Hernia is one of the commonest surgical disorder due to weakness in the anatomical structures of the region.Understanding the anatomical aspects is therefore pivitol in successfull treatment of this potentially dangerous condition. The presentation provides a road map for understanding and treating hernias.

1. HERNIA
by
Dr. Ketan Vagholkar.
MS, DNB, MRCS, FACS
Professor of Surgery
&
Consultant Surgeon

2. Surgical Anatomy Of Anterior
Abdominal Wall
n Fascias
n Rectus Sheath
n Abdominal Muscles
n Inguinal Canal

3. Inguinal Canal
n Boundaries & Contents n External ring is a triangular
n Anteriorly-External oblique aperture in the aponeurosis
aponeurosis &internal oblique of the external oblique.It is
laterally 1.25 cms above the pubic
n Posteriorly-Transversalis fascia tubercle.
and conjoined tendon
n Superiorly-Conjoined tendon n Deep ring is a U shaped
n Inferiorly-Inguinal ligament opening in the transversalis
n Contents
fascia.It lies 1.25 cms above
n In males-spermatic cord and the mid inguinal point.
Ilioinguinl nerne.
n In Females-round ligament
and Ilioinguinal nerve

4. Natural Mechanisms Preventing
Hernia
n Obliquity of the canal
n Internal oblique muscle opposite the deep ring
n Shutter action of the arched fibres of internal
oblique and transversus abdominis
n Plugging action of the spermatic cord due to
contraction of the cremaster muscle
n Sliding valve action of the U shaped internal ring

5. Definition of Hernia
n Hernia is defined as an
abnormal protrusion of
viscus or part of viscus
through a normal or
abnormal opening in the wall
of the cavity containing it.
n Classification depending on
the anatomical site of the
hernia. (Inguinal, femoral,
epigastric etc.)
n Incidence: Inguinal-
73%,Femoral-
17%&Umbilical-8.5%)

6. Pathology
n Composition n Contents
n Sac- Diverticulum of n Intestine-enterocele
peritoneum and consists n Omentum-omentocele or
of mouth, neck, body and epiplocele
fundus. The diameter of n Meckel’s diverticulum-
the neck determines the Littre’s hernia
outcome.
n Circumference of bowel-
n Coverings well Richter’s hernia
amalgamated hence
indistinguishable. n W loop of intestine-
Maydl’s hernia

7. Natural history
n Reducible
n Irreducible
n Obstructed
n Strangulated
n Inflammed

8. Clinical features of inguinal hernias

9. Direct inguinal hernia

10. Morbid Anatomy

11. Clinical Features

12. Clinical Features

13. Clinical Evaluation
n History
n Chief complaints (odp)
n Complications
n Etiology
n Treatment taken
n Inference from history

14. Clinical Evaluation
n Physical examination.
n Inspection-site,impulse
n Palpation-
n Getting above
n Impulse on coughing
n Reducibility-Taxis
n Deep ring occlusion test
n Invagination test
n Tone-Inspection/palpation
n Other systems

15. Clinical Diagnosis
n Site, side, complicated or not, direct or indirect
inguinal hernia
n Status of tone
n Possible etiological factor

16. Investigations
n Haematological
n CBC
n Blood sugar (fasting &
postprandial)
n BUN, creatinine, Electrolytes
n Urine examination
n Ultrasound of Abd.
n ECG
n CXR

17. Principles of repair
n Herniotomy for an indirect sac
n Identify
n Dissect
n Open
n Reduce the contents
n Transect
n Twist, tansfix, ligate & excise the redundant portion
n Slit open the distal sac

18. Principles of repair
n Herniotomy for direct sac
n Identify
n Dissect around the neck
n Purse string suture
n Invert the sac and tighten the purse string
n Direct sac never to be opened

19. Principles of repair
n Special cases
n Pantaloon hernia
n Sliding hernia
n Strangulated hernia

20. Principles of repair
n Herniorrhaphy
n Selection of patients
n Principles (anatomic considerations)
n Types
n Bassini’s
n Shouldice
n Lichtenstein Repair(T abd to Ing Lig with relaxing
incision& Ext obl behind the cord)
n Other types (Ogilvie’s, Lyttle’s ,skeletonization of cord
etc.)

21. Principles of repair
n Hernioplasty (Open approach)
n Patient selection
n Types
n Mesh plasty
n Darning
n Material used
n Endogenous
n Exogenous
n Requirements of a mesh

22. Requirements of a mesh

23. Mechanism of action

24. Meshplasty
nLaparoscopic Approach
TAPP
TEPP

25. Surgical Aftercare
n Avoid straining
n Avoid heavy work
n Bowel function
n Urinary system
n Care to be taken for at least 3 months after
surgery

26. Complications
n Intraoperative
n Post operative
n Infection
n Neurological complications
n Recurrence
n Types
n True
n False