mesh which is sutured to the external
oblique, latissimus dorsi, and the lumbar periosteum.
SPLEGIAN AND OBTURATOR HERNIA
• OPEN
• LAPROSCOPIC (USUALLY TAPP IN OBTURATOR
HERNIA)
78. COMPLICATIONS OF SURGERY
• Reduction of hernia content is essential for a
successful repair. extensive dissection can lead to
bowel injury.
• bowel resection with subsequent risks of infection
and bowel anastomotic complications.
• There is risk of fluid formation within the sac
(seroma).
• simple closure of a hernia defect by sutures alone
leads to a high recurrence rate.
• Absorbable mesh has shown higher recurrence
rates.
Hernia Means to bud or to protrude. It is an abnormal protrusion of a viscous or a part of a viscous through an opening, artificial or natural with a sac covering it.
Inguinal Most common hernia 73%, Umbilical , Femoral, Incisional 15%. Groin Hernia is 25 times more common in men than in women Femoral is 10 times more common in females.
Two types: Direct & Indirect Hernia.
Hesselbachs Triangle: Direct hernia occurs through Hesselbach’s triangle which is bounded by inferior epigastric artery laterally, lateral border of rectus medially, inguinal ligament below.
Incomplete:
Bubonocele: Here sac is confined to the inguinal canal.
Funicular: Here sac crosses the superficial inguinal ring,
but does not reach the bottom of the scrotum.
x Complete: Here sac descends to the bottom of the scrotum. Saddle-bag or pantaloon hernial sac has got both medial and lateral component.
Inguinal hernia is above and medial to the pubic tubercle. Femoral hernia is below and lateral to pubic tubercle.
