Hernia

Hernias - Panel Discussion
Department of General Surgery - Sree Balaji Medical College & Hospital, Chrompet, TN, India

1. Panel Discussion on Hernia
Unit 2 – Prof.P.K.BASKARAN
Prof.Varadarajan
MODERATOR
Dr.B.Krishna Mohan
ASST.PROF
Dept of General Surgery
SBMCH

2. Define HERNIA?

3. •Definition:
Hernia is defined as protrusion of a viscous in
part or in whole through a normal or
abnormal opening in relation to the wall of
the cavity containing it

4. Historical development of hernia
repair ?

5. •Egyptians (1500 BC), Phoenicians (900 BC) and
Ancient Greeks (400 BC) all describe the diagnosis of
hernia and various methods of treatment.
• The word hernia is derived from the Greek word
hernios, a bud or shoot.
•For hundreds of years various surgical and non-
surgical treatments were offered to patients
suffering from chronic pain, obstruction and
strangulation related to their hernias , which were
not proper until mid-1700s

6. •Edoardo Bassini (1844-1924) was an Italian surgeon
who not only described a durable inguinal hernia
repair based on an understanding of inguinal (groin)
anatomy and physiology but he also studied and
followed his patients long-term to learn outcomes.
•The Shouldice clinic in Toronto opened in 1945 and
has been practicing a technique that bears the same
name. Similar in nature to the repair initially
described by Bassini, the Shouldice clinic reports a
1% recurrence rate with very close follow up.

7. •In 1900s various forms of woven soft metal grafts
were used and found to be unsatisfactory.
•Starting in the 1940s various forms of synthetic
polymers were used in inguinal hernia repair. By the
1960s, Dr Richard Newman had performed over
1600 inguinal hernia repairs using polypropylene. In
1987 Dr Irving Lichtenstein published the results of
6,321 patients followed for 2-14 years after inguinal
hernias repair with Marlex (polypropylene) mesh.
Lichtenstein reported a recurrence rate of 0.7 %. The
technique bearing his name called for a “tensionless”
repair and over time this has become a pillar of
hernia surgery.

8. •The first laparoscopic inguinal hernia surgery was
described in 1979 but it wasn’t until 1989 that a
prosthetic mesh was used during laparoscopic hernia
repair. Over the next decade various laparoscopic
techniques were developed. Two techniques, TAPP
and TEP, have become the most common techniques
used today.

9. List out the different
types/classification of hernia?

10. •Anterior
•Posterior
•Pelvic and special types
•Inguinal
•Femoral
•Epigastric
•Para umbilical
•Umbilical
•Obturator
•Superior lumbar
•Inferior lumbar
•Gluteal
•Sciatic
•Incisional
•Special types- internal hernia, diaphragmatic hernia, hiatus hernia and
uncal herniation of brain

11. Most common hernia encountered
in surgical practice?

12. Frequency of types of hernias:
•Inguinal – 75%
•Umblical and Para-umblical– 15%
•Femoral – 8.5%
•Rarer forms – 1.5 %

13. INGUINAL HERNIA

14. Anatomy of inguinal canal?

15. Anatomy
•Inguinal canal is an intermuscular slit situated
between the deep and superficial inguinal
rings .
•It forms medial 1/3
rd
of the inguinal ligament

17. Boundaries of inguinal canal:
•Roof – conjoint tendon
•Anterior and floor – external oblique
aponeurosis
•Posterior – transversalis fascia
Contents of inguinal canal:
•Male- cord structures
•Female – round ligament
•Ilio-inguinal nerve

18. What do you mean by cord
structures?

19. •Vas deferens
•Pampniform plexus of veins
•Artery of vas
•Testicular artery
•Genital branch of genito-femoral nerve

20. Parts of inguinal hernia?

21. •The hernia is got a sac, coverings and content
•The sac has got a neck ,body and fundus
•The coverings differ based on the type of hernia
•Contents can be varied, i.e,omentum, intestine
,meckel’s diverticulum ,appendix ,urinary bladder
,etc., depending on the type and site

22. TWO Nerves encountered in
inguinal hernia repair?

23. •ILIO-INGUINAL (T12-L1)
•ILIO-HYPOGASTRIC(T12-L1)
•GENITO-FEMORAL NERVE(L1,2,3)

24. Identify the true statements ?
•Internal ring is a U-shaped condensation of fascia tranversalis
•External inguinal ring is formed by two crurae of external
oblique aponeurosis
•Strongest posterior layer is the transversalis fascia
•Conjoined tendon is the fusion of fibers from internal oblique
aponeurosis and aponeurosis of tranversus abdominis
•Inguinal hernia is the most common hernia in females

25. Boundaries of Hesselbech’s
triangle ?

26. •It is defined by the following structures:
•Medial border: Lateral margin of the rectus
sheath, also called linea semilunaris
•Superolateral border: Inferior epigastric
vessels
•Inferior border: Inguinal ligament

27. Surgical importance of
Hesselbach’s triangle?

28. •It is the site of occurrence of the direct
inguinal sac, medial to the inferior epigastric
artery

30. What is myopectineal orifice of
Fruchard?

31. •1956, Henry Fruchaud proposed the theory that all groin (inguinofemoral)
hernia 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’.
•Superiorly Internal oblique and transverses abdominis
muscles.
•Inferiorly Superior pubic ramus.
•Medially Rectus muscle sheath.
•Laterally Iliopsoas muscle.
•Weakness through this area leads to inguinofemoral hernia. Proper
exposure of the area is essential during a preperitoneal (posterior) repair!
•The orifice is divided through the Iliopubic tract and the inguinal ligament
into an ‘inguinal’ defect and a ‘femoral defect’.

33. What is the space of Bogros?

34. •It is the pre-peritoneal space just beneath the
posterior lamina of the transversalis fascia
•It is the lateral extension of the retro-pubic
space of Retzius
•This space is utilised in laparoscopic hernial
repair

35. triangle of doom ?

36. •Triangle of doom – it is defined by vas
deferens medially, spermatic vessels laterally
and external iliac inferiorly

37. Triangle of pain ?

38. •Triangle of pain – it is defined by spermatic
vessels medially, ilio-pubic tract laterally and
inferiorly by the inferior edge of incision

39. circle of death ?

40. •Corona mortis or circle of death is the vascular
ring formed by aberrant with the normal
obturator artery.

42. Anatomical safety mechanisms to
prevent inguinal hernia?

45. Inguinal Hernia etiology and
causative factors?

46. •Congenital
•Acquired
i.Increased intra-abdominal pressure
ii.Smokers
iii.Intra-abdominal malignancy
iv.Obesity
v.Multiparity
vi.TA/TF deficiency

47. •Hereditary
•Collagen vascular and connective tissue
disorders
•The evolutionary factors are:
i.The absence of posterior rectus sheath below
arcuate line
ii.Adoption of upright position
iii.Change from quadripedal to bipedal
locomotion

48. Metastatic emphysema of READ?

49. •It is Acquired herniation as an end result of a
collagen deficiency
•It is a mis-nomer

50. Richter’s hernia?

51. •RICHTER’S HERNIA is when a part of the
circumference of the bowel forms the content
of the hernial sac

52. Maydl’s hernia?

53. •This is otherwise called W loop hernia where
the small intestine forms a W loop within the
hernial sac.

54. Littre’s hernia?

55. •Here the content is meckel’s
diverticulum

56. Amyand’s hernia

57. •Here the
appendix forms
the content of
the inguinal
hernia
•It is also called
as little’s hernia

58. Sliding hernia?

59. Here a part of the
bowel or the urinary
bladder slides behind
the hernial sac to
form the posterior
wall.

60. What is Ogilvie’s Hernia ?

61. •It is funicular direct inguinal hernia / pre-
vesical hernia
•It is a narrow necked hernia with pre-vesical
fat and sometimes portion of the bladder

62. Pantaloon hernia and its surgical
significance ?

63. •This is a type of hernia where sacs straddle
the inferior epigastric artery on either side,
one being medial and other lateral.

64. Nyhus classification?

65. •Nyhus classification
Type1: indirect hernia in which the internal
ring is of normal size . The area of
hesselbach’s triangle remains normal
Type2:indirect hernia in which the internal
ring is attenuated but does not impinge on
then floor of the canal. The hesselbach’s
triangle is pathophysiologically intact

66. Type 3:
Type 3A: Direct inguinal hernia
Type 3B: Indirect inguinal hernia with a large
dilated ring that has expanded medially and
encroaches on the inguinal floor
Type 3c: femoral hernia
Type 4: recurrent hernia
Recurrent direct -4A
Recurrent indirect -4B
Recurrent Femoral-4C
Combination- 4D

67. Gilberts classification?

68. Rutkow and Robbins modification of
Gilberts classification
•Type 1: Tight internal ring
•Type 2: Moderately enlarged internal ring
•Type 3: Patulous internal ring with
sliding/scrotal component impinging on direct
space
•Type 4 : Entire floor of the canal is defective
•Type 5: direct hernia
•Type 6: Both direct and indirect
•Type 7: Femoral hernia

69. BENDAVID CLASSIFICATION(TSD)?

70. BENDAVID CLASSIFICATION(TSD):
TYPE:
TYPE I – ANTEROLATERAL (INDIRECT)
TYPE II – ANTEROMEDIAL (DIRECT)
TYPE III – POSTEROMEDIAL (FEMORAL)
TYPE IV – POSTEROLATERAL (PREVASCULAR)
TYPE V – ANTEROPOSTERIOR (INGUINOFEMORAL)
STAGE :
I – FROM DR TO SR
II – BEYOND SR
III – REACHES INTO SCROTUM
DEFECT SIZE- diameter of hernial defect

71. T1S3D3.5 in inguinal hernia
means?

72. •It means type I – indirect type
•Stage 3- reaches upto the scrotum
•Defect size of 3.5cm

73. Direct and Indirect Inguinal hernia
differences?

74. S.NO DIRECT INDIRECT
1 Extend to scrotum Does not go down to the
scrotum
Can descend into the
scrotum
2 Direction of reductionReduce upwards and the
straight backwards
Reduce upwards, then
laterally and backwards
3 Controlled by pressure on
internal rings after
reduction
Not controlled Controlled
4 Direction of reappearnce
after reduction
The bulge appears
outwards to the original
position
The bulge appears in
the middle of the
inguinal region and
medially
5 Palpable defect yes Not palpable
6 Relationship of cord
structures
Sac appears medial to
the inferior epigastric
artery and is outside the
spermatic cord
The sac is lateral to the
inferior epigastic
artery ,within the cord

75. Diagnosis of inguinal hernia is?
a)Purely clinical
b)Purely on imaging and investigations
c)Both
d)None of the above

76. inguinal hernia Differential
diagnosis ?

77. Differential diagnosis
•Femoral hernia
•Vaginal hydrocoele
•Undescended testis
•Hydrocoele of cord
•Lipoma of cord
•Infantile hydrocoele
•Ectopic testis
•Hydrocoele of canal of nuck
•Psoas bursitis
•Saphaeno- varix
•Lymph nodes
•Femoral aneurysm

78. What is obstructed inguinal
hernia?

79. •Obstructed hernia- this is irreducible hernia
that is obstructed from without or within, but
there is no interference to blood supply

80. Strangulated inguinal hernia?

81. •Strangulated – is when the blood supply of a
obstructed hernia is seriously impaired

82. Incarcerated inguinal hernia ?

83. •Incarcerated hernia – is term only used to
denote when the lumen of the bowel within
the hernial sac is blocked with feces

84. Inflamed inguinal hernia ?

85. • Inflamed hernia – when the contents of the hernia
are inflamed

86. Is it possible to get strangulation
without features of obstruction?

87. •Yes , in case of Richter’s hernia

88. Prerequisites to be taken before
inguinal hernia repair?

89. •Digital rectal examination to rule out prostate
pathology/enlargement
•Usg abdomen and pelvis
•Usg for residual urine and prostate volume to
rule out BPH
•Thoracic physcian opinion and treatment for
chronic cough and COPD
•Treat chronic constipation

90. surgical procedures available for
inguinal hernia?

91. •There is no conservative management for
inguinal hernia
•Surgical procedures available:
Herniotomy
Herniorraphy(tissue repair) and
Hernioplasty (mesh repair)
Laparoscopic repair
•TAPP- transabdominal preperitoneal repair
•TEP- total extraperitoneal repair

92. Herniotomy ?

93. Herniotomy:
In children herniotomy alone is sufficient
because:
•The obliquity of the canal is less
•For all practical purposes the superficial and
deep inguinal rings are almost superimposed
and therefore there is no need for repair
•The posterior wall is strong in children

94. Herniorraphy / tissue repair?

95. Herniorraphy
•They are tissue based repairs
•They are not followed now a days because
they are repair under tension and recurrences
are common
•There are two types:
Shouldice repair
Bassini’s repair
Darn and Mc vay’s repair less used now a days

96. Explain Bassini’s repair?

97. •Bassini’s repair:
Here the posterior wall is strengthened by
approximating the TF and conjoint tendon to
inguinal ligament .

99. Explain Shouldice repair?

100. •Shouldice repair:
The basic principle of shouldice technique ,is a
four layer repair ,is division of TF obliquely
and imbrication of double layer of TF to
inguinal ligament followed by double layer of
conjoint tendon to the inguinal ligament .

102. HERNIOPLASTY?

103. Hernioplasty
•The gold standard current hernia surgery is
the lichenstein tension free hernioplasty.
•A prolene mesh is placed anterior to the
posterior wall after herniotomy and
overlapping it generously in all directions
including medially over the pubic tubercle

105. Hernioplasty better than
herniorraphy ? Why?

106. •Tension-less repair
•Strengthening of posterior wall by prosthetic
mesh
•Less chance of recurrence

107. Advantages of hernial repair under
local anesthesia/Inguinal block ?
A)Per-operative assessment of repair is possible
B)Day-care surgery is feasible
C)Post-operative urinary retention and other spinal related
complications can be avoided
D)It is comparatively tension-less
E)All of the above

108. Most important step in
strangulated inguinal hernia
surgery?

109. •Identifying and opening of sac and letting out
the toxic fluid and proper examination of
content before releasing the constriction ring
•If there is excessive contamination then mesh
should be avoided

110. stoppa’s repair ?

111. •Stoppa’s repair (GPRVS) – It is a giant
prosthetic mesh placed in pre-peritoneal
space , ideal for bilateral cases, but recurrence
rate is high.

112. Prolene hernia system?

113. •Prolene hernia system- is a complex mesh
with a overlay and underlay mesh with a
connecting limb

114. contraindications of laparoscopic
hernia repair?

115. Absolute indications:
•Recurrent hernia
•Bilateral hernia
Absolute contra-indications:
•Strangulated hernia
•Ascites
•Bleeding disorders

116. What is Desarda repair or
technique?

117. •The upper flap of the external oblique aponeurosis is sutured
to the inguinal ligament, behind the spermatic cord. Then the
external oblique is incised again, 1-2 centimeters above the
inguinal ligament, simultaneously creating (1) a new lower
edge to the upper flap, and (2) a "strip," or in my words a
patch, made out of a strip of external oblique that is several
centimeters wide. The upper edge of this "patch" is sutured
to the internal oblique. The difference is, that (1) this is a
patch of living tissue and (2) the strip of external oblique
aponeurosis is still attached normally to external oblique
muscle and contractions of the external oblique muscle have
a dynamic affect on countering intra-abdominal pressure,
rather than merely static effect that the non-living patch used
in a Lichtenstein repair, would have.

118. What is Bassini’s stitch?

119. •The first stitch taken from the periosteum of
the pubic tubercle in strengthening of
posterior wall

120. Complications of hernia surgery ?

121. Complications of hernia surgery
•Hematoma
•Seroma
•Wound infection
•Infection of mesh /mesh migration
•Scrotal edema
•Post-herniorraphy hydrocoele
•Recurrence
•Ischaemic orchitis and testicular atrophy
•Chronic residual neuralgia
•dysejaculation

122. Causes for recurrence after
inguinal hernia surgery?

123. •Failure to treat precipitating factors like BPH,
hemorrhoids, COPD
•No proper lifestyle modification
•Improper surgical technique

124. commonest site of recurrence
after inguinal hernia repair ? Why?

125. •Medial recurrence is the commonest
•This occurs if the mesh is not reaching beyond
the pubic tubercle for 1cm
•Second most commonest site is at the internal
ring

126. Identify the true statements?
A)Ischemic orchitis occurs due to thrombosis or ligation
of pampniform plexus of veins
B)Testicular artery ligation always leads to testicular
atrophy
C)Overzealous skeletonization of cord is one of the
reasons for post-herniorraphy hydrocoele
D)Infection of mesh does not necessarily imply removal of
a mesh unless the mesh is sequestered and bathed in
purulent exudates

127. Inguinodynia after inguinal hernia
repair and what are the causes?

128. •Primary damage to the nerve- stretching,
contusion, crushing and suture or mesh
entrapment
•Secondary damage – cicactrial compression
and suture granuloma

129. What is the treatment ?

130. •Drugs / analgesics
•Nerve block
•Neurectomy
•TENS

131. What is Garrey’s stricture?

132. •Constriction that occurs due to ischaemic
narrowing of small bowel which has reduced
from an obstructed hernia

133. Identify the false statement ?
a) Inverted ink bottle effect is seen in infantile hydrocoele
b) Herniography was a old technique of visualizing hernial sac by
injecting contrast into peritoneal cavity
c) Other name of inguinal ligament is Poupart’s ligament
d) In children both the superficial ring and deep ring are
superimposed without any obliquity
e) Silk glove sign is elicited in childhood inguinal hernias

134. Femoral Hernia

135. Identify the false statements?
A)Femoral hernia is below and lateral to the pubic tubercle
B)The swelling is placed medially than the inguinal hernia
C)Irreducibility is encountered ten times more frequently with
a femoral hernia
D)The visible cough impulse is always present
E)Femoral hernia is more common in females

136. Boundaries of femoral canal ?

137. •Medially – lacunar ligament
•Laterally - femoral vein
•Superoanteriorly – inguinal ligament
•Inferoposteriorly –pectineal ligament

139. Stages of femoral hernia ?

140. •Stage I – There is a rounded reducible swelling below
the medial end of the inguinal ligament
•Stage II – The hernia after passing through the
femoral canal bulges into the femoral triangle, and
usually reducible
•Stage III – Further expansion downwards is
prevented by the blending fascia , the fundus mounts
upwards in front of the inguinal ligament and
overlies the inguinal canal. Finally the hernia takes
the shape of a retort

141. Clinical presentation of femoral
hernia?

142. •Common in females (2:1)
•Presents as a groin swelling below and lateral
to the pubic tubercle
•Irreducibility and absence of cough impulse
are more common with femoral hernia
•Often associated with inguinal hernia

143. What is false about femoral
hernia?
A)Usually femoral hernia’s have a narrow neck
B)Femoral hernia’s are less likely to undergo strangulation than
inguinal hernia
C)Pressure of the hernial sac on superficial epigastric vein
causes gaur’s sign
D)Femoral hernia’s should be operated as early as possible to
avoid strangulation

144. Differential diagnosis of femoral
hernia?

145. •Inguinal hernia
•Enlarged cloquet node
•Saphena varix
•Femoral artery aneurysm
•Psoas abscess
•Distended psoas bursa
•Lipoma
•Hematoma

146. Low surgical approach for femoral
hernia?

147. •Lockwood operation (low approach )- incision
is 1cm below and parallel to the inguinal
ligament , sac is identified and ligated as high
as possible and the inguinal ligament is
sutured to the iliopectinate ligament/line by
interrupted sutures/ mesh can also be used.

148. Lotheissen’s operation?

149. •Lotheissen’s operation (High approach) – The
skin incision is above the inguinal ligament
and the tranversalis fascia is divided and sac
identified and ligated , and the conjoined
tendon is sutured to the ilio-pectinate line

150. McEvedy’s approach?

151. •McEvedy’s approach – Here a vertical incision
is made starting from above the inguinal
ligament to below , the advantage is the
entire course of the sac can be visualised and
ligated and the conjoined tendon is sutured to
the ilio-pectinate line ,mesh also can be used.

152. Surgical procedure of choice for
femoral hernia?

153. •Laparoscopic repair

154. Special Types of femoral hernia?

155. •Laugier’s femoral hernia - hernia through the
defect in lacunar ligament
•Narath’s femoral hernia – herniation lateral to
psoas muscle, occurs only with congenital
dislocation of hip
•Cloquet’s hernia – here the sac lies under the
fascia covering the pectineus muscle.

156. Abdominal wall hernia’s

157. Defect and contents of epigastric
hernia?

158. •It is the fatty herniation through linea alba
between the xiphisternum and umblicus
•They occur through the opening for the para-
midline nerves and vessels
•It usually sacless, with only the pre-peritoneal
fat content

159. Identify the false statements?
A.It is more common in men
B.It always has a sac
C.Usually there bowel/omentum as content
D.Reducibility can be absent even in uncomplicated
cases

160. umblical hernia and
para-umblical hernia differences?

161. UMBLICAL HERNIA PARA-UMBLICAL HERNIA
1 The abdominal contents bulge out
through week umblical scar
Herniation through linea alba above or
below the umblicus
2 Umblicus is everted Umblicus becomes cresent shaped
3 The entire fundus of the sac is
covered by the umblicus
Only half of the fundus is covered by
umblicus and the reminder by adjacent
skin
4 May be congenital/acquired Always acquired
5 Ascitis is an important precipitating
factor
Obesity and lax abdominal wall are
factors
6 Neck of the sac is wide Neck of the sac is narrow
7 Congenital type can wait upto 4
years for spontaneous closure
Always needs surgery

162. differential diagnosis for para-
umblical hernia?

163. •Lipoma
•Neurofibroma
•Desmoid tumor
•Hematoma

164. Investigations for umblical hernia?

165. •Routine investigations
•CXR and AXR-erect
•Ultrasound of the abdomen to identify the
size of defect and also to know the content of
sac

166. Types of umblical hernia repair?

167. Tissue repair /rraphy (< 4cm defect)–
Anatomical repair
Mayo’s repair
Mesh repair/plasty (>4cm defect)

168. What is Mayo’s repair and describe
the incision?

169. •The incision is classically a infra-umblical
smilie incision
•Closure of defect by double breasting of
rectus sheath/aponeurosis with/without
removal of umblicus is mayo’s repair

170. indications for mesh repair in
umblical hernia ?

171. •Large defect >4cm
•Multiple defect
•Lax abdominal wall
•Recurrent cases

172. congenital umblical hernia ?

173. •It is due incomplete closure of umblical ring at
birth

174. Reasons for acquired umblical
hernia ?

175. •Ascitis
•Malignant peritoneal effusion
•Connective tissue disorders
•Gross hypothyroidism

176. Surgical intervention in congenital
umblical hernia? When?

177. •Umblical ring size more than 2cm
•Usually we can wait till four years of age for
spontaneous closure

178. What is omphalocoele?

179. •Omphalocoele is failure of a part of the
midgut to return into the coelom during early
fetal life. Has an investing sac

180. What is gastroschsis?

181. •Gastroschsis is a defect in the abdominal wall
to the right of the normal insertion of the
umblical cord, without an investing sac.
•Both conditions are best treated by staged
surgical closure

182. interstitial hernia?

183. •Here the hernial sac passes between the
layers of the abdominal wall

184. Types of interstitial hernia?

185. •Pre-peritoneal (20%)
•Inter-muscular (60%)
•Inguino-superficial(20%)

186. What is spigelian hernia?

187. •It is a rare variety of inter-parietal hernia
occurring at the level of arcuate line
•It presents as a soft reducible lateral to the
rectus initially and gradually passes in
between the internal and external oblique
muscles.
•It easily gets strangulated

188. Define spigelian triangle ?

189. •Medially by rectus
abdominus
•Laterally by internal
and external oblique
•Superiorly by linea
semilunaris

190. Best investigation to confirm
spigelian hernia?
A)ULTRASOUND ABDOMEN
B)CT ABDOMEN
C)X-RAY ABDOMEN ERECT
D)NONE OF THE ABOVE

191. surgical treatment of spigelian
hernia?

192. •Surgery should be done as early as possible to
prevent strangulation
•Muscle splitting incisions are put over the
hernia and sac identified and transfixed and
the three muscle layers are repaired by
sutures /mesh.

193. Causes of incisional hernia?

194. •Wound infection
•Poor nutrition status
•Obesity/ascitis/malignancy/jaundice
•Anemia
•COPD/Persistent vomiting/coughing
•Collagen deficiency
•Improper technique
•Type of incision –midline more prone
•Suture material- absorbable sutures are more prone
•Placing drainage tube through the wound
•Creation of stoma

195. incisional hernia – SURGICAL
PROCEDURES?

196. •Anatomical repair – small defect <4cm
•Mesh repair
•Component separation technique- not
commonly used
•Autogenous repair by vascularized innervated
muscle flaps – for large and recurrent cases

197. various types of ventral hernia
mesh repair based on placement
of mesh?

199. What is this mesh called?

200. What are internal hernia’s?

201. •Internal hernias occur when there is protrusion of an
internal organ into a congenital/acquired defect in
the peritoneal lining . If a loop of bowel passes
through a mesentric defect it can become
strangulated, or can become a lead point for a small
bowel obstruction/volvulus.

202. Types of internal hernia’s?

203. •Trans-mesentric
•Para-duodenal
•Foramen of winslow
•Intersigmoid
•Pelvic floor
•Para-caecal

204. Diaphragmatic hernia

205. diaphragmatic hernia and name its
types?

206. •It is the herniation of abdominal content
through a defect(congenital/acquired) in the
diaphragm into the chest.
•Types – congenital and acquired
•Congenital – eventration , Bochdalek hernia
and Morgagni hernia
•Acquired are usually traumatic in nature

207. Triad of clinical features in
congenital diaphragmatic hernia?

208. •Respiratory distress
•Scaphoid abdomen and
•Mediastinal shift

209. Investigations in diaphragmatic
hernia?

210. •CXR –PA View
•CT chest with abdomen is the most important
investigation in traumatic diaphragmatic
hernia’s

211. Surgical procedures for
diaphragmatic hernia?

212. •Laparotomy or laparoscopic repair can be done
•Repair can be done using mesh or non-absorbable
sutures
•In traumatic cases , a thorough laparotomy should be
done to rule out any abdominal organ injury
•In congenital diaphragmatic hernia, the abdominal
cavity should be prepared(pneumatic insufflation) to
accommodate the bowel before repair , to avoid
compartment syndrome.

213. Hiatus hernia

214. What is hiatus hernia?

215. •It is the herniation of the distal esophagus and
proximal stomach into the mediastinum
through the esophageal hiatus

216. Types of hiatus hernia?

217. •Sliding /type I – when the gastro-esophageal junction
herniates with the proximal stomach into the
mediastinum
•Rolling /type II – here the gastro-esophageal junction
is place and the fundus of the stomach herniates into
the mediastinum
•Combined / type III
•Type IV – para-esophageal type with other
abdominal viscera

218. Treatment of hiatus hernia?

219. •It can be done by abdominal/thoracic
/laparoscopic approach
•Irrespective of approach, the hernia is
reduced and fundoplication is done with
reduction of the hiatus by sutures/mesh
•In asymptomatic/ small hernia’s and in old
age and where surgery is contraindicated
medical line of management can be tried.

220. Obturator hernia

221. Anatomy of obturator canal?

222. •The obturator canal is a
passageway formed from
the obturator foramen by
part of the obturator
membrane. It connects
pelvis to the thigh.
•Obturator vessels and
nerve traverse the canal
•Obturator hernia occurs
through this canal

223. Clinical presentation of obturator
hernia?

224. •The signs and symptoms are non specific and
generally the diagnosis is made during exploration
for the intestinal obstruction
•pain on the medial aspect of thigh called as Howship
Rombergs sign
• palpable mass on the medial aspect of thigh
•repeated attacks of Intestinal Obstruction.
•It is a diagnosis of exclusion

225. Treatment of obturator hernia ?

226. •Laparotomy and repair
•Laparoscopic repair – it is more preferred
because better visualization and access
compared to open technique

227. READ THE X-RAY ?

228. Name the Laparoscopic instrument used in
ventral hernia repair to fix the mesh in this
picture?

229. Name the technique used to fix the
mesh in this picture ?

230. Match the following ?
1.Gibbon’s hernia a) hernia through pectineal fascia
2.Petit’s hernia b) localised muscle bulge following paralysis
3.Phantom hernia c)hernia through lower lumbar tiangle
4.Cloquet’s hernia d) lateral to femoral artery
5.Hesselbach’s hernia e) hernia with hydrocoele

231. CASE SCENARIO

232. •50 year old female patient with irreducible
swelling in the right upper thigh for 10 days,
with h/o pain,vomiting ,constipation and
abdominal distention for 2 days.

234. •What is the probable diagnosis and why?

235. •A 40 year old male patient presents with
obstructed inguinal hernia, usg showed
obstructed inguinal hernia with bowel as
content and was taken up for emergency
surgery, as soon as the patient was given GA,
the hernia reduced partially and the sac was
opened, contents was found to be normal
bowel and hernial repair was done, but patient
developed signs of peritonitis and sepsis on
POD ‘3’.
•What is the probable diagnosis and why?

236. Thank you