1

CASE
Inguinal Hernia

• History • Herniorrhaphy
• Local Examination • Femoral Hernia Surgery
• Differential Diagnosis • Strangulated Hernia
• Investigations • Miscellaneous
• Treatment • Dual Hernia
• Anatomy of Inguinal Hernia • Ogilvie Hernia
• Coverings of Inguinal Hernia • Consolidation
• Surgeries for Hernia

DEFINITION
Hernia is an abnormal protrusion of a part or whole of the viscus through a normal
or abnormal opening through the wall of the cavity that contains it.

HISTORY
Name: Young Age—indirect
Old Age—direct

Most common hernia in females—indirect inguinal hernia
Age: Most common hernia in males—indirect
Femoral hernia most common among—females

Sex: Direct hernia never occurs in females and children

Occupation: Most common in strenous labor

Presenting Complaints
I. About the hernia
II. Due to hernia (Complications)
I II. Precipitating factors

About the Hernia

1. Duration
2. Onset: Suddenly/gradually
3. Site of start: From groin to scrotum (hernia)
From scrotum to groin (hydrocele and varicocele)
2 Long Cases in General Surgery

4. Aggravating factors:
–– On straining
–– On standing
–– On coughing
5. Relieving factors:
–– By lying down
–– Manually by himself
6. Associated with pain: Usually painless
Pain in inguinal hernia is usually in the region of the umbilicus due to drag in the root
of mesentery as bowel enters the sac

Complications
1. Irreducibility:
i. Crowding of the contents
ii. Adhesion between sac and contents
iii. Adhesion between contents
iv. Adhesion between sac.
2. Obstruction:
Four cardinal features
i. Colicky abdominal pain
ii. Vomiting
iii. Abdominal distension
iv. Obstipation (Absolute constipation)—not passing flatus and feces.
3. Strangulation:
(Obstruction + irreducibility + Arrest of blood supply)
i. Colicky abdominal pain if continues and becomes gangrenous pain
disappears
ii. Sudden increase in size of hernia; becomes tense and tender.

History of Precipitating Factors

1. Chronic bronchitis/asthma/TB
2. Difficulty in micturition
3. Difficulty in defecation
4. Weightlifting.

Past History
•• History of diabetes mellitus/Hypertension/Ischemic heart disease/Bronchial
asthma/Tuberculosis
•• History of previous surgery

History of appendicectomy:
Ilioinguinal or iliohypogastric nerve if damaged by grid iron incision or during keeping the
drain; Direct Hernia Occurs
If ilioinguinal nerve is cut in the inguinal canal, direct hernia never occurs
Because the nerve supplies the abdominal muscles before entering the canal
 Inguinal Hernia 3
Family History
History of connective tissue disorders in family.

Personal History
History of Smoking: Smoking leads to chronic bronchitis
Collagen deficiency occurs in smokers.

General Examination
•• General condition
•• Anemia
•• Lymph adenopathy
•• Blood pressure
•• Pulse rate

Cardiovascular System
Respiratory System:
Respiratory infections.

Abdomen
•• Mass abdomen
•• Malgaigne’s bulgings
•• Ascites

Malgaigne’s bulging
Oval, longitudinal, bilateral bulging produced on straining, in inguinal region or above it;
and are parallel to medial half of inguinal ligament
•• Present in direct hernia
•• Indicates poor muscle tone
•• Signifies hernioplasty is the treatment

LOCAL EXAMINATION

Inspection
Patient in standing position
1. Site
Shape
2. Size
Pyriform—indirect (Fig. 1.1)
3. Shape
Hemispherical—direct (Fig. 1.2)
4. Extent
Retort—femoral
5. Surface
6. Skin over the swelling
7. Visible peristalsis
8. Cough impulse Position
9. Draining lymph nodes Femoral—below and lateral to pubic tubercle
10. Penis Inguinal—above and medial to pubic tubercle
11. Urethral meatus
12. Opposite scrotum
4 Long Cases in General Surgery

Fig. 1.1: Indirect hernia: Pyriform shaped Fig. 1.2: Direct hernia: Hemispherical

Palpation
1. Temperature
2. Tenderness
3. Site Consistency:
4. Size Soft elastic—intestine
5. Shape Doughy granular—omentum
6. Extent
7. Surface
8. Skin over
9. Consistency Get above the swelling is a classical feature of hydrocele
10. Reducibility
11. Get above the swelling
12. Cough impulse
13. Invagination test
14. Ring occlusion test
15. Zieman's technique.

Discussion of Palpation
1. What is taxis? (Do not mention unless asked by the examiner)
Method of reducing the inguinal hernia
Procedure: Flex the knee, Adduct and internally rotate the hip
↓
Relaxes the abdominal muscles
*With the thumb and fingers hold the sac; guide with other hand at superficial
ring*

Complications of Taxis
–– Bowel injury
–– Reduction en masse: Reducing the sac with the constriction being present
at the neck; thereby making the hernia with obstruction to go into the
abdomen
–– Sac may rupture at its neck and the contents may be reduced extra
peritoneally.
 Inguinal Hernia 5
2. What is cough impulse?
`Propulsive and Expansile Impulse on Coughing'
Can be performed by:
–– Making the child cry
–– Valsalva maneuver
–– Head raising and abdomen contraction

To Demonstrate by Inspection
•• No need to reduce the content
•• Just ask the patient to stand and cough

Inference
•• Swelling increases in size, or
•• Impulse seen and swelling reappears

To Demonstrate by Palpation
•• Hold the right side of the root of scrotum with your left thumb and index
finger without reducing the content and ask to cough.
•• You will get expansile and propulsive impulse.
•• In Bubonocele—keep your thumb at deep ring.

Absent cough impulse:

•• Strangulated hernia
•• Incarcerated hernia
•• Neck of sac becomes blocked by adhesions

Where else you see cough impulse:

•• Varicocele—expansile and thrill like not propulsive
•• Morrissey’s cough impulse—in case of varicose veins, expansile impulse at sapheno-
femoral junction
•• Laryngocele

3. Difference between:
Reducibility Compressibility
After reducing the swelling opposite force is Opposite force is not required for reappear-
required to make the swelling reappear ing. It appears slowly to its original size
Swelling can be completely reduced Swelling cannot be completed reduced
For example: Hernia For example: Hemangioma

On Testing the Reducibility

a. Intestine: Last part is easy to reduce; Initial part is difficult to reduce; gets
reduced with gurgling sound.
b. Omentum: First part easy to reduce, last part is difficult because omentum
adheres to fundus of sac.
6 Long Cases in General Surgery

4. How will you demonstrate hernia in children?

Gornall's Test
–– Child held from back by both hands of clinician on its abdomen
–– Abdomen is pressed and child is lifted up
–– Hernia appears due to increase in the abdominal pressure exerted.
5. Zieman's technique (Fig. 1.3A)
For right side inguinal hernia, place the right hand
–– Index finger over deep ring
–– Middle finger over superficial ring
–– Ring finger over saphenous opening
See where the impulse is felt
–– Direct hernia—superficial ring
–– Indirect hernia—deep ring
–– Femoral hernia—saphenous opening
6. Deep ring occlusion test:
After reducing the contents, patient in standing position, occlude the deep
ring with thumb. Ask the patient to cough.
If swelling appears - Direct
Does not appear - Indirect
Fallacy of deep ring occlusion test (When will you get the swelling even though it
is an indirect hernia by deep ring occlusion test?)
•• Pantaloon hernia
•• Wide deep ring
(Occlude in such cases with index and middle finger together)

B
Figs 1.3A and B: (A) Zieman’s technique (three-finger test), (B) Finger invagination test
 Inguinal Hernia 7
7. Ring invagination test (Fig. 1.3B)
Only test in hernia; done in lying position.
Prerequisite:
–– Swelling should be reducible
–– Lax of skin should be there for invaginating (so this test could not be done
in females)

Procedure
1. Reduce the swelling.
2. For right side, invaginate with right little finger into the superficial ring.
3. Rotate the little finger medially so that the pulp faces medially.
4. Note the direction of entry and site of impulse.
Look for:
•• Strength of superficial ring: Normal ring admits only the tip
•• Direction of canal:
Direct hernia—directly backwards
Indirect—goes upwards, backwards and laterally
•• Site of impulse:
Pulp—direct
Tip—indirect
•• Strength of posterior wall
•• To find early cases of hernia, impulse felt at tip

Percussion
•• Enterocele: Resonant
•• Omentum: Dull

Auscultation
Peristaltic sounds occasionally heard.

Others
1. Testis: ‘Traction Test’ to find whether the inguinal swelling is an Encysted
Hydrocele of Cord.
2. Epididymis.
3. Penis:
–– Phimosis
–– Penile strictures
–– Pinhole meatus
4. Regional nodes.
5. Opposite groin.

Per-rectal Examination
To Rule out:
1. Benign Prostate hypertrophy—micturition difficulty
2. Malignant obstruction
3. Chronic fissure—constipation
8 Long Cases in General Surgery

Diagnosis
•• Side—right/left
•• Type—indirect/direct
•• Inguinal—femoral
•• Complete/Incomplete
•• Complicated/Uncomplicated
•• Content—enterocele/omentocele

DIFFERENTIAL DIAGNOSIS
Inguinal Swelling Inguinoscrotal Swelling Femoral Hernia
1. Enlarged lymph nodes 1. Encysted hydrocele of cord 1. Inguinal hernia
2. Undescended testis 2. Varicocele 2. Saphenavarix
3. Lipoma 3. Lymphvarix 3. Cloquet’s node
4. Femoral hernia 4. Diffuse lipoma of cord 4. Lipoma
5. Saphena varix 5. Inflammatory thickening of cord 5. Femoral aneurysm
6. Psoas abscess 6. Psoas abscess
7. Femoral aneurysm

INVESTIGATIONS
I. Routine
•• Hemoglobin
•• Bleeding time/Clotting time
•• Total count, differential count, ESR
•• Urine—albumin, sugar deposits
•• Blood—urea, sugar
•• Blood grouping/typing—for irreducible hernia/huge hernia
II. Anesthetic Purpose
•• X-ray chest (Chronic TB, Asthma—precipitate hernia)
•• ECG all leads
III. USG Abdomen and Pelvis
•• In old age group—to find benign prostate hyperplasia calculate post-voidal
residual urine. If >100 ml it is significant
•• To find any mass

TREATMENT
Treat the precipitating cause of hernia first.
For example:
1. Benign prostate hypertrophy
2. Tuberculosis
3. Stop smoking
Conservative management is indicated only in cases of very old man with
direct hernia; since there is no chance of obstruction.

Truss
•• Truss is not curative for hernia.
–– It is a special belt devised to keep the hernia reduced at the deep ring
or Hesselbach triangle for those who are unfit or unwilling for surgery
(Fig. 1.4).
 Inguinal Hernia 9
•• Hernia should be reducible to wear a truss.
•• Contraindicated in cases of irreducible hernia, undescended testis, associated
huge hydrocele, unintelligent people.
Do not say about truss in exams as the treatment unless the examiner
asks you.

ANATOMY OF INGUINAL HERNIA

(Author’s warning: Friends do not go to examination hall without knowing
anatomy of inguinal canal. Most of the students are failed only because of not
answering the anatomy properly).

Types of Hernia (Figs 1.5A to C)

1. Vaginal (Complete)—descends up to scrotum base, testis not felt (separately).
2. Funicular—testis felt separately, processus vaginalis closed above epididymis.
3. Bubonocele—inguinal swelling only.

Boundaries of Inguinal Canal (Fig. 1.6)

Anterior Wall: External oblique aponeurosis, arched fibers of internal oblique
laterally.

Fig. 1.4: Truss for inguinal hernia

A B C

Figs 1.5A to C: Types of hernia

10 Long Cases in General Surgery

Fig. 1.6: Boundaries of inguinal canal

Posterior Wall: Fascia transversalis, conjoint muscles (tendon) in medial half.

Floor: Grooved part of external oblique aponeurosis; Medial end there is
lacunar ligament.
Roof: Conjoint muscles (Internal oblique and transversus abdominis)

Inguinal Canal (House of Bassini)

•• 3.75 cm length
•• Extends from deep ring to superficial ring
•• Deep ring is a semioval opening in the fascia transversalis
•• Superficial ring is a triangular opening in the external oblique aponeurosis,
guarded by two crura of muscle fibers.

Contents of Inguinal Canal

•• Ilioinguinal nerve
•• Spermatic cord in male, round ligament in female
Contents of spermatic cord
Arteries : Testicular Artery
Artery of Vas
Artery to Cremaster
Veins : Pampiniform plexus of veins
Veins corresponding to Arteries
Lymphatics of testis
Testicular plexus of sympathetic nerves
Genital branch of genitofemoral N
Vas deferens
 Inguinal Hernia 11

Landmarks (Fig. 1.7)

Deep ring: Half inch above mid inguinal point (Between anterior superior iliac spine and
pubic symphysis)
(Remember here: Femoral artery is palpated at Midpoint of inguinal ligament- between
ASIS and Pubic tubercle)
Superficial ring: Just above pubic tubercle
Saphenous opening: 4 cm below and lateral to pubic tubercle

Mechanisms that prevent hernia when abdominal pressure rises.

1. Shutter mechanism—arched fibers of internal oblique
2. Flap valve mechanism—oblique canal; approximation of anterior and
posterior wall.
3. Ball valve mechanism—cremaster contracts, thereby superficial ring plugged
by spermatic cord.
4. Slit valve mechanism—crura of the superficial ring.

Hesselbach Triangle (Figs 1.8A and B)

Weak spot in anterior abdominal wall through which direct hernia appears.
•• Medial: Outer border of rectus abdominis
•• Lateral: Inferior epigastric vessels
•• Below: Medial part of inguinal ligament
•• Floor: Fascia transversalis
–– Traversed by medial umbilical fold; (Obliterated Umbilical Artery)

Other names:
Inguinal ligament: Poupart’s
Lacunar ligament: Gimbernat’s
Iliopectineal ligament: Cooper’s
Saphenous opening: Fossa ovalis

Fig. 1.7: Anatomical landmarks of all the openings

12 Long Cases in General Surgery

Figs 1.8A and B: (A) Various locations of hernias (B) Hesselbach’s triangle—bounded by
inferior epigastric artery (lateral), rectus abdominis (medial) and inguinal ligament (below)

COVERINGS OF INGUINAL HERNIA

Indirect Hernia
1. Peritoneum
2. Internal spermatic fascia (from fascia transversalis)
3. Cremasteric fascia (from internal oblique)
4. External spermatic fascia (from external oblique)
5. Scrotum

Direct Hernia
1. Peritoneum
2. Transversalis fascia (from fascia transversalis)
3. External spermatic fascia (from external oblique) usually does not descend
into scrotum.
 Inguinal Hernia 13
How can you identify the neck of the sac?
•• Narrowest part
•• Extraperitoneal pad of fat will be present
•• Inferior epigastric vessels will be on medial side
What is the color of sac?
•• Sac of hernia is pearly white
•• Sac of hydrocele is bluish

Anatomy of hernia
1. Sac
2. Contents
3. Coverings
Sac: 1. Mouth
2. Neck (narrowest past)
3. Body
4. Fundus
Sac that lacks neck:
1. Direct hernia
2. Incisional hernia
Sacless hernia:
Epigastric hernia

How does Ilioinguinal Nerve enter the Inguinal Canal?

Does not enter through deep ring; but enters through the intermuscular plane
between internal oblique and transverse abdominis and supplies anterior scrotum,
medial side of thigh, root of penis in males, labia majora, and clitoris in females.

Femoral Hernia: Anatomy (Figs 1.9 and 1.10)

Femoral canal: 2 x 2 cm size

Medial compartment of femoral sheath
Base: Femoral ring
Bounded
Anteriorly—inguinal ligament
Posteriorly—cooper’s ligament
Medially—lacunar ligament
Laterally—femoral vein
Contents: Cloquet’s node
Lymphatics
Areolar tissue

•• Femoral canal is bounded above by femoral ring with extraperitoneal pad of

fat; below by saphenous opening covered by cribriform fascia.
•• Femoral hernia is Retort shaped: Because as it goes down through saphenous
opening Holden's Line prevents the contents going further down. Hence, the
contents turns up and enters inguinal canal.
[Holden's Line - Fascia scarpa (deep membranous layer of superficial fascia)
attaches firmly with deep fascia (fascia lata)].
14 Long Cases in General Surgery

B
Figs 1.9A and B: Femoral hernia

Fig. 1.10A
 Inguinal Hernia 15

Fig. 1.10B
Figs 1.10A and B: Femoral hernia–anatomy

SURGERIES FOR HERNIA

Herniotomy
1. Separation of sac from cord structures Relation of sac with cord:
2. Reducing the content Direct sac: Posteromedial to the cord
3. Transfixation and ligation of sac Indirect sac: Anterolateral to the cord
4. Excise the redundant sac.
(Don't separate the sac beyond pubic tubercle, as we will damage the scrotal
blood supply doing so).

Herniotomy (transfixation and ligation of the sac) is done only for indirect inguinal hernia.
For direct hernia just push the sac back into abdomen without opening

HERNIORRHAPHY
1. Herniotomy
2. Narrowing of the deep ring with 2'0 prolene (Lytle's Repair)
3. Approximation of conjoint tendon with inguinal ligament using 1'
polypropylene material (Fig. 1.11).

Color of suture materials:

Prolene (polypropylene) - Dark blue
Vicryl (polyglycolic acid) - Violet
Silk - Black
Catgut - Brown
Prolene mesh - White
Increasing order of size of materials:
3’0 < 2’0 < 1’0 < 1’ < 2’ < 3’

Hernioplasty
There is already weakness of abdominal wall muscles, so no approximation can
be done.
16 Long Cases in General Surgery

Fig. 1.11: Herniorrhaphy

:Classification of herniorrhaphy
Original Bassini Modified Bassini
• He laid opened the fasica transversalis from • Fascia transversalis not opened.
pubic tubercle to deep ring.
• Approximated with interrupted stitches of silk. • Approximated with continuous
locking stitch with Prolene.
• Approximated conjoined muscles (Internal • Approximated conjoined tendon
oblique and transversus abdominis) and upper with inguinal ligament.
of the fascia transversalis with inguinal ligament
and lower leaf of fascia transversalis during each
stitch.
• (3 layers above with 2 layers below for every • Getting obsolete slowly (Mesh
stitch). repair is followed for all types of
hernia).
• Not done nowadays.

Hence we use Prolene Mesh to bridge the gap between inguinal ligament and
conjoint tendon (Fig. 1.12).
Herniorrhaphy Hernioplasty
1. Original Bassini 1. Lichtenstein
2. Modified Bassini 2. Gilbert’s plug
3. McVay’s 3. Prolene hernia system
4. Shouldice 4. Laparoscopic mesh repair
5. Stoppas repair
 Inguinal Hernia 17

Fig. 1.12: Hernioplasty

Shouldice Technique
•• He gave additional strength to the posterior wall by double breasting the fascia
transversalis.
•• Best among all anatomical repairs (Herniorrhaphy).
•• Least recurrence among herniorrhaphy.

McVay's Repair
•• Approximated conjoined tendon with iliopectineal ligament of Cooper.
•• It prevents both inguinal and femoral hernia.

Tanner's muscle slide

•• Basically all the herniorrhaphy are tension repairs
•• To avoid tension in the rhaphy site, the incision made curvilinearly over the anterior
rectus sheath
•• This relaxes the conjoined muscles and thus gets approximated with inguinal ligament
without tension

Lichtenstein Hernioplasty
•• Prolene mesh 16 × 10 cm size is taken and fixed in the inguinal canal.
•• First bite taken from periosteum of pubic tubercle; and fix the mesh to a point
beyond the deep ring.
•• Fix the mesh with inguinal ligament and conjoined tendon using 1'0 or 2'0
prolene without tension.
Lichtenstein’s tension free mesh repair is used for all types of inguinal hernia nowadays
for its least recurrence

Gilbert's Plug Repair

•• A plug mesh is kept in the deep ring and also to reinforce the posterior wall.
18 Long Cases in General Surgery

Stoppas Procedure
•• For bilateral direct hernia, a modified Pfannenstiel incision made in the lower
abdomen and a huge mesh placed in between the peritoneum and the fascia
transversalis (Preperitoneal mesh repair).

Darning
•• A type of herniorrhaphy which is done by suturing the conjoined tendon with
inguinal ligament using 1 prolene without tension.
•• The suture material appears like mesh due to multiple crossings.
Kuntz operation Hamilton Bailey operation
• Orchidectomy is done along with the • Cord is removed from the inguinal canal by
removal of the entire cord and testis. ligating at the external and internal ring.
• Posterior inguinal canal repaired. • Testis is retained for psychological reasons.
• Done in old age patients with recurrent • Inguinal canal is repaired.
hernias.
• Testis derives its blood supply from the
scrotal vessels and survives.

Laparoscopic Hernia Repair (Figs 1.13 and 1.14)

•• Most surgeons are now getting trained in laparoscopic hernia surgeries
•• Though all the hernias can be done by Laparoscopic method, NICE guidelines
for hernia surgery advice the laparoscopic repair for
–– Recurrent hernias
–– Bilateral hernias

Fig. 1.13: Transabdominal preperitoneal (TAPP) repair

 Inguinal Hernia 19

Fig. 1.14: Total extraperitoneal (TEP) repair

:Complications of hernia surgery

Intraoperative Immediate postoperative Late complications

1. Injury to the blood vessels 1. Urine retention 1. Recurrence
(inferior epigastric and
femoral)
2. I njury to bowel and blad- 2. Hematoma 2. Numbness over the
der local region if the
nerve was cut during
surgery
3. I njury to ilioinguinal and 3. Infection
iliohypogastric nerves
4. Injury to cord structures 4. P  eriostitis of pubic tubercle (as
the stitch is taken from perios-
teum)
5. P
 ostherniorrhaphy hydrocele
(due to obstruction of lymphat-
ics at deep ring when narrowed
tightly)
•• There are two methods for laparoscopic hernia repair.
•• In both the methods a huge mesh is kept preperitoneal.
TAPP- Transabdominal preperitoneal repair TEP- Total extraperitoneal repair
Approach: By entering the peritoneal cavity Peritoneal cavity is not entered, we create
extraperitoneal space by using balloon or
direct inflation to reach the preperitoneal
space of lower abdomen
Advantages: • As we go totally extraperitoneal no
• Easy for the beginners chance of intra-abdominal visceral injuries
• Easy recovery
• Can be done for those people who had
open prostatectomy (where extraperito-
neal space is not available)
Disadvantage:
• Chance of visceral injuries more than TEP • Difficult training course. Needs a lot of
training
20 Long Cases in General Surgery

Author’s Note
For PG standard, you should know everything about the TEP and TAPP and their
complications.

FEMORAL HERNIA SURGERY

Basic principle: Approximate Inguinal Ligament with Cooper's Ligament (Ilio-
pectineal ligament).
Three approaches:
1. Lotheissen's inguinal approach:
–– Inguinal incision made similar to inguinal hernia.
–– Fascia transversalis opened.
–– Approximate inguinal ligament with iliopectineal and also conjoint tendon
with inguinal ligament.
–– Prevents inguinal hernia also.
2. High approach of McEvedy:
–– Vertical incision made over the femoral canal continued above to inguinal
ligament.
–– Very useful for irreducible and strangulated hernia.
3. Low operation of Lockwood:
–– Groin crease incision.
–– Indicated in uncomplicated femoral hernia only.
–– Just approximate inguinal ligament and iliopectineal ligament.
–– Not prevents inguinal hernia.

Operative surgery for inguinal hernias:

Under spinal anesthesia:
•• An incision made half inch above and parallel to the medial 2/3 of the inguinal
ligament
•• Superficial vessels identified and ligated
•• Superficial ring identified as a opening in the external oblique aponeurosis
•• External oblique aponeurosis laid open from superficial ring to the level of deep ring
•• Ilioinguinal nerve and Iliohypogastric nerve may be seen on opening the external
oblique aponeunosis—preserve them
•• Cremasteric muscle along with cord structures seen
•• Cremasteric muscle and fascia opened
•• Cord structures identified and they are separated from the sac
•• Indirect hernia—sac separated up to the deep ring, transfixation and ligation done at
deep ring. Herniotomy done
•• Direct hernia—just push back the direct sac into the abdomen and strengthen the
posterior wall defect approximating fascia transversalis with 2’0 prolene
•• Lytle’s repair: Narrow the deep ring with 2’0 prolene
•• Herniorrhaphy started after lateralizing the cord
•• First bite taken from the periosteum of pubic tubercle and completed at deep ring
•• Assuring complete hemostasis cord kept back and layers closed
 Inguinal Hernia 21
STRANGULATED HERNIA (FIG. 1.15)
Management
1. Resuscitation: Nasal oxygen, Intravenous fluids.
2. Parenteral antibiotics.
3. Delay should not be made for operation.
‘Danger is in delay not in operation’
Don't attempt
1. Taxis
2. Foot end elevation
Take the patient to operation theater
Under General Anesthesia
*Paint with povidone iodine from xiphisternum to midthigh (may need
laparotomy for nonviable bowel).
•• Inguinoscrotal incision made
•• Before separating the sac from cord structures, open the fundus of sac first to release
the toxic contents
If you push the toxic fluid into the abdomen peritonitis may develop
•• Constriction is usually seen in 50 percent cases at deep ring and 50 percent cases
at superficial ring
•• Look for the bowel viability and hold the bowel before releasing the constriction with
Hernia Director (Grooved hernia director)
•• Normal bowel is pinkish red; peristalsis seen, glistening
•• In such cases push the bowel inside and do herniorrhaphy

If Bowel is not Viable; (Gangrenous, Lustureless, No Peristalsis)

1. Keep a warm pad over the bowel.
2. 100 percent oxygen given nasal.

Fig. 1.15: Strangulated bowel

22 Long Cases in General Surgery

3. Wait for 10 minutes

4. If viable put it back in the abdomen
5. If nonviable; abdomen opened through midline incision.

Nonviable Bowel
Small bowel—end to end resection anastomosis
Omentum—excise the gangrenous part.

Large Bowel
Patients who are unfit for resection and anastomosis the following procedures are
done in emergency:
1. Paul Mikulicz’s procedure—gangrenous loop excised and proximal colostomy
and distal mucus fistula done for a temporary period. 6 weeks later re-
anastomosis done.
2. Hartmann’s operation—colon is excised and the proximal end is brought out
as colostomy and distal end closed and left inside temporarily. 6 weeks later
re-anastomosis is done.

Strangulation in Maydl's Hernia

1. Maydl's hernia (Retrograde strangulation) ‘W’ shaped hernia (Fig. 1.16).
2. Gangrene in the obstructed bowel starts first at the neck of sac; then
immediately at the antimesentric border distally.
3. Therefore in Maydl's hernia; the distal antimesentric border is inside the
abdomen; which goes for strangulation first.
4. Hence look for the full length of intestine by pulling out the loop inside the
abdomen.

Sliding Hernia
Definition
Part of the posterior wall formed not only by the peritoneum but also by part of
retroperitoneal structures.
For example: Urinary bladder, cecum, sigmoid colon.

Clinical Features
1. Incompletely reducible
2. Huge scrotal hernia
3. Appears slowly after reduction
4. Old male.

During Surgery
1. Do not dissect the sac from the retroperitoneal structures, just push part of the
sac along with them.
2. Hernioplasty is ideal.

Scrotal Abdomen
Very huge hernia, with most of the intestines inside the scrotum.
 Inguinal Hernia 23

Fig. 1.16: Maydl’s hernia Fig. 1.17: Spigelian hernia

Clinical Features
1. Mostly irreducible
2. Cough impulse—negative

During Surgery
1. Assess the respiratory status, because if you suddenly push the whole bowel
into the abdomen he may go for respiratory distress postoperatively.
2. Pneumoperitoneum should be created and the patient allowed to work with it
for a few months before surgery.
3. Inguinal incision made as usually and the pneumoperitoneum released;
gradually reduce the content.
4. Do hernioplasty.

Spigelian Hernia (Fig. 1.17)

•• Type of interstitial (Hernia that comes in between the layers of anterior
abdominal wall muscles).
•• This occurs through spigelian fascia, thin strip of fascia that runs parallel to the
outerborder of rectus sheath from tip of 9th costal cartilage to pubic tubercle.
•• This fascia contributes to few fibers of anterior rectus sheath and is wide at
the level of ARCUATE LINE, where the hernia occurs and runs in between
external and internal oblique muscles.

MISCELLANEOUS
Richter's Hernia
•• A portion of the circumference of the intestine becomes the content of the sac.
•• Strangulation occurs when associated with femoral or obturator hernia.
•• Diarrhea is seen in cases of strangulation.
Unless more than half of the circumference is involved there is no consti-
pation.

Littre's Hernia
Meckel's diverticulum is seen in the sac.
24 Long Cases in General Surgery

Sacless Hernia
Epigastric hernia of linea alba.

Nyhus classification of hernia

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
c. Femoral
Type IV: Recurrent

DUAL HERNIA
(Pantaloon/Saddle Bag)
•• Has two sacs. Gilbert Classification
•• Actually a posterior wall defect in which sac Type 1 - Small, indirect
comes through Hesselbach's triangle and Type 2 - Medium, indirect
deep ring. Type 3 - Large, indirect
•• Isthmus behind is inferior epigastric vessels. Type 4 - Entire floor, direct
•• If one sac is not treated properly recurrence Type 5 - Diverticular, direct
will occur. Type 6 - Combined, pantaloon
•• Ring occlusion test: Not significant. Type 7 - Femoral

OGILVIE HERNIA
•• Direct hernias are always acquired. Indirect may be congenital or acquired.
•• Only congenital direct hernia is ogilvie hernia; through a rigid circular orifice
in the conjoined tendon just lateral to where it inserts into the rectus sheath.

CONSOLIDATION

Factors S.No. Direct Indirect

Age 1. Older Young
Sex 2. Never occur in female M:F = 20:1
History 3. Reduced on lying down Reduced by manipulation
4. Mostly bilateral Usually unilateral to start
Inspection 5. Hemispherical shape Pyriform shape
6. Malgaigne's bulge (+) No Malgaigne's bulge
7. Incomplete variety Complete/Incomplete
Palpation 8. Deep ring occlusion-swelling appears Swelling not appears
9. Finger invagination - impulse felt at Impulse at tip of finger
pulp of little finger
10. Zieman's technique - impulse at Impulse at deep ring
superficial ring
Contd...
 Inguinal Hernia 25
Contd...
Factors S.No. Direct Indirect
Complication 11. Strangulation very rare Common
During surgery 12. Sac is posteromedial to cord Sac is anterolateral to cord
Sac is medial to inferior epigastric Lateral to inferior epigas-
vessels tric vessels
Comes through
Hesselbach’s triangle Comes through deep ring
Hernioplasty must be done Hernioplasty/Hernior-
rhaphy