DefnitionDefnition
 
AnatomyAnatomy  T#e inguina cana &'
 T#e inguina cana is appro(imatey ) cm ong an" is "irecte"
obi*uey
inerome"iay t#roug# t#e inerior part o t#e anteroatera ab"omina $a% T#e cana ies parae an" +') cm superior
to t#e me"ia #a o t#e inguina igament%T#is igament e(ten"s rom t#e anterior superior iiac spine to t#e pubic
tuberce%
 T#e inguina cana #as openings at eit#er en" & ,
 T#e "eep -interna. inguina ring is t#e entrance to t#e inguina cana% It is t#esite o an outpouc#ing o t#e transversais
ascia% T#is is appro(imatey 1%+/ cm superior to t#e mi""e o t#e inguina igament
 T#e superfcia0 or e(terna inguina ring is t#e e(it rom t#e
 
Inguina canaInguina cana $as o T#e inguina cana &'
 T#e anterior $a is orme" mainy by t#e aponeurosis o t#e
e(terna 2bi*ue
 
 
 T#e roo is orme" by t#e arc#ing fbres o t#e interna
obi*ue an"
transverse ab"omina musces%
 
 T#e 4oor is orme" by t#e inguina igament0 $#ic# orms a
s#ao$ troug#% It is reinorce" in its most me"ia part by t#e acunar
igament%
Content &'
1% 5permatic cor" - roun" igament o t#e uterus in emae .
 T#e Cor" Itse%6T#e contents o t#e spermatic cor" are
-a. t#e "uctus -vas. "eerens an" its artery %
 -b. t#e testicuar artery an" venous -pampiniorm. pe(us%
 -c. t#e genita branc# o t#e genitoemora nerve%
 -d . ymp#atic vesses an" sympat#etic nerve fbers%
 -e. at an" connective tissue surroun"ing t#e cor" an" its coverings in various amounts
+% Iioinguina nerve %
 
8emora Cana8emora Cana
 T#e major eature o t#e emora cana is t#e emora s#eat#%
 T#is s#eat# is a con"ensation o t#e "eep ascia -ascia ata. o t#e t#ig# an" contains0 rom atera to me"ia0 t#e emora artery0 emora vein0 an" emora cana% T#e emora cana is a space me"ia to t#e vein t#at ao$s or venous e(pansion an" contains a ymp# no"e -no"e o
 
anterior is t#e inguina igament
 posterior is t#e iiopsoas0 pectinea0 an" ong a""uctor musces -4oor.%
!e"ia is acunar igament
 
Pre"isposing&Pre"isposing&
 
usuay "ue tousuay "ue toC#ronic coug#
5training
Pregnancy
=omiting
Ascetic 4ui"
 Types Types
 
• In"irect Inguina Hernia Hernia t#roug# t#e inguina cana
• Direct Inguina Hernia  T#e sac passes t#roug# a $eaness or "eect o t#e
transversais ascia in t#e posterior $a o t#e inguina cana
• 8emora Hernia Hernia me"ia to emora vesses un"er inguina igament
• ?mbiica Hernia Hernia t#roug# t#e umbiica ring
• Paraumbiica Hernia A protrusion t#roug# t#e inea aba just above or sometimes  just beo$ t#e umbiicus
• Epigastric Hernia Protrusion o e(traperitonea at t#roug# t#e inea aba
any$#ere bet$een t#e (ip#oi" process an" t#e umbiicus
• Incisiona Hernia Hernia t#roug# an incisiona site
 
+%2ccupation - nature .
)%5ystemic symptoms& i t#ere is obstruction or stranguation
/%Precipitating actors
1%Inspection or site0 siBe0 s#ape an" coor%
+%Papation or surace0 temp0 ten"erness0 composition an" re"ucibiity%
7%E(pansibe coug# impuse%
 
#ernias#ernias
 
 
Indirect Inguinal Hernia Direct Inguinal Hernia
Pass t#roug# inguina cana% <uge rom t#e posterior $a o t#e inguina cana
Can "escen" into t#e scrotum% Cannot "escent into t#e scrotum%
9atera to inerior epigastric vesses% !e"ia to inerior epigastric vesses%
Re"uce"& up$ar"0 t#en ateray an" bac$ar"%
Re"uce"& up$ar"0 t#en straig#t bac$ar"%
Controe"& ater re"uction by pressure over t#e interna -"eep. inguina ring%
Not controe"& ater re"uction by pressure over t#e interna -"eep. inguina ring%
 T#e "eect is not papabe -it is be#in" t#e fbers o t#e e(terna obi*ue musce.%
 T#e "eect may be et in t#e ab"omina $a above t#e pubic tuberce%
Ater re"uction& t#e buge appears in t#e mi""e o inguina region an" t#en 4o$s me"iay beore turning "o$n to t#e scrotum%
Ater re"uction& t#e buge reappears e(acty $#ere it $as beore%
Common in c#i"ren an" young a"uts%
Common in o" age%
 
Note t#at e(amination using fnger an" t#umb across t#e nec o t#e scrotum $i #ep to "istinguis# a
 
5ma emora #ernia may be
 
History Age uncommon in c#i"ren 0 most
common in o" age emae % 5e( $omen men -but sti commonest
#ernia in $omen t#e inguina #ernia .  T#e patient came $it# oca symptoms 1' "iscomort an" pain +' s$eing in t#e groin @enera emora #ernia is more iey to
 
#ernia#ernia Inguinal hernia Femoral hernia
1-more common in mae 1-more common in emaes
2-pass t#roug# t#e inguina cana
2-pass t#roug# t#e emora cana
3-nec o t#e sac is above an" me"ia t#e pubic tuberce
3-nec o t#e sac is beo$ an" atera t#e pubic tuberce
4-ess common to be stranguate"
4-more common to be stranguate"
5-can be treate" $it#out surgery 5-must be treate" surgicay
6-t#e t$o "iagnostic signs o #ernia+
6-t#e t$o "iagnostic signs o #ernia-
 
5igns an" symptoms
Age "oesnt appear unti t#e umbiica cor" #as separate" an" #eae" %
No specifc symptoms
Have $i"e nec an" re"uce easiy 0 rarey give intestina obstruction%
 
E(amination Inspection 5ite in t#e center o t#e umbiicus 5iBe an" s#ape siBe can vary rom vary
sma to very arge % 5#ape is usuay #emisp#erica%
Papation Composition contain bo$e 0 $#ic# maes
it resonant to percussion % T#ey re"uce spontaneousy $#en t#e c#i" ies "o$n %
Re"ucibiity easy Coug# impuse invariaby present %
 
Ac*uire" umbiica #erniaAc*uire" umbiica #ernia
Hernia t#roug# t#e umbiica scar 0 so it is a true umbiica #ernia%
Not common an" is usuay secon"ary to increase intra ab"omina pressure%
 
Incision #erniaIncision #ernia
5igns an" symptoms Previous operation or acci"enta trauma Age a ages 0 but more common in o" age% 5ymptom ump 0pain 0intestina obstruction - "istention
0coic0 vomiting 0constipation 0 sever pain in t#e ump . E(amination 1' re"ucibe ump +' e(pansie coug# impuse 7' i t#e ump "ose not re"use an" "ose not #ave coug#
 
Preoperative assessmentPreoperative assessment
 
1% 9ab &
C<C & to c#ec #emogobin eve  anemia an" :<Cs  inections
?JE & to c#ec or any eectroyte imbaance
98Ts & in"icate" in jaun"ice" patients an" suspecte" #epatitis or any cotting probems
PT J PTT
+% Imaging &
C#est K ray & or a patients
 
Preoperative assessmentPreoperative assessment
current me"ications or aergies any major -c#ronic. iness pre op or"ers &
1% sin preparation
F% <a""er preparation
Inguinal floor 
&preparation&preparation
:atc#u :aiting 5urgica TTT
!ay be appropriate or pt $it# asymptomatic #ernia or e"ery pt $it# minima symptoms or easiy re"uce" inguina #ernia%
Routine F/U ith health care profe!!ional
" Randomi#ed trial concluded that thi! i! an accepta$le option for men ith minimall% !%mptomatic inguinal hernia and that dela%ing repair until !%mptom! increa!e i! !afe
due to lo rate of  incarceration '() of pt initiall% treated ith atchful aiting cro!!ed over to !urgical ttt due to increa!e in !%mptom! *mo!t often hernia+related
pain, - onl% . pt *(), e0perienced acute hernia incarceration ithout !trangulation ithin '%ear!- a !econd had acute incarceration ith
 
!ost pt are treate" surgicay
Increase IAP abnormaities -C#ronic coug#0 Constipation0 <a""er outet
obstruction. s#ou" be evauate" an" reme"ie" to e(tent possibe beore
eective #erniorr#ap#y%
In case o intestina obstruction an" possibe stranguation0 <roa" spectrum
 
?ncompicate"&
!anua @ente pressure over #ernia @ente traction over t#e mass   se"ation an" tren"eenburg position%
Compicate" -stranguate".&
 
preerre"
 
+%TTT 28 HERNIA9 5AC+%TTT 28 HERNIA9 5AC
INDIRECT& sac is "issecte" ree rom t#e cor" structures an" creamsteric fbers% 5ac s#ou" be open a$ay rom any #erniate" contents% Contents are t#en re"uce"0 an" t#e sac is igate" "eep to inguina ring $it# an absorbabe suture
DIRECT&  Too broa"y base" or igation an"
 
t#e inguina 4oor is necessary in a
a"ut #ernia repairs to prevent recurrence%
3.Inguinal
Floor
Reconstruction
repair 
Laproscopic&
1%Primary tissue repair1%Primary tissue repair
<assini repair& inerior arc# o transversais ascia -T8. or conjoint ten"on is appro(imate" to s#eving portion o inguina igament%
!c=ay& T8 is suture" to cooper igament%
5#ou"ice& T8 is incise" an" reappro(imate"%
 
+%2pen tension ree+%2pen tension ree
repairrepair 9ic#tenstein repair JPatc# an" Pug tec#ni*ue& !es# is use" to
reconstruct inguina 4oor
mes# in t#e #ernia "eect
 
 preperitonea repairspreperitonea repairs  TAPP -transab"omina prepeitonea proce"ure.& 
peritonea space entere" by conventiona ap at umbiicus an" peritoneum overaying inguina 4oor is "issecte" a$ay as 4ap%
 TEP -Tota e(traperitonea repair.& preperitonea space is "eveope" $it# a baoon inserte" bet$een posterior rectus s#eat# an" peritoneum  baoon in4ate" to "issect t#e peritonea 4aps a$au rom posterior ab"omian $a an" t#e "irect an" in"irect spaces0 ot#er ports inserte" into t#is preperitonea space $it#out entering peritonea cavity%
 
8emora #ernia repair8emora #ernia repair • 8emora #ernias s#ou" be repaire" very soon ater t#e "iagnosis #as been ma"e because o t#e #ig# ris o stranguation%
• T#ere is no pace or a truss or a emora #ernia%
• Di>erent approac#es &
 T#ree approac#es #ave been "escribe" or open surgery &
1%Inra'inguina approac# -9oo$oo".
+%5upra'inguina approac# - !cEve"y.
 
Eac# tec#ni*ue #as t#e principe o "issection o t#e sac $it# re"uction
 
9oc$oo"s inra'inguina9oc$oo"s inra'inguina
approac#approac#  T#e sac is "issecte" out beo$ t#e
inguina igament via groin crease incision%
 T#en t#e sac is opene" an" t#e contents are inspecte" an" re"uce" into t#e ab"omen%
 T#en t#e nec o t#e sac is pue" "o$n 0 igate" an" ao$e" to retract t#roug# emora cana%
 
!cEve"ys #ig# approac#!cEve"ys #ig# approac#
=ertica incision is ma"e over t#e emora cana an" continue" up$ar"s above t#e inguina igament%
 T#is incision provi"es goo" access to t#e preperitonea space an" t#en to t#e peritoneum itse%
?se fnger "issection to s$eep peritoneum rom anterior ab"omina $a 0 so t#e nec o t#e sac can be i"entife"%
 
approac#approac#  T#e incision is ma"e superior an"