Hernia and its surgeries

this slides are referred from sub manual for surgery, Swartz surgery textbook

1. HERNIA

2. MEANING 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.

3. AETIOLOGY Straining. Lifting of heavy weight . Chronic cough Chronic constipation Urinary causes Old age—BPH, carcinoma prostate. Young age—stricture urethra. Very young age— phimosis , meatal stenosis. Obesity . Pregnancy and pelvic anatomy Smoking . Ascites . Appendicectomy through McBurney’s incision causes direct inguinal hernia. An indirect inguinal hernia occurs in a congenital cause like remains of processus vaginalis Familial collagen disorder— Prune Belly syndrome . Acquired herniation is also probably due to collagen deficiency called as metastatic emphysema of Read.

4. Old appendicectomy scar with direct inguinal hernia. It is due to injury to ilioinguinal nerve during appendicectomy . Inguinal hernia in a patient who is having benign prostatic hyperplasia (BPH )

5. PARTS OF HERNIA Covering Sac Content

6. COVERING layers of the abdominal wall through which the sac passes.

7. SAC IT IS “diverticulum of peritoneum with MOUTH, NECK, BODY and FUNDUS .” NECK-Neck is narrow in indirect sac but wide in direct sac . BODY-Body of the sac is thin in infants, children and in indirect sac ; but is thick in direct and long-standing hernia.

8. CONTENTS OF SAC Omentum Intestine Richter’s hernia : A portion of circumference of bowel is the content. Urinary bladder Ovary often with fallopian tube. Meckel’s diverticulum — Littre’s hernia . Fluid

9. Littre’s hernia with Meckel’s diverticulum as content .

10. CLASSIFICATION OF THE HERNIA Clinical classification Reducible hernia Irreducible hernia Obstructed hernia Inflamed hernia Strangulated hernia

11. 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.

12. IRREDUCIBLE HERNIA Here contents cannot be returned to the abdomen due to narrow neck, adhesions, over crowding . Irreducibility predisposes to strangulation.

13. OBSTRUCTED HERNIA It is an irreducible hernia with obstruction, but blood supply to the bowel is not interfered. It eventually leads to strangulation.

14. 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.

15. STRANGULATED HERNIA It is an irreversible hernia with obstruction to blood flow . The swelling is tense, tender, with no impulse on coughing and with features of intestinal obstruction. Features of intestinal obstruction may be absent in case of omentocele , Richter’s hernia, Littre’s hernia.

16. Classification II Congenital—Common It occurs in a preformed sac/defect. present at a later period by precipitating causes like in indirect inguinal hernia. Acquired secondary to any causes increases intra-abdominal pressure leading into weakening of the area like in direct inguinal hernia.

17. CLASSIFICATION III: BASED ON SITES Inguinal hernia—occurring in inguinal canal. Femoral hernia—occurring in femoral canal. Obturator hernia. Diaphragmatic hernia. Lumbar hernia. Spigelian hernia. Umbilical hernia. Epigastric hernia.

18. CLASSIFICATION IV – BASED ON CONTENTS Omentocele — omentum . Enterocele —intestine. Cystocele—urinary bladder. Littre’s hernia— Meckel’s diverticulum. Maydl’s hernia. Sliding hernia. Richter’s hernia—part of the bowel wall.

19. INGUINAL HERNIA

20. SURGICAL ANATOMY SUPERFECIAL INGUINAL RING DEEP INGUINAL RING INGUINAL LIGAMENT INGUINAL CANAL

21. Superficial inguinal ring : a triangular opening in external oblique aponeurosis (1.25 cm above the pubic tubercle & bounded by superomedial and inferolateral crus.) Deep inguinal ring : is U-shaped condensation of transversalis fascia (1.25 cm above the inguinal ligament midway between symphysis pubis and ASIS.) Inguinal ligament : is formed by lower border of external oblique aponeurosis (which is thickened and folded backwards on itself, extending from ASIS to pubic tubercle .) Inguinal canal : It is an oblique passage in lower part of abdominal wall (4 cm long, situated above medial ½ of inguinal ligament, extending from deep inguinal ring to superficial inguinal ring .)

22. In infants both superficial and deep rings are superimposed Inguinal canal in female is called as ‘canal of Nuck .’ Inguinal ligament is also called as Poupart’s ligament

23. Contents of inguinal canal Spermatic cord in males Round ligament in females Ilioinguinal nerve

24. BOUNDARIES OF INGUINAL CANAL I n 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.

25. CLASSIFICATION OF INGUINAL HERNIA

26. ANATOMICAL CLASSIFICATION Indirect hernia It comes out through “internal ring” along with the cord. It is lateral to the inferior epigastric artery . Direct hernia It occurs through posterior wall of the inguinal canal through ‘ Hesselbach’s triangle’

27. ACCORDING TO THE EXTENT 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 . COMPLETE Here sac descends to the bottom of the scrotum. Saddle-bag or pantaloon hernial sac has got both medial and lateral component.

28. NEWER CLASSIFICATIONS Gilbert classification Nyhus classification Bendavid classification Casten classification Halverson and mcvay classification Ponka’s classification

29. INDIRECT INGUINAL HERNIA most common type ( 65%). more common in young age whereas direct is more in adults. more common on R ight side in 1st decade; but in 2 nd decade incidence is equal on both sides. Hernia is bilateral in 30% of cases. Sac is thin in indirect type. Neck is narrow and lies lateral to inferior epigastric vessels.

30. TYPES OF INDIRECT INGUINAL HERNIA Bubonocele – limited to inguinal canal Funicular - Processus vaginalis is closed just above the epididymis. Contents of the sac can be felt separately from testis , which lies below the hernia. Complete - Testis appears to lie in lower part of hernia. contents descend into pre-existing sac , only when there are precipitating causes which force the content down.

31. CLINICAL FEATURES Prevalence is 25 % (males); 2% (females). Patient presents with dragging pain and swelling in the groin which is better seen while coughing and standing with an expansile impulse . In infants, swelling appears when the child cries and is often translucent . It is usually reducible , but can go for irreducibility, inflammation, obstruction , strangulation.

32. CLINICAL EXAMINATION Internal ring occlusion test Ring invasion test Zeiman test Head or leg raising test Per rectal test

33. Indirect inguinal hernia Can occur in any age from childhood to adult Occurs in a pre-existin g sac Protrusion through the deep ring ; herniation occurs later Pyriform /oval in shape; descends obliquely and downwards Sac is anterolateral to cord No Impulse felt after occlusion of deep ring Direct inguinal hernia common in elderly Always acquired Herniation through posterior wall of the inguinal canal Globular/round in shape; descends directly forward bulge Sac is posterior to cord Impulse felt even after occlusion of deep ring.

34. THANK YOU

35. MANAGEMENT OF INGUINAL HERNIA

36. Investigations Chest X-ray to rule out chronic bronchitis . Ultrasound of abdomen . Tests relevant for precipitating causes.

37. TREATMENT Always surgery is preferred in the cases of the hernia.

38. HERNIAL SURGERY IN INFANTS Only herniotomy is preferred in infants in both hernia and hydrocele. This surgery is called as “ Michaelis plank operation”

39. HERNIAL SURGERY IN ADULTS It includes two steps: HERNIOTOMY - excision HERNIORRHAPHY – posterior wall strengthening HERNIOPLASTY – posterior wall strengthening with mesh usage

40. 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.

41. 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.

42. HERNIORRHAPHY Modified bassini’s herniorrhaphy Lytle’s repair Shouldice repair Tanner side operation Daming Koontz operation Mcvay operation Nyhus repair Wilkinson method removal of cord at inguinal region. Andrew operation

43. MODIFIED BASSINI’S HERNIORRHAPHY ‘ CONJOINT TENDON’ and ‘INGUINAL LIGAMENT’ are APPROXIMATED using interrupted NONABSORBABLE sutures usually prolene . Medial most stitch is taken from the PERIOSTEUM OF PUBIC TUBERCLE. ABSORBABLE suture material like catgut NOT be used as 50% of its tensile strength will be lost in 7 days.

44. 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).

45. SHOULDICE REPAIR strengthening the posterior wall by DOUBLE BREASTING of TRANSVESALIS FASCIA using continuous sutures using nonabsorbable material. After herniotomy - transversalis fascia is INCISED along the line of the wound LOWER FLAP of fascia is sutured to posterior part of the upper flap . UPPER FLAP is sutured to the inguinal ligament. 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.

46. 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.

47. Darning (Abrahamson Nylon Darning ) Continuous nonabsorbable sutures are placed between : conjoint tendon and inguinal ligament to give good support to posterior wall of inguinal hernia.

48. Koontz Operation ORCHIDECTOMY is done along with removal of entire cord, testis and total closure posteriorly It is generally done in the aged persons.

49. Other procedures Andrew’s Operation - It involves overlapping of the external oblique apo -neurosis . McVay Operation - It is repair by placing interrupted sutures between transversalis fascia to Copper’s ligament (superior pubic ligament ) Nyhus Iliopubic Repair - Transaponeurotic arch (transverse abdominis muscle and transversalis fascia) is sutured below to Copper’s ligament and iliopubic tract . Wilkinson Method - Transversus abdominis and internal oblique are sutured to inguinal ligament with continuous monofi lament sutures

50. HERNIOPLASTY

51. CONTENTS INTRODUCTION SURGICAL ANATOMY INDICATIONS PROCEDURE COMPLICATIONS

52. What HERNIOPLASTY is actually? IT is strengthening of posterior wall using a supportive material . This allows good fibroblast proliferation strengthens the weak posterior wall popularized by LICHTENSTEIN after recognizing that T ension is the main cause of R ecurrence.

53. MATERIALS USED FOR SUPPORT Two types synthetic and biological SYNTHETIC: Prolene mesh vipro mesh Dacron mesh Morlex mesh Merselene sheath BIOLOGCAL: Tensor fascia lata Temporal fascia skin

54. INDICATIONS Direct hernia Recurrent hernia Re-recurrent hernia Incicional hernia Old age Hernia with weak abdominal muscle tone Sliding hernia (presently it is done for all cases of hernia except in the paediatric age group and it is the gold standard in the treatment of hernias.)

55. TYPES OF MESH REPAIR Onlay repair ( lichtenstein tension free repair) Inlay repair ( mesh is placed at myopectineal level) Underlay repair (mesh is placed in the preperitoneal space) ex: nyhus repair Gillbert patch and plug repair ( onlay+sublay sandwich technique) Stoppa’s giant prosthesis reinforcement Laparoscopic surgeries- TAPP (trans abdominal pre peritoneal laparoscopic mesh repair) TEP (totally extra peritoneal laparoscopic mesh repair)

56. LICHTENSTEIN TENSION FREE ONLAY MESH REPAIR PROCEDURE Pre-operative medications: Opioids (morphine, pethedine ) Sedatives and anti-anxiety drugs(diazepam) Anticholinergics (atropine) Neuroleptics (chlorpromazine) Antiemetics (metoclopramide, domperidone , ondansetron )

57. Pre-operative preparation detail history about previous experience with surgery and anesthesia, medical history and drug history. Routine blood investigations, electrolytes, liver function tests, urine analysis, ECG, chest radiography, HIV Starvation for 4 hours for liquids and 6 hrs for solids Bowel & bladder should be emptied { enema, catheterization} The patient is asked to take a scrub bath, dressed with a sterile gown and exposed adequately.

58. The region to be operated is painted with povidone iodine and draped. Anaesthesia - spinal or local infiltration block (general anaesthesia in case of uncooperative patients) Incision- oblique and parallel to the inguinal ligament and above it (3-4 cm) Opening of the subcutaneous fat along the line of the incision Opening of the Scarpa fascia down to the external oblique aponeurosis and visualization of the external inguinal ring and the lower border of the inguinal ligament

59. Division of the external oblique aponeurosis from the external ring laterally for up to 5 cm, safeguarding the ilioinguinal nerve Mobilization of the spermatic cord, along with the cremaster , including the ilioinguinal nerve, the genitofemoral nerve, and the spermatic vessels; all of these structures may then be encircled in a Penrose drain or tape Opening of the coverings of the spermatic cord and identification and isolation of the hernia sac Inversion, division, resection, or ligation of the sac, as indicated

60. A sheet of proline or vipro mesh is fashioned to fit the inguinal canal. A slit is made in the lateral aspect of the mesh, and the spermatic cord is placed between the two tails of the mesh. The spermatic cord is retracted in the cephalad direction. The medial aspect of the mesh overlaps the pubic bone by approximately 2 cm. The mesh is secured to the APONEUROTIC TISSUE OVER PUBIC TUBERCLE nonabsorbable monofilament material. The suture is continued laterally to the shelving edge of the inguinal ligament to a point just lateral to the internal inguinal ring.

61. A second suture is placed at the level of the pubic tubercle and continued laterally suturing the internal oblique aponeurosis The lower edges of the two tails are sutured to the shelving edge of the inguinal ligament to create a new internal ring made of mesh. The spermatic cord structures are placed within the inguinal canal overlying the mesh. In males, gentle pulling of the testes back down to their normal scrotal position Closure of spermatic cord layers, the external oblique aponeurosis , subcutaneous tissue, and the skin

62. Post-operative care IV fluids- initially isotonic fluids are given and changed to 0.45% saline with dextrose. Pulse, blood pressure and respiration should be monitored Wound care and regular dressing Adequate pain relief and continuation of antibiotics Sutures removed after 10 days.

63. COMPLICATIONS Recurrence Chronic groin pain Nerve damage- iliohypogastric ilioinguinal genitofemoral Cord and testicular- hematoma ischaemic orchitis testicular atrophy dysejaculation hydrocele Wound hematoma and infection

64. Prosthetic complication s- erosion rejection infection Laparoscopic- visceral injury gas embolism Miscellaneous- nausea and vomiting respiratory insufficiency

65. Thank you