ordinary book on Bedside clinics in Surgery the 2nd edition by. Dr Makhan Lal Saha published by M/s Jaypee Brothers Medical. Publishers (P) Ltd, New Delhi. Bedside Clinics SURGERY in Surgery r/ s.i ns isa e r.p iv p /: / t tp h r/ s.i ns isa e r .p iv p /: / t tp h Se o d ditio c n E n Bedside Clinics in Surgery. This second edition brings trainees fully up to date with the latest advances in general surgery. Each section has been fully revised and covers numerous.

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    Treatment History Whether using truss or not. In enterocele. When the hernia has reached the scrotum. This is no longer necessary to mention about this test in routine examination of hernia.

    In omentocele. The demonstration of this test is painful. Normally the superficial ring does not admit the tip of index finger. Test is positive when no impulse or hernial bulge is seen medial to the deep inguinal ring on coughing after the deep ring is occluded. This is a case of right-sided reducible complete indirect inguinal hernia containing intestine without any features of complication at present. The swelling appeared insidiously. On palpation temperature is normal and there is no tenderness over the swelling.

    The pain increases with straining as the swelling increases. Right sided inguinal hernia months. Skin over the swelling is normal and there is visible peristalsis and expansile impulse over the swelling.

    The swelling is pyriform in shape. The swelling disappears completely when the patient lies down. On local examination of inguinoscrotal regions. On physical examination general survey is essentially normal. Bladder and bowel habits are normal. No history of chronic constipation.

    Patient complains of a dull aching pain over the swelling for last 6 Figure 2. Summary of a case of inguinal hernia This 40 years male patient. Chapter 2 Hernias 41 E. Patient complains of chronic cough and breathlessness for last 3 years. The left inguinoscrotal region is normal and the systemic examination is also normal.

    Why do you say this is an inguinal hernia? This patient presented with a swelling in the groin which subsequently descended to the scrotum. The deep ring occlusion test is positive and on percussion the swelling is resonant and bowel sounds are audible over the swelling on auscultation.

    The swelling increased in size after walking and following strenuous activities. The content of the swelling reduces with a gurgling sound. What is your diagnosis? This is a case of right sided. Why do you say this is a case of hernia? This 40 years male patient presented with a swelling which started in right groin and subsequently increased in size and descended to the scrotum. The swelling is soft and elastic in feel. Why do you say this is an incomplete hernia?

    The hernia has extended upto upper pole of the right testis. The swelling extends above up to the deep inguinal ring and below upto the upper pole of right testis. What do you mean by Bubonocele? Bubonocele is an incomplete inguinal hernia where the hernial sac is confined to the inguinal canal Fig. In case of femoral hernia the hernial swelling lies below and lateral to the pubic tubercle. So this is an indirect inguinal hernia. On examination of inguinoscrotal region there is a right sided inguinoscrotal swelling as it is not possible to get above the swelling.

    What is hernia? Hernia is abnormal protrusion of a part or whole of a viscus through the wall of its containing cavity. So this is a hernia. Why do you say this is a reducible hernia? The content of the hernia can be reduced into the abdominal cavity. On inspection the swelling extends downward and forward from the inguinal canal upto the bottom of the scrotum.

    The testis and epididymis can be palpated separately from the hernial swelling. There is expansile impulse on cough over the swelling. This hernial swelling lies above and medial to the pubic tubercle. The swelling lies above and medial to the pubic tubercle. During reduction the hernial contents go upward and backward. On lying down swelling is reducible. So this is an inguinal hernia. The swelling disappears or reduces partially on lying down.

    On lying down the swelling is easily reducible. Why do you say this is an indirect and not a direct hernia? Indirect hernia is usually unilateral. The deep ring occlusion test is positive. From history. What are the differential diagnoses in this patient? The important causes of inguinal or inguinoscrotal swellings are: A Complete. So this is an enterocele. Testis and epididymis could not be felt seprately from the hernial swelling.

    What do you mean by complete hernia? In complete hernia the hernial contents reaches up to the bottom of scrotum. C Funicular Incomplete What is funicular type of inguinal hernia?

    In this type the hernial sac goes beyond the superficial inguinal ring and reaches upper pole of testis. B Bubonocele Incomplete. While attempting reduction. Why do you say this is an enterocele? By definition.

    The testis and epididymis can be felt separately from the hernial contents Fig. Types of inguinal hernia. Why hernia examination should be done in standing position? In majority of patients with hernia the swelling reduces on lying down position.

    So in lying down position the description of the swelling will be fallacious. This is visible expansile impulse on cough. It is possible to get about the swelling—scrotal swelling How will you demonstrate expansile impulse on coughing?

    On inspection patient is asked to cough—the expansile impulse on cough may be seen over the swelling. Start palpation at the scrotum Figure 2. So it is not possible to get above the swelling in case of inguinoscrotal swelling Figs 2.

    Palpation at root of scrotum—the swelling is still palpable—so it is not possible to get above the swelling—inguinoscrotal swelling A B Figures 2. Start palpating the swelling from the bottom of the scrotum between the thumb in front and index and middle fingers behind and gradually palpate upward toward the root of the scrotum. Figure 2. In case of the inguinoscrotal swelling the thumb and other two fingers do not meet at the root of the scrotum as the swelling continues in the groin.

    In case of a scrotal swelling the thumb and other two fingers meet each other at the root of the scrotum and only the spermatic cord is palpable inbetween the fingers.

    B At the root of scrotum swelling is not palpable—spermatic cord may be felt. In scrotal swelling it is possible to get above the swelling. A Start palpation at the scrotum. Normally the superficial inguinal ring does not admit the tip of index finger. Patient is asked to lie down and the hernial content is reduced. The expansile impulse can be appreciated by the palpating finger as the thumb and other fingers get separated Figs 2. How will you do invagination test? As discussed earlier the invagination test is no longer routinely done in hernia examination.

    The finger may go directly back into the inguinal canal suggesting this to be a direct inguinal hernia or the finger may go upward and laterally suggesting this to be an indirect inguinal hernia. Once the size of the superficial inguinal ring is assessed and when it is patulous. Palpate with the thumb infront and the index and middle finger behind and ask the patient to cough.

    The method for demonstration invagination is however described. Expansile impulse may be appreciated by the palpating fingers What other swellings show expansile impulse on cough? Apart from hernia the following swellings may show expansile impulse on Cough: A B Figures 2. The scrotal skin is invaginated with the tip of the index finger from the upper pole of the testis and the finger reaches upto the superficial inguinal ring Figs 2.

    Chapter 2 Hernias 45 On palpation: Patient lies down supine. Gentle squeezing is carried out with one hand alternating with the other till the hernia is reduced Figs 2. Push the index finger up to reach with the index finger from the upper pole of the superficial inguinal ring testis Do not take the testis up Figure 2. The other hand grasps the swelling near the fundus.

    Some cases require taxis for reduction of the hernia. Invagination test: The index finger assess the superficial inguinal ring How will you test for reducibility? In some cases hernia gets reduced once the patient lies down. The fingers of one hand surround the swelling near the superficial inguinal ring and guide the content through the superficial inguinal ring into the inguinal canal.

    In majority of cases patient can reduce the hernia better. Start invaginating the scrotal skin Figure 2. The position of deep inguinal ring is marked out. The anterior superior iliac spine is marked by following the groin crease towards the lateral side.

    Method for reduction of hernia: Finding the anterior superior iliac Figure 2. The first bony point at the lateral end is the anterior superior iliac spine. Keep fingers of one hand at the Patient lies down and Flex the hip and knee superficial inguinal ring and the other hand at the fundus of hernia sac and the hernia contents are then pushed upwards from the scrotum. The first bony point felt at the spine—pass the finger along the groin crease lateral end of the groin crease is anterior superior laterally iliac spine To find the pubic symphysis follow the midline from below the umbilicus.

    The fingers in the superficial ring guides the contents into the inguinal canal How will you do deep ring occlusion test? Patient is asked to lie down and the hernia is reduced. If you follow the iliac crest from back.

    The first bony point in the midline is the symphysis pubis Figs 2. The deep ring lies 1. Chapter 2 Hernias 47 Figure 2. If no expansile impulse is seen in lying down position patient is asked to stand with the deep ring occluded and is asked to cough again. The deep ring is located 1. Again look for any expansile impulse on cough medial to deep ring Fig. B The first bony point in the midline is the symphysis pubis Measure the distance between the anterior superior iliac spine and the symphysis pubis using a tape and take the midpoint at the inguinal ligament.

    This is midinguinal point which lies over the inguinal ligament. A Follow the midline below the umbilicus. The deep inguinal ring is marked 1. Look whether any cough impulse is seen medial to the deep ring. The midinguinal point is found out by measuring the distance between the anterior superior iliac spine and the symphysis pubis Figure 2.

    This is described as deep ring occlusion test is positive. Occlude the deep inguinal ring by pressing with the thumb How to interpret deep ring-occlusion test? On occlusion of deep ring and asking patient to cough—no expansile impulse on cough is seen medial to deep ring. On asking the patient to cough. On asking the patient to cough there is no expansile cough impulse medial to with the deep ring occluded.

    Three fingers are placed—index finger over the deep ring. Chapter 2 Hernias 49 Figure 2. This is described as deep ring occlusion test is negative. On occlusion of the deep ring and asking patient to cough—expansile impulse on cough is seen medial to the deep ring suggesting this to be direct inguinal hernia Fig. This is tested by rising test. He is asked either to lift the head and chest or both the legs above the bed. The contracting muscle may be palpated with the hand placed on the abdominal wall Figs 2.

    Patient lies supine on the bed. If there is weakness of abdominal muscles. Ask the patient keep his hands over the chest and lift the head above the level of bed and look at the flanks for appearance of any bulging. Patient is asked to lift the leg appearance of bulging in the flanks may also be above the bed leg rising and the tone of observed by leg rising test the abdominal muscles are assessed with the palpating fingers How will you differentiate inguinal and femoral hernia? Inguinal hernia lies above and medial and the femoral hernia lies below and lateral to the pubic tubercle Figs 2.

    Femoral hernia. Relation of pubic tubercle with inguinal tubercle. Chapter 2 Hernias 51 Figure 2. The finger is placed in the pubic Figure 2.

    Abdominal muscle tone and Figure 2. The hernial sac lies above and medial and femoral hernia to the pubic tubercle. How will you do percussion of hernia swelling? This is to be done with the patient in standing position. Trace the adductor longus tendon upwards. Percussion over the hernia swelling in standing position I will suggest following investigations: Leg adducted against resistance.

    The patient is asked to adduct the thigh against resistance. Dull percussion note—Suggest content is omentum omentocele. How will you differentiate direct and indirect inguinal hernia? I will do a pulmonary function test to exclude any obstructive or restrictive pulmonary disease.

    How will you manage this patient? This adult male patient presented with indirect complete uncomplicated reducible inguinal hernia. Resonant percussion note—Suggest content is intestine enterocele. I will plan for surgical treatment after some routine investigations. The tendon of the adductor longus is palpated at the upper medial aspect of the thigh. Less postoperative pain following regional anesthesia. After external oblique aponeurosis is incised the inguinal canal is exposed.

    If used with adrenaline larger volume may be used. What anesthesia will you prefer for hernia surgery in adult? What is the technique of local infiltration for inguinal hernia surgery? A large volume of local anesthetic is required so either lignocaine 0. After skin and subcutaneous tissue are incised similar infiltration is done deep to external oblique aponeurosis. The hernial sac is then infiltrated. Here 4 cm wide area is infiltrated from anterior superior iliac spine to symphysis pubis.

    There are two technique of local anaesthetic block: Shouldice technique: This is a type of field block with local anesthetic. In day care surgery units often the hernia operations are done under local anesthesia and patient is discharged on the same day. Chapter 2 Hernias 53 What operation will you do in this patient? I will consider Lichtenstein tension free mesh hernioplasty in this patient under regional anesthesia. The first layer of infiltration is subcutaneous tissue.

    Can this operation be done under local anesthesia? Hernia operation can also be done under local anesthesia. The lateral edge of the mesh is split around the cord at the deep inguinal ring. Lichtenstein described a technique of repair of both direct and indirect hernia by a tension free technique without closing the defect by direct suturing and by placement of a mesh in the defect of inguinal canal Fig. In case of large direct hernia this sac may be invaginated by imbricating suture using an absorbable suture to allow proper placement of the mesh.

    Chapter Local anesthetic point block 10 ml of 0. The external oblique aponeurosis is sutured in front of the spermatic cord. The hernial sac is dealt with by dissecting the sac and invaginating it into the abdomen. Describe the steps of Lichtenstein mesh hernioplasty. Procedure may be done under local anesthesia. The two split arch of the mesh are then crossed over each other and sutured down to the inguinal ligament to create a new deep ring.

    The superior edge is sutured to the conjoint tendon. The medial edge of the mesh is sutured to the rectus sheath. See Operative Section.

    Bedside Clinics in Surgery 2nd Edition

    What is Lichtenstein tension free repair? In Page No. How will you identify the neck of an indirect hernia sac? The indirect hernial sac is dissected upto the neck of the sac. While doing herniotomy where do you ligate the sac?

    The sac is dissected all around the deep inguinal ring twisted and ligated in the neck of the sac. What is herniotomy? Herniotomy involves dissection of the hernial sac and once the sac is dissected it is opened at the fundus. The neck of the indirect hernial sac is identified by: He reinforced the posterior wall of the inguinal canal by apposing internal oblique. What is the standard skin incision for inguinal hernia repair? The pain in postoperative period is less when hernial sac is not ligated proximally.

    The external oblique aponeurosis is sutured in front of the cord. He dissected the hernial sac upto the deep inguinal ring and ligated the neck of the sac high up near the deep inguinal ring. The hernial sac is twisted and ligated at the neck and redundant part of the sac is excised. The lower edge of the transversus abdominis aponeurosis and the conjoint tendon with fascia transversalis attached to it is apposed to inguinal ligament with interrupted non-absorbable suture. Bassini first performed herniorrhaphy.

    The defect closes rapidly within hours or days. The rectus sheath comes in the medial end of the repair. The content of the sac is reduced and a sliding component is excluded.

    An adequate incision provides good exposure for dissection of the sac and repair of posterior wall can be done easily. Why braided silk is not preferred for hernia repair? When can a patient return to normal activities after operation?

    So it is not an ideal suture for hernia repair. There is no evidence that lengthy rest reduces the chance of recurrence. Which suture is ideal for hernia repair?

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    Following hernia repair. The fascia transversalis is split from pubic tubercle to the deep inguinal ring. What is Shouldice repair for inguinal hernia? This is a multilayered repair of hernia first practiced at Shouldice clinic in Toronto.

    Patient can return to normal activities as soon as postoperative discomfort is over. He initially started repair of posterior wall in three layers and later modified it with repair in two layers. These sutures being braided polyfilament suture causes more tissue reaction. What is modified Shouldice repair for inguinal hernia? Berliner modified six layers repair of inguinal hernia.

    Eighty percent wound tensile strength is achieved in 6 months. Beginning at pubic tubercle a series of sutures are placed between the upper edge of the fascia transversalis and aponeurosis of transversus abdominis and the Cooper's ligament upto the medial margin of femoral vein.

    Particularly in patient with overt cardiac diseases. The second layer of continuous suture approximate the superior margin of fascia transversalis and transversus abdominis aponeurosis to the inguinal ligament. General complications: The Cooper's ligament is dissected by dividing the iliopubic tract.

    Local complications: What is Macvay repair for inguinal hernia? Usually caused by overzealous fluid administration leading to diuresis and atony of the overfilled bladder. What are the parts of a hernia? A hernia consists of: The external oblique aponeurosis is sutured in front of the spermatic cord in single layer.

    Chapter 2 Hernias 57 abdominis aponeurosis is apposed to lower leaf of fascia transversalis. The hernial sac has following parts Fig. What may be the different contents of a hernia?

    The hernia may contain different intra-abdominal structures which includes: When the hernia sac is exposed at the inguinal canal the coverings include the cremesteric muscle and fascia and the internal spermatic fascia. The hernial sac is the prolongation of the parietal peritoneum. What are the coverings of complete inguinal hernia?

    Apart from skin. What is sliding hernia? When the wall of the hernial sac usually the posterior wall is formed by a viscus then it is called a sliding hernia. The most distal closed part of the sac 4. On the right cecum or urinary bladder may form the posterior wall of the sac and on the left side sigmoid or urinary Figure 2. What do you mean by pantaloon or saddle bag hernia? A pantaloon hernia is described as having both a direct and indirect inguinal hernial sac lying on either side of inferior epigastric vessels.

    This can be: When the hernial sac is confined to the inguinal canal and does not reach beyond the superficial inguinal ring see Fig. When hernial sac goes beyond the superficial inguinal ring and reaches upto the upper pole of the testis see Fig. It is the extension of the inguinal ligament. Sliding hernias: A Posterior wall of hernia sac formed by urinary bladder. Chapter 2 Hernias 59 A B Figures 2. What are the different types of inguinal hernia depending on the distal extent of the hernia?

    The hernia may be: When the hernial sac reaches upto the bottom of scrotum and the testis cannot be felt separately see Fig. When the hernial sac does not descend upto the bottom of the scrotum. It is also known as dual hernia. What are the different techniques of hernioplasty? Abrahamson nylon darn repair: The principle of this operation is to reinforce the posterior wall of the inguinal canal with the muscle of the musculoaponeurotic arch along with a simple lattice of monofilament suture under no tension on which fibrous tissue develops.

    A third layer of suture may be applied from lateral to medial end thus providing a lattice of nylon suture in posterior wall of inguinal canal. The mesh is passed upward behind the cord. If the conjoined tendon and inguinal ligament cannot be apposed without tension then approximation is not forced and a gap is left between the inguinal ligament or the upper elements of repair.

    External oblique aponeurosis is sutured in front of the cord. When the repair of hernia is done by reinforcing the gap by placement of some prosthetic materials like mesh or natural tissues like fascia lata. The hernial sac is dealt with. The gap is bridged by a number of layers of the polypropylene suture. The suture is not tied tightly. The suture is then taken laterally taking bites below to the inguinal ligament and above to rectus sheath medially and laterally to the conjoint tendon and more laterally muscular part of transversus abdominis and internal oblique.

    The external oblique is closed in front of the cord. The mesh is fixed above by interrupted suture to the combined thickness of internal oblique. The first bite is to take over the most medial fiber of inguinal ligament over the pubic tubercle and then through the medial edge of the rectus sheath. The repair begins by suturing the medial edge of rectus sheath and the musculoaponeurotic arch conjoint tendon to the posterior portion of the inguinal ligament and to the iliopubic tract with a continuous suture of polypropylene.

    What is Rives prosthetic repair of inguinal hernia? When the deep ring is patulous. How is the mesh anchored in place? When correctly placed. A large sheet of mesh mersilene.

    This is called giant prosthetic reinforcement of visceral sac devised by Stoppa. What is the approach for placement of the mesh? The mesh may be placed in the preperitoneal space by either a midline abdominal incision or Pfannensteil incision. This technique is particularly useful for: How do you measure the size of the mesh required for a bilateral giant mesh placement?

    The mesh is chevron-shaped and the width of the mesh is 2 cm less than the distance between the two anterior superior iliac spines. There is presence of persistent processus vaginalis. The mesh stretches in the lower abdomen and pelvis from one end to the other enveloping the lower half of the parietal peritoneum with which it gets incorporated by scar tissue.

    The prosthesis may be fixed by a single suture to umbilical fascia only. Small indirect inguinal hernias. Unilateral mesh placement may also be done by an inguinal incision.

    Deep ring is patulous. Nyhus has classified groin hernias into four types: No defects in the deep inguinal ring or the inguinal canal. The vertical dimension equals the distance between the umbilicus and the symphysis pubis. What is Nyhus classification for groin hernia? Depending on the anatomical defects in the groin. What is the boundary of Fruchauds myopectineal orifice? Fruchaud myopectineal orifice is an osseo- myo-aponeurotic tunnel through which all the groin hernia comes out Fig.

    Inguinal canal intact. What do you mean by groin hernia? All the hernias occurring through the myopectineal orifice at the groin are grouped as groin hernias. Variable defect in the deep inguinal ring or the inguinal canal. This orifice is bounded by: Anatomy of inguinal canal see Surgical Figure 2. These include the indirct inguinal hernia. All recurrent hernias. Patent processus vaginalis—Snug internal inguinal ring.

    This includes large indirect inguinal hernias. What are the characteristics of irreducible hernias? The contents of the hernial sac cannot be reduced inside the abdomen on lying down or after manipulation. What do you mean by obstructed hernia? Hernia containing intestine may lead to acute intestinal obstruction due to obstruction of the lumen of the gut inside the hernia. The hernia may become irreducible.

    Chapter 2 Hernias 63 What are the complications of hernia? Untreated the hernias may lead to a number of complications. Apart from irreducibility there are no symptoms and signs. Patient complains of pain over the swelling and may be febrile. The hernial contents may be indented with the finger. What do you mean by incarcerated hernia? This is a type of obstructed hernia where the lumen of the colon is blocked with faecal matter.

    In addition to irreducibility patient complains of colicky pain initially over the hernia and later on colicky abdominal pain. What do you mean by inflamed hernia? When the contents of the hernial sac get inflamed. The hernial swelling becomes irreducible. The term incarcerated hernia is often used as an alternative to obstructed or strangulated hernia. What are the characteristics of strangulated hernia? Due to impairment of blood supply there is ischaemic necrosis of the hernial contents.

    These includes: This is usually due to adhesion of the hernial contents. The hernia becomes tense and tender and there may be visible peristalsis over the hernia. So irreducible hernia should be operated early. The ischemic gut may perorate leading to initially localised and then generalised peritonitis and septicemia.

    In strangulated omentocoele the symptoms and signs may be mild and if not relieved ischemic necrosis of omentum may lead to bacterial invasion leading to a localised abscess. In strangulated enterocoele symptoms and signs are more severe with features of acute intestinal obstruction and if not treated patient condition will deteriorate rapidly.

    Unrelieved the patient may present with cardinal features of acute intestinal obstruction—pain abdomen. Unrelieved the obstruction may lead to impairment of blood supply to the gut causing strangulation of the hernial contents. What are the aetiological factors for development of hernia? Any chronic straining factors like chronic cough, lower urinary tract obstruction, straining at defecation may increase the intraabdominal pressure which may be one of the important precipitating factor for development of hernia.

    May cause stretching of muscles due to interposition of fat in between muscles which makes the muscles weak. Fat may also weakens the fascia and aponeurosis and may lead to hernias. Smoking may result in an acquired collagen deficiency and may result in hernia. What is herniography? Radiographic contrast material is injected into peritoneal cavity and patient is turned to different position. X-ray of local area will demonstrate contrast in the hernial sac, if hernia is present.

    A 60 years male patient with a right sided incomplete, direct, reducible inguinal hernia containing intestine with features of benign prostatic enlargement. As this patient has chronic urinary obstruction due to prostatic enlargement, I will do the following special investigations in addition to routine investigation.

    If the patient has significant prostatic enlargement how will you treat this patient? As the patient has significant prostatic enlargement, the patient should be treated by prostatectomy and hernia repair in same sitting.

    I will do transurethral resection of prostate and right-sided inguinal hernioplasty in same sitting. What is the role of medical treatment in benign prostatic hyperplasia? See Page No. Can you do open prostatectomy and hernia repair in same sitting?

    This can also be done. A Pfannensteil incision extending slightly to the side of hernia is suitable. A transvesical or retropubic prostatectomy and repair of hernia may be done in same sitting. What is direct inguinal hernia? What are the characteristics of direct inguinal hernia? Smoking, strenuous activities, damage to ilioinguinal nerve are predisposing factors.

    What is funicular direct inguinal hernia? The chance of strangulation is high in this variety or direct inguinal hernia. How will you tackle a direct hernial sac? The neck of the sac is wide and hernia is usually incomplete.

    After dissection of the hernial sac it may just be inverted into the peritoneal cavity. Excision of the sac is usually not required. In case of a large hernial sac the fascia transversalis may be plicated to keep the sac reduced. Only when direct hernial sac is like a diverticulum with a narrow neck, the sac is dissected, ligated at neck and redundant sac is excised.

    How will you differentiate a direct and indirect inguinal hernia at operation? In direct hernia there is usually a wide gap in the posterior wall of the inguinal canal so Iwill consider Lichtenstein tension free mesh hernioplasty in this patient.

    What are other techniques for repair of direct inguinal hernia? This is a case of recurrent right sided complete, reducible indirect inguinal hernia containing omentum Fig. Right sided recurrent inguinal hernia. What is the most important factor for development of recurrence after operation?

    What are the important causes of recurrence of hernia? What are the problems of surgery in recurrent hernia? Because of previous repair, the anatomy of the inguinal canal is distorted.

    There is scarring of tissues. The hernia usually descends through a large defect in the inguinal canal. What investigations will you do in this patient?

    I will do a routine workup to assess his fitness for surgery. Other special investigations depending on any underlying disease: What operation will you do in this patient? As the patient has undergone an open operation earlier, it will be difficult to dissect the different layers in the inguinal canal.

    It is preferable to do a laparoscopic mesh repair of hernia in this patient. What other operation may be suitable to this patient? What is the indication of orchiectomy? When in a recurrent hernia cord cannot be dissected free from the scar tissue then excision of the cord and orchiectomy may be considered.

    Orchiectomy may also be required when cord has been damaged during dissection or in repair of complicated recurrent hernia. Informed consent is to be taken for orchiectomy. What is the role of laparoscopic repair of inguinal hernia? Advances in laparoscopic surgery made possible management of groin hernias with laparoscopy.

    There are two techniques for laparoscopic groin hernia repair: Transabdominal preperitoneal repair TAPP repair 2. Totally extraperitoneal repair TEP repair: Describe the steps of TAPP operation.

    Puliyur Krishnaswamy Duraiswami

    Describe the steps of TEP operation: Particulars of the Patient 2. Relation of pain with the swelling, any aggravating or relieving factor. The operative history includes, type of operation, emergency or elective, nature of operation, postoperative recovery, any history of cough or abdominal distension in the postoperative period any wound infection, any wound gaping or burst abdomen, whether required secondary suture, duration of hospital stay.

    Time gap between the operation and appearance of swelling. Past History Detail history about the operation, if not included in history of present illness. Treatment History Whether using abdominal belt. Any History of Allergy. General Survey 2. Examination of abdomen Detail abdomen examination: What is your case? This year female patient developed gradual onset of a swelling in lower abdomen since last 1 year.

    Following hysterectomy patient developed wound infection and the wound required dressings for about 2 months for healing. One year back the swelling appeared at the site of abdominal wound, starting at the lower end of the wound, gradually increased in size over the last 1 year with occasional episodes of pain, dull-aching in nature, which Figure 2.

    Incisional hernia aggravated when the swelling increases in size and gets relieved on rest when the swelling reduces in size. The swelling appears on standing and walking and gets aggravated on coughing and other strenuous activities and disappears fully on lying down and manipulation by the patient.

    There is no period of irreducibility. She is not a known diabetic and hypertensive Fig. On examination patient is obese. There is a wide-scar of lower-midline incision in right abdomen. The skin over the swelling is tense, thinned out with evident visible-peristalsis. The gap in the abdomen is about 6 cm vertically and 4 cm horizontally in diameter.

    No other organomegaly or lump abdomen detected. Chest is clear. Cardiovascular system appears within normal limit. This is a case of incisional hernia through lower midline incision following hysterectomy, content of hernia being intestine and it is reducible.

    What operative history is relevant in a case of incisional hernia? How will you assess the gap in the abdominal wall? The hernial content is reduced and the gap in the anterior abdominal wall may be felt with the fingers.

    Patient is asked to lift both the legs with knee extended and with both arms folded over chest. This causes contraction of muscle of abdominal wall and hernial gap may be felt distinctly. In an irreducible hernia the gap cannot be felt properly. What are the important causes for development of incisional hernias? Many factors singly or in combination are responsible for development of incisional hernia.

    Poor surgical technique: Non-anatomic incision: Method of closure: Layered closure has higher incidence of developing incisional hernia than wound closed in single layer.

    Inappropriate suture material: Maximum strength is gained in 1 year. Sutures are responsible for maintaining wound strength for 6 months. Wound closed with nonabsorbable suture material are followed by a far lesser incidence of postoperative hernia than wound closed with absorbable suture. Suturing technique: Closing abdominal incision with suturing under tension causes pressure necrosis of intervening tissues and is an important cause for development of incisional hernia. Drainage tube: When drain tubes are brought out through the main wound the chance of developing incisional hernia is increased.

    Preoperative straining factors: Chronic cough, chronic constipation and urinary obstruction. Postoperative complications: Abdominal distension, cough, respiratory distress due to pneumonia or lung collapse, and postoperative wound infection. General factors: Age elderly patients , malnutrition, hypoproteinemia, jaundice, malignancy, diabetes, chronic renal failure, steroid or immunosuppressive therapy and alcoholism.

    Tissue failure: Late development of hernia after 5, 10 or more years after operation is usually associated with tissue failure. Abnormal collagen production and maintenance has been shown to be associated with increased incidence of incisional hernia.

    When does majority of incisional hernia start? Majority of incisional hernia starts in the immediate postoperative period due to partial disruption of deep layers of the wound. As the skin remains intact the event may pass unnoticed in immediate postoperative period.

    What are the types of defects in incision line? The hernial opening may vary in size. The whole of the incision line may have a long and wide gap. A small area may have gap or there may be multiple gaps along the incision line. What is the role of rectus abdominis muscle in midline incisional hernia?

    Due to gap in midline the rectus muscle is stretched and pushed laterally. Contraction of rectus muscle now expels the abdominal contents out into the hernial sac rather than retaining them into the abdominal cavity. What are the problems with large incisional hernias? If this continues for a long time the intra- abdominal capacity is reduced. During operation, if such contents are reduced into abdominal cavity forcibly under tension, it may cause compression of inferior vena cava and may also cause splinting of diaphragm leading to respiratory distress abdominal compartment syndrome.

    It may be difficult to raise the intra-abdominal pressure leading to problems of micturition and defecation. Skin becomes atrophic devoid of subcutaneous fat and spontaneous ulceration may develop in the skin.

    Does all incisional hernia need operation? Attacks of subacute intestinal obstruction, irreducibility and strangulation are definite indications for repair of incisional hernias. What operation is preferable for this patient?

    In those cases anatomical repair may be done. So a mesh repair is preferable in this patient. In case of midline incisional hernia what do you mean by anatomical repair? The skin flaps are raised. What do you mean by anatomical repair in case of hernias through paramedian incision? The lateral edge will be composed of anterior and posterior rectus sheath and rectus muscle between, then with all three layers fused by scar tissue.

    The lateral edge is incised and the anterior and posterior rectus sheath is dissected free. Mass approximation of the medial and lateral edge by continuous or interrupted polypropylene suture taking good bite of tissue from the edge. What is Shoelace darn technique for repair of incisional hernia?

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