Hernia is defined as an abnormal protrusion of an organ or tissue through an opening. The inguinal region is a common area for hernias due to weaknesses in the abdominal wall muscles. There are two main types of inguinal hernia: indirect and direct. Indirect hernias are more common in younger patients while direct hernias are more common in elderly patients. Treatment involves herniotomy to remove the hernia sac, with herniorrhaphy or hernioplasty used to repair the abdominal wall defect. Hernioplasty utilizing a mesh is now the preferred treatment approach.
2. DEFINITION
Hernia means—’To bud’ or ‘to protrude’ ‘off
shoot’ (Greek)
‘rupture’ (Latin)
Hernia is defined as an abnormal protrusion of a
viscous or a part of a viscous through an opening,
artificial or natural with a sac, covering it.
4. Inguinal hernia is the commonest hernia (73%)
because the muscular anatomy in the inguinal
region is weak and also due to the presence of
natural weakness like deep ring and cord
structures
Femoral is 17%
Umbilical is 8.5%
Others are 1.5%
6. PARTS OF HERNIA
• Covering
• Sac
• Content
Coverings
of the sac are
the layers of
the abdominal wall through which the sac
passes
7. Sac is a diverticulum of peritoneum with
mouth, neck,body and fundus
Neck is narrow in indirect hernia but wide in
direct hernia
Body of the sac is thin in infants, children
and in indirect sac thick in direct and long
standing hernia
8. Contents of Sac
• Omentum—Omentocele (Epiplocele) initially it can
be reduced easily difficult to reduce the sac later
• Intestine—Enterocele— commonly small bowel, but
sometimes even large bowel difficult to reduce the sac
initially
• Richter’s hernia- A portion of circumference of bowel
is the content
• Cystocele-Urinary bladder may be the content or part
of the posterial wall of the sac
• Ovary, often with fallopian tube
• Meckel’s diverticulum—Littre’s hernia
9. INGUINAL HERNIA
ANATOMY OF INGUINAL CANAL
Boundaries
In front: External oblique aponeurosis
and conjoined muscle laterally
Behind: Inferior epigastric artery,
fascia transversalis and conjoined
tendon medially
Above: Conjoined muscle (Arched
fibres of internal oblique)
Below: Inguinal ligament
DEF:It is an oblique passage in lower part
of
abdominal wall, 4 cm long extending from
deep inguinalring to superficial inguinal ring
Contents of inguinal canal
• Spermatic cord in males
• Round ligament in females
• Ilio-inguinal nerve
10. Superficial inguinal ring
triangular opening in the external oblique
aponeurosis and is 1.25 cm above the pubic
tubercle
bounded by a superomedial and inferolateral
crus
Deep inguinal ring
U-shaped condensation of the transversalis
fascia, lies 1.25 cm above the inguinal
ligament midway between the symphysis
pubis and the anterior superior iliac spine
12. Contents of spermatic
cord
• Vas deferens
• Artery to vas
• Testicular and cremasteric
artery
• Genital branch of
genitofemoral nerve
• Pampiniform plexus of veins
• Sympathetic plexus around
the artery to vas
• Remains of processus
vaginalis
Coverings of
Spermatic Cord
• Internal spermatic
fascia from fascia
transversalis
• Cremasteric fascia
• External spermatic
fascia from external
oblique aponeurosis
13.
14.
15. Defence mechanism of inguinal
canal
• Obliquity of inguinal canal(flap valve
mechanism)
• Arching of conjoint tendon
• ‘Shutter mechanism’ of internal oblique
• ‘Ball valve mechanism’ due to contraction of
cremaster muscle which plugs to superficial
ring
• When external oblique muscle contracts
intercrural fibres of superficial ring appose
causing ‘slit valve mechanism’
• Hormones
16. CLASSIFICATION OF INGUINAL
HERNIA
1)Anatomical classification
Indirect hernia:
It comes out through internal ring along with the
cord
lateral to the inferior epigastric artery
Direct hernia:
It occurs through the posterior wall of the
inguinal canal through ‘Hesselbach’s triangle
medial to the inferior epigastric artery
17.
18. Gilbert classification
Type I: Hernia has got snug internal ring through which
peritoneal sac passes out as indirect hernia
Type II: Hernia has a moderately enlarged internal ring which
admits one finger but lesser than two finger breadth
Type III: Hernia has got large internal ring with defect more
than two finger breadth Hernia descends into the scrotum or with
sliding hernia
Type IV: It is direct hernia with large full blow out of the
posterior wall of the inguinal canal internal ring is intact
Type V: It is a direct hernia protruding out through punched out
hole/defect in the transversalis fascia internal ring is intact
Type VI: Pantaloon/double hernia
Type VII: Femoral hernia
Type VI and VII are Robbin’s modifications
19. NYHUS classification
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 hernia
c. Femoral hernia
Type IV: Recurrent hernia
20. INDIRECT (OBLIQUE) INGUINAL
HERNIA
This is the most common type of hernia (65%)
It is more common in younger age group as
compared to direct inguinal hernia which is
more common in elderly
21. Coverings of indirect
hernia(from inside out)
• Extraperitoneal tissue
• Internal spermatic fascia
• Cremasteric fascia
• External spermatic fascia
• Skin
22. TYPES OF INDIRECT HERNIA
Bubonocele: Where the hernia
is limited to inguinal canal
Funicular:hernia present at the root of
the scrotum
Processus vaginalis is closed just above the
epididymis. Contents of the sac can be felt
separately from testis, which lies below the
hernia
Complete (Scrotal): hernia present in the
bottom of the scrotum
Testis appears to lie within the lower part of
hernia
23. DIRECT HERNIA
• 35% of inguinal hernias are direct.
• It is uncommon in females.
• It is always acquired, due to weakening of
posterior
wall of inguinal canal.
• Hernia is medial to the inferior epigastric artery
24. Coverings of direct hernia (from
inside out)
• Extraperitoneal tissue
• Fascia transversalis
• Conjoined tendon
• External spermatic fascia
• Skin
25. CLINICAL EXAMINATION
Indirect hernia is most common in males and
and direct is uncommon in females
Direct hernia is reducible on lying down
Indirect is irreducible
Shape : pyriform in indirect
spherical in direct
retort in femoral
26. If swelling is soft and elastic : enterocele
firm and granular: omentocele
Cough impulse: a characteristic feature of hernia
can be felt on palpation seen as bulging in
inspection
Get above the swelling: complete scrotal
swelling its positive
Inguinoscrotal swelling will not be able to get
above the swelling
27. Internal ring occlusion test
Internal ring is located half inch above the mid-inguinal
point (center point between anterior superior iliac
spine and pubic symphysis) After reducing the
contents, in lying down
position, internal ring is occluded using the thumb
Patient is asked to cough
If a swelling appears
medial to the thumb, then it is a direct hernia
If swelling does not appear and on releasing the
thumb
swelling appears during coughing, then it is an indirect
hernia
28.
29. Ring invagination test
After reduction of hernia, the little finger/index
finger of the examiner is used to invaginate
from the bottom of the scrotum, gradually
pushed up and rotated to enter the superficial
inguinal ring impulse on coughing if impulse is
felt at the
tip of the invaginated finger:indirect
Pulp of the inaginated finger : direct
This test is done only in males
30. Zieman’s test
The examiner places his index finger on the deep
inguinal ring and middle finger on the
superficial inguinal ring, ring finger over saphenous
Opening, patient is asked to cough or to hold the
nose and blow If the impulse is felt on the
index finger it is indirect hernia,
middle finger its direct hernia,
Ring finger femoral hernia
31. Head or leg rising test
done to look for abdominal wall muscle tone and
Malgaigne bulgings
Malgaigne bulgings are It is protrusion of
abdominal wall muscles during leg rising test as
weak, soft, supple, swelling, which signifies
poor abdominal muscle tone
32. Indirect inguinal hernia
Can occur in any age from childhood
to adult
Occurs in a pre-existing sac
Protrusion through the deep ring
Pyriform/oval in shape;
descends obliquely and downwards
Can become complete by descending
down into scrotum
Neck of the sac is narrow
and lateral to inferior epigastric artery
Sac is antero-lateral to the cord
Ring occlusion test does not
show any impulse after occluding the ring
ring Invagination test shows impulse
on the tip of the of the little finger
Zieman’s test shows impulse on the
index finger
Commonly unilateral but can be
bilateral
Obstruction/strangulation are common
Sac should be opened during surgery
Direct inguinal hernia
Common in elderly
Always acquired
Protusion occurs through posterior wall
Globular/round in shape
descends directly forwardwards bulge
Descent down into the scrotum is rare
Neck of sac is wide and medial to inferior
epigastric artery
Sac is posterior to the cord
Test shows impulse even after occluding the
deep ring
Impulse is felt over the pulp
little finger
Test shows impulse on the
middle finger
Commonly bilateral
Rare but can occur
Sac is not necessarily opened unless
obstruction
is present
33. Differential diagnosis
• Hydrocele – infantile/encysted/large vaginal/
bilocular
• Undescended testis
• Femoral hernia
• Lipoma of the cord
• Hydrocele of the canal of nuck (in females)
• Inguinal lymph node enlargement
• Groin abscess
35. Treatment
Treat the precipitating cause first
Surgeries are the treatment of choice
In children always HERNIOTOMY is done
In adults HERNIOTOMY
HERNIOPLASTY
HERNIORAPHY
36. Herniotomy
excision of hernial sac
Anaesthesia: Spinal or G/A
Procedure: After cleaning and draping, skin is
incised 1.25 cm above and parallel to the
medial two/third of inguinal ligament
Two layers of superficial fascia (outerCamper’s
fascia and inner Scarpa’s fascia) are incised
37. External oblique aponeurosis is incised
Upper leaf is reflected above and lower leaf is reflected
downwards to visualise and expose the inguinal ligament
Ilioinguinal nerve is safeguarded
Cremasteric muscle is opened Cord structures are
dissected
Sac which is anterior and lateral to cord is identified and
is pearly white in colour
Dissection is usually started from the fundus and
extended towards the neck which is identified by
extraperitoneal fat
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
39. Modified Bassini’s
Herniorrhaphy
It is strengthening of the posterior wall of the
inguinal canal by approximation of the conjoint
tendon to inguinal ligament using
INTERUPPTED monofilament nonabsorbable
suture material
External oblique is closed and other layers are
also closed
Commonly used suture material is either
polypropylene [prolene (blue in colour)] or
polyethylene [ethylon (black in colour)].
40.
41. Shouldice Repair
multilayered repair
After doing herniotomy ,transversalis fascia is
incised from deep ring to pubic tubercle
Lower flap of fascia is sutured to posterior
part of the upper flap
Upper flap is sutured to the inguinal ligament
It is called DOUBLE BREASTING of
transversalis fascia
42. Then conjoint tendon and inguinal
ligament is further approximated by two layers of
continuous sutures. External oblique aponeurosis
is
sutured in two layers (double-breasting) in front of
the
cord. Hence the original Shouldice repair is 6
layered
procedure. First two layers of transversalis fascia,
next
two layers of conjoint tendon and last two layers
43. Complications of herniorrhaphy
• Haemorrhage
• Haematoma
• Infection–1-5%
• Haematocele
• Post-herniorrhaphy hydrocele, lymphocele
• Hyperaesthesia over the medial side of inguinal
canal due to injury to ilioinguinal nerve -
neuralgia
• Recurrence
• Osteitis pubis
• Injury to urinary bladder/bowel
• Testicular atrophy, penile oedema rarely can occur
44. 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
45. Hernioplasty
It is strengthening of posterior inguinal wall in
case of
indirect hernia or in any large hernia with weak
abdominal wall using a supportive material. This
allows
and supports good fibroblast proliferation which
in turn
strengthens the weak posterior wall of inguinal
canal or
abdominal wall
46. Hernioplasty is the present choice (ideal) for all
inguinal and groin hernias
Mesh is placed either
onlay (over conjoint tendon to inguinal ligament)
or
inlay (in preperitoneal space)
Polypropylene mesh is used
Herniotomy is done prior to mesh placement
Lichtenstein, Rives, Gilbert, Stoppa,TEP,
TAPP
47. Material Used
• Synthetic: Prolene mesh (white in colour)
Dacron
mesh, Morlex mesh, Mersilene sheath
• Biological: Tensor fascia lata, temporal fascia
and
skin. (presently biological materials are not well
accepted as infection is common and its efficacy
is
not proved
48. Indications
• Direct hernia.
• Recurrent hernia.
• Re-recurrent hernia.
• Incisional hernia.
• Old age.
• Hernia with weak abdominal muscle tone.
• Sliding hernia.
Complications
• Infection.
• Mesh extrusion.
• Foreign body reaction
49. Types of mesh repair
1. In lay mesh
2. On lay mesh
3. Nyhus preperitoneal mesh repair
4. Stoppa procedure
5. Gilbert mesh repair
6. Lichtenstein’s method
7. TAPP
8. TEP
50. Onlay mesh repair by placing mesh in front. It
is
sutured above to conjoint tendon and below to
inguinal ligament using monofilament non
absorbable
suture material.
Inlay mesh repair by placing mesh deep to
conjoint
tendon
51. LICHENSTIEN METHOD
Tension free , simple , flat polypropylene mesh
repair
After HERNIOTOMY
a piece of mesh of 8*15cm is placed over
posterior wall and split to wrap the spermatic
cord at deep inguinal ring
interrupted sutures are made between mesh,
inguinal ligament and conjoint tendon
52.
53. Transabdominal Pre Peritoneal
Mesh Repair (TAPP)
Done using Laparoscope
This is used in large indirect hernia or irreducible inguinal hernia
10 mm umbilical port is used for Laparoscope
5 mm ports are placed one on each side on pararectal point at
the or above the level of umbilicus so as to achieve adequate
triangulation
Contents of the hernia are reduced
Hernial sac is dissected in preperitoneal plane after making
horizontal incision at the upper part of the sac opening
Vas, gonadal vessels,pubic bone, inferior epigastric vessels are
identified
Once sac is dissected and excised, a prolene/vipro/ultrapro
mesh of 15 × 10 cm sized or smaller is placed in preperitoneal
space
It is fixed to pubic bone using tacks
Peritoneum is closed with continuous prolene sutures
54. Totally Extra Peritoneal Repair
TEP Repair
Done using Laparoscope
This technique is gaining more popularity than TAPP
Through sub-umbilical incision (10 mm) extra peritoneal space is reached
After CO2 insufflation, another 5 mm port is inserted 4 cm below the first port
in the midline
Third 5 mm port is inserted in the same line 4 cm below or in the right iliac
fossa.
Dissection is carried out downwards carefully, then medially up to the pubic
tubercle, iliopectineal ligament, laterally to iliac vessels, and inferior epigastric
vessels
15 × 15 cm mesh is placed and spread
Care should be taken not to have any folding in the mesh
Mesh may be sutured to iliopectineal ligament
Displacementof mesh is not common
Other side also can be done together
55.
56. Ports used for
TEP and for TAPP
TEP after dissection prior to placement of
mesh.
Direct defect, inferior epigastric artery,
pubic symphysis and
Cooper’s ligament
57. Conservative treatment
:
1. Taxis: Patient is placed in supine position with
hip and knee flexed and hip internally rotated.
Contents are pushed with one hand directing with
other hand
2. Use of Truss: Rat-tailed sprung truss is used.
Measurement is taken from the tip of greater
trochanter to third piece of sacrum circumferentially
– Complications are discomfort, ulceration,
strangulation, inflammation
– It may be used in elderly people, who are not
fit for anaesthesia and surgery
– Conservative treatment should be avoided in
hernia as much as possible
– Truss is absolutely contraindicated in femoral
and sliding hernia
59. •Irreducible hernia: Here contents cannot be returned
to the abdomen due to narrow neck, adhesions,
overcrowding
Irreducibility predisposes to strangulation
•Obstructed hernia: It is an irreducible hernia with
obstruction, but blood supply to the bowel is not interfered
It eventually leads to strangulation.
Garrey’s stricture: Constriction that occurs due to
ischaemic narrowing of small bowel which has reduced
from an obstructed hernia
Inflamed hernia: It is due to inflammation of thecontents of
the sac e.g. appendicitis, salpingitis. Here hernia is tender
but not tense; overlying skin is red and oedematous.
60. STRANGULATED HERNIA
.
It occurs when blood supply of the contents of hernia is
seriously impaired leading to formation of gangrene
Strangulation commonly occurs in the small bowel
and also in large bowel
Occasionally strangulated omentocele also can occur
without any intestinal obstruction
Strangulation can occur in inguinal, femoral,
obturator, umbilical or any hernias.
Indirect inguinal hernia is more prone for
strangulation
than direct inguinal hernia. It is due to
narrow neck, adhesions, narrow external ring in
children
61. 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 occurs.
62. TREATMENT
The patient is admitted.
• Ryle’s tube aspiration.
• Intravenous fluids to correct dehydration and
electrolyte imbalance.
• Antibiotics.
• Catheterisation to maintain adequate urine
output.
• Emergency HERNIOTOMY
63. 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
66. FEMORAL HERNIA
Surgical Anatomy of Femoral Canal
It is the medial, most compartment of the femoral sheath, which
extends from femoral ring above to saphenous opening below
It contains fat, lymphatics, lymph node of Cloquet
It is 1.25 cm long and 1.25 cm wide at the base.
Below it is closed by cribriform fascia.
Femoral ring is bounded
anteriorly by inguinal Ligament
posteriorly by ilio pectineal ligament of Cooper,
pubic bone and fascia covering the pectineus muscle;
medially by concave, sharp lacunar (Gimbernat’s) Ligament
laterally by a thin septum separating from
femoral vein
67.
68. Clinical Features
• Common in females (2:1 ratio), common in multipara
• Rare before puberty. 20% occurs bilateral, however more common on
right side
• Presents as a swelling in the groin below and lateral
to the pubic tubercle. (Inguinal hernia is above and
medial to the pubic tubercle)
• Swelling, impulse on coughing, reducibility, gurgling
sound during reduction, dragging pain, are the usual
features
• When obstruction and strangulation occurs which is more common,
presents with features of intestinal obstruction—painful, tender,
inflamed, irreducible swelling without any impulse
They also present with abdominal distension, vomiting and features of
toxicity.
69. Femoral hernia repair
Lockwood low operation
Mc’Evedy-High operation
Lotheissen’s operation
AK Henry’s approach
Inguinal ligament is
approximated to Cooper’s
[Iliopectineal line] ligament
Lotheissen’s repair conjoined
tendon is sutured to ilio
pectineal line.
70. PANTALOON HERNIA (DOUBLE
HERNIA,
SADDLE HERNIA, ROMBERG
HERNIA)
Here both direct and indirect inguinal sacs are
present and clinically present as direct hernia.
• During surgery, indirect sac may be missed and
so
leads to recurrent hernia through indirect sac
71. SLIDING HERNIA (HERNIA-EN-
GLISSADE
• Here posterior wall of the sac is not only formed by
the parietal peritoneum, but also by sigmoid colon
on
left side; caecum on right side and often with portion
of the bladder (Both sides)
• Content of the sac is usually small bowel or
omentum.
• Sliding hernia occurs exclusively in males. Mainly
on the
left side, if it occurs on right side appendix and
caecum will be present on the posterior wall
72. Large globular swelling will be present over
the inguinal region
Treatment is always surgery
Posterior wall of Sac should not be seperated
from the colon and other structures
73. VENTRAL HERNIA
Any protrusion through abdominal wall with the
exception of hernia through the inguinofemoral
region is defined as ventral hernia
Incisional hernia (80%) and primary defects in
abdominal fascia causing
umbilical hernia, epigastric hernia, paraumbilical
hernia or Spigelian hernia are grouped under
ventral
hernia.
74. Umbilical hernia
Develops due to absence of umbilical fascia or
incomplete closure of umbilical defect
It can be congenital or acquired
Acquired through weak umbilical scar
Congenital will be presented few months after birth
which presents as a swelling in the umbilical region
which increase during crying
TREATMENT
Initially conservative
INDICATIONS FOR SURGERY
Persists after two years of age
>2 cm size
acquired
75. PARAUMBILICAL HERNIA
(Supra- and Infraumbilical
Hernia
It occurs commonly in adults. It is a protrusion or
herniation through linea alba, just above or below
the umbilicus
It enlarges ovally, often attains a large size and
sags
downwards.
• Neck of the sac is relatively narrow. Contents are
usually omentum, small bowel, sometimes large
bowel.
• It has got tendency to go for adhesion, irreducibility
and obstruction
76. It presents as a swelling in with smooth
surface, distinct edges and impulse on cough
Surgery is the treatment of choice
Common for umbilical and para umbilical
Dissection of sac with mesh placement
Mayo’s operation: sac is identified & reduced
sac is transfixed, rectus sheath is double
breasted
77. Incisional hernia
It is herniation through a weak abdominal scar of previous
surgery
Predisposing Factors
• Vertical scar, midline scar, lower abdominal scar— may injure
the nerves of the abdominal muscles
• Scar of major surgeries (biliary, pancreatic)
• Scar of emergency surgeries (peritonitis, acute abdomen)
• Faulty technique of closure
• Poor nutritional status of the patient
• Presence of
cough,tuberculosis,jaundice,anaemia,hypoproteinaemia
• Malignancy, immunosuppression
• Smoking in postoperative period
• Causes which increases the intra-abdominal pressure
(BPH, straining, stricture urethra or rectum, ascites)
78. Clinical Features
• Swelling in the scar region
• Pain
• Impulse on coughing
• Gurgling sound
• Often bowel peristalsis may be visible under
the skin
• Eventually features of irreducibility, obstruction,
strangulation is seen
79. TREATMENT
Surgeries for incisional hernia
• Mesh repair—commonly done and ideal
Done either sublay or onlay method or combined
Rive’s Stoppa’s method of placing mesh
between
posterior rectus sheath and rectus muscle
Laproscopically can also be placed
• Layer by layer closure—Cattell’s operation
• Double breasting of the rectus sheath
80. • Keel operation—not commonly used now
Sac in inverted using continuous/interrupted
inverting non-absorbable sutures, layer by layer until
the defect margins are apposed together which is then
again sutured with interrupted sutures
• Nuttall’s operation—not commonly used now
done for lower midline incisional Hernia
Recti attachments are detached from
the pubic bones and are crossed over to fix
to opposite
pubic bones so as to create a firm abdominal
wall support by crossed recti muscles
81. Spigelian hernia
It is a type of interparietal hernia(between external
oblique and internal oblique)
Hernial sac lies either deep to the internal oblique or between
external and internal oblique muscles
Clinical Features
• Presents as a soft, reducible mass lateral
to the rectusmuscle and below the umbilicus
impulse on Coughing
Strangulation is common
Treatment
• lengthy transverse incision herniotomy
and closure of the defect layer by layer using
Nonabsorbable interrupted sutures
• mesh is required to cover the defect
properly
82. Obturator hernia
It is hernia occurring through obturator canal between superior ramus of
pubis and obturator membrane
Presents with features of intestinal obstruction
Howship-Romberg sign
Referred pain in knee joint through geniculate branch of obturator nerve
Treatment
• Laparotomy is done and the sac
is identified dissected and ligated
If strangulation is present
resection and anastomosis is done
• Mesh placement is the ideal way
of repairing obturator defect
83. Epigastric hernia(Fatty hernia of
linea alba)
It occurs usually through a defect in the decussation
of the fibres of linea alba, any where between xiphoid
process and umbilicus.
• Extraperitoneal fat protrudes through the defect as
fatty hernia of the linea alba presenting like a swelling
in the upper midline with an impulse on coughing.
• It is sacless hernia
Swiss cheese type : hernias are multiple
84. Clinical Features
• Often symptomless
• Swelling in the epigastric region which is tender.
• Pain in epigastric region
TREATMENT
Through a vertical incision, sac is dissected
Defectis closed with non-absorbable interrupted
sutures
• Large defect is supported with preperitoneal
85. RICHTER’S HERNIA
It is a hernia in which the sac contains only a portion
of the circumference of the intestine (small bowel). It
is
usually seen in femoral and obturator hernia.
Clinical Features
• It mimics gastroenteritis with pain abdomen,
diarrhoea,
toxicity, vomiting
• Gangrene (strangulation) of a part of bowel occurs,
eventually leading to peritonitis
Treatment
Resection and anastomosis
86. LUMBAR HERNIA
• It is herniation either through superior or inferior
lumbar triangle
• Superior lumbar triangle (Grynfelt’s/Lesgaft’s triangle)
is bounded by sacrospinalis, 12th rib and posterior
border of internal oblique
• Inferior lumbar triangle is bounded by latissimus
dorsi, external oblique and iliac crest (triangle of Petit)
• Lumbar hernia is common through inferior lumbar
Triangle
Treatment
Repair using fascial flaps or mesh
87. SCIATIC HERNIA
• It is the protrusion of the peritoneal sac through the
greater or lesser sciatic foramen
Types
Classified based on their relationship to the pyriformis
muscle and ischial spine
1. Suprapyriformis
2. Infrapyriformis
3. Subpyriformis
Sac lies deep to gluteus maximus
Treatment
Defect is covered by fascia mobilised from pyriformis
muscle after reducing the sac contents
88. PHANTOM HERNIA
• It is a muscular bulge as a result of local
muscular paralysis due to interference with
nerve supply of the affected muscles, like
poliomyelitis in lumbar region