This Presentation describes the historical background of ALMOST ALL types of hernia that general surgery resident can face, along with the rationale of why each type of hernia is so named.

1. Etymology of Hernia
Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore

2. Etymology
• Hernia means – ‘To bud’ or ‘to protrude’,
‘off shoot’ (Greek)
‘Rupture’ (Latin)

3. Parts of Hernia
• Sac
– diverticulum of peritoneum with mouth, neck, body and fundus.
– Neck is narrow in indirect sac but wide in direct sac
• Hernia without neck: Those hernias with larger mouth lack neck, e.g.
direct hernia, incisional hernia
– Body of the sac is thin in infants, children and in indirect sac but
is thick in direct and long standing hernia.
– Hernia without sac:
• Epigastric hernia—it is protrusion of extra-peritoneal pad of fat
• Covering
– layers of the abdominal wall through which the sac passes

4. Parts of Hernia
• Contents
– Omentum—Omentocele (Epiplocele). Difficult to reduce the sac later, initially it can be
reduced easily.
– Intestine—Enterocele— commonly small bowel, but sometimes even large bowel.
Difficult to reduce the sac initially.
– Richter’s hernia: A portion of circumference of bowel is the content.
– Urinary bladder may be the content or part of the posterial wall of the sac—cystocele.
– Ovary, often with fallopian tube.
– Meckel’s diverticulum—Littre’s hernia
– Fluid:
• secreted from congested bowel or omentum or
• infected fluid or
• ascitic fluid or
• blood from the strangulated sac.

5. Clinical Classification
• Reducible hernia
– Reduced on its own or by patient or by surgeon
– Expansile cough impulse positive
• Irreducible hernia
– Contents can’t be returned to abdomen due to
• narrow neck,
• adhesions(incarcerated),
• overcrowding
– Predisposes to strangulation
Enterocele Reduces with gurgling difficult to reduce 1st portion
Omentocele doughy difficult to reduce last portion

6. Clinical Classification
• Obstructed hernia
– Lumen of gut present in the hernial sac gets obstructed like any intestinal
obstruction
– NOT seen in omentocele or richter’s hernia
• Inflamed hernia
– Inflammation of contents of sac
– e.g. appendicitis and salpingitis
– Tender but NOT tense with red and edematous overlying skin
• Strangulated hernia
– Compromised blood supply
– Tense as well as tender with no cough impulse
– Associated with obstruction in case of enterocele (exception: Richter’s hernia)

7. • Garrey’s Stricture
– Constriction due to ischemic narrowing of small
bowel which has reduced from an obstructed
hernia

8. Richter’s Hernia
• Portion of antimesenteric border of gut gets
incarcerated and eventually strangulated
without obstruction of lumen in the hernial
orifice
• segment of the engaged bowel is nearly
always the lower portion of the ileum
– but any part of the intestinal tract, from the
stomach to the colon, including even the appendix

9. Richter’s Hernia
• Precondition for the formation of this
particular hernia, as stated by Richter, is
determined by the size and consistency of the
hernial orifice
– big enough to ensnare the bowel wall, but small
enough to prevent protrusion of an entire loop of
the intestine
– margin of the hernial ring must be firm or, in
Richter’s words, “possess strong spring-force.

10. Richter’s Hernia
• Tend to progress more rapidly to gangrene than
ordinary strangulated ones
– firm constricting ring that exerts direct pressure on the
bowel wall
– free border of the intestine opposite the mesentery with
the predominance of terminal arterioles that is involved
– late diagnosis or even misdiagnosis, thus allowing time for
bowel necrosis to develop.
• Also seen at site of laparoscopy port site
– Thus incidence might increase with time
– Especially if fascia not closed at 10 mm port site

11. Richter’s Hernia
• first description of a case of Richter’s hernia was
made by Fabricius Hildanus (1560–1634) in 1606
– illustrates a typical clinical presentation of a
perforated Richter’s hernia
• In his famous Treatise on the Ruptures in 1785,
August Gottlob Richter (1742–1812) gave the first
comprehensive description of hernias in which
only part of the circumference of the bowel is
strangulated, and termed them “the small
ruptures.”

12. Richter’s Hernia
• The nomenclature of this hernia subsequently
resulted in confusion
• Only 100 years later, in 1887, did the famous London
surgeon Sir Frederick Treves distinguish these types of
hernias from herniation of a Meckel diverticulum, which
was classically described by Littre.
• Treves credited Richter with the distinction of having given
the first scientific description of this particular lesion and
suggested the term Richter’s hernia,
– “(partly) because with Richter must rest the main credit of
establishing the individuality of this lesion.”
Sir Frederick Treves
(1853–1923)

13. Richter’s Hernia
• 10% of strangulated hernias are Richter’s hernias (5–15%)
• 60 to 80 years old
– but cases have been described even in infants
• In whites, the most common site is the femoral ring (36–
88%),
– followed by the inguinal canal (12–36%) and abdominal wall
incisional hernia (4–25%).
– Rare sites, such as
umbilical, Obturator, supravesical, spigelian, triangle of
Petit,sacral foramen, Morgagni, internal,or (traumatic)
diaphragmatic hernias

14. Richter’s Hernia
• since the first description of a Richter’s-type
herniation through a laparoscopy incision in
1977
– similar case reports have increasingly been
published

15. Busoga Hernia
• variety of direct inguinal hernia common in the Busoga
area of Uganda and some other African countries,
including South Sudan and Ghana where it particularly
occurs in women.
• caused by a narrow defect in the conjoint tendon or
transversalis fascia and consequently there is a risk of
strangulation.
– The neck of the sac is small, so that when strangulation
occurs, often only part of the circumference of the gut is
involved causing what is known as a Richter's hernia

16. Littre’s Hernia
(persistent omphalomesenteric duct hernia)
• Alexis de Littre (1700) reported ileal diverticula and
attributed them to traction.
– report three cases of incarcerated femoral hernia containing a
small bowel diverticulum
• August Gottlieb Richter (1785) defined them as preformed,
and
• Johann Friedrich Meckel (1809) postulated their
embryologic origin.
• Sir Frederic Treves (1897) distinguished between Littre and
Richter hernia (partial enterocele)
Johann Friedrich Meckel (1781–1833),
German anatomist

17. Litre’s Hernia
• also described the mucous urethral
glands of the male urethra (littre’s
gland)
• first to suggest the possibility of
performing a lumbar colostomy for
an obstruction of the colon
• Jean Louis Petit was one of his
students. So was Jacques-Bénigne
Winslow in 1707
Alexis Littré
(1654 – 1726)
French physician and
anatomist

18. • Meckel's diverticulum an out-pouching of the ileum, part of
the small intestine, and found in approximately 2% of the
population.(1809)
• Meckel's cartilage A cartilaginous bar from which
the mandible is formed. Described in 1820.
• A syndrome – Meckel syndrome – is also named after him.
This condition was described in 1822.
• A protein – mecklin – the gene for which is found
on chromosome 8 (8q21.3-q22.1) is named after him.

19. Amyand Hernia
• rare form of inguinal hernia in which the
vermiform appendix is located within the
hernial sac.
• Seen in < 1% of inguinal hernia
• Claudius Amyand (1681-1740), French born English
surgeon
– performed the first successful appendectomy in 1735, on
an 11-year-old boy who presented with an inflamed,
perforated appendix in his inguinal hernia sac

20. De Garengeot Hernia
• appendix-containing incarcerated
femoral hernia
• Akopian and Alexander, named this hernia
after the 18th century Parisian surgeon Rene
Jacques Croissant de Garengeot(1688-1759).
– He is quoted in the surgical literature as the first
to describe this situation in 1731.

21. Maydl's hernia (Hernia-in-W)
• hernial sac contains two loops of bowel with another
loop of bowel being intra-abdominal
– loop of bowel in the form of 'W lies in the hernial sac and
the centre portion of the 'W loop may become
strangulated, either alone or in combination with the
bowel in the hernial sac
– more often seen in men, and predominantly on the right
side
• Postural or manual reduction of the hernia is contra-
indicated as it may result in non-viable bowel being
missed
Karel Maydl (1853 –1903)
Austrian surgeon

22. Gibbon’s Hernia
Hernia with Hydrocele
Edward Gibbon
(1737–1794)
English historian and Member of Parliament
Suffered from hydrocele;
Due to in fashion close fit clothing his conditions lead to chronic and disfiguring inflammation
followed by numerous surgeries, last 3 of which lead to peritonitis and eventually death

23. Berger’s Hernia
Hernia in pouch of Douglas
(Cul-de-sac)
______________________________________________________________________________
Berger(’s) Disease/syndrome ( IgA Nephropathy/nephritis)
-associated with Henoch Schonlein Purpura(HSP)
Buerger(’s) Disease (Thromboangiitis Obliterans/Presenile Gangrene)
(Winiwarter–Buerger syndrome)

24. History of Berger Disease
• In 1801, William Heberden, English Physician (1710-1801) first
described the disease
– in a 5-year-old child with abdominal pain, hematuria, hematochezia
and legs purpura
• In 1837, Johann Lukas Schönlein*, German naturalist and
professor of medicine (1793-1864) described
– purpura rheumatica (Schönlein's disease) an allergic non-
thrombopenic purpura rash(now HSP)
.
___________________________________________________________________
*also discovered the parasitic cause of ringworm or favus (Trichophyton schönleinii)
*also attributed with naming the disease, Tuberculosis, in 1839
(Prior to Schönlein's designation, Tuberculosis had been called
"consumption“)

25. History of Berger Disease
• In 1868, Eduard Heinrich
Henoch, German physician (1820 –1910)
– a student of Schönlein's,
– further associated colic bloody diarrhea, painful joints
and renal involvement
• Jean Berger (1930–2011)
– Pioneering French Nephrologist and Pathologist
– in 1968, were the first to describe IgA deposition in
this form of glomerulonephritis

26. William Heberden Johann Lukas Schönlein

27. Eduard Heinrich Henoch Jean Berger

28. History of Buerger Disease
• In 1876, Carl Friedländer*, German pathologist and microbiologist (1847–
1887)
– referred to it as "arteritis obliterans".
• In 1879, Felix von Winiwarter, Austrian Physician (1852 -1931)
– 57-year old male patient who had an unusual obliteration of
the arteries and veins of the leg
– attributed this disorder to new growth of tissue from the intima, and
– proposed the name "endarteritis obliterans" for the disease
• In 1908, Leo Buerger, Austrian American Pathologist, Surgeon & Urologist
(1879–1943)
– called it "presenile spontaneous gangrene" after studying amputations in 11
patients.
– in 1924 published a monograph based on analyses taken from 500 patients
*died a premature death, aged 39 or 40, after a brief stint with a respiratory
disease, believed to be caused by his discovered infectious organism,
the Friedlander's Bacillus (Klebsiella pneumoniae )

29. Felix von Winiwarter

30. Pouch of Douglas*
• Also called
– Rectouterine pouch/excavation
– Rectovaginal/Ehrhardt-Cole Recess
– Douglas pouch/cavity/space/cul-de-sac (cavum
Douglasi)
* Scottish anatomist Dr. James Douglas (1675–1742)
Three other nearby anatomical structures are also named for him –
the Douglas fold, the Douglas line and the Douglas septum

31. • Douglas fold
– A fold of peritoneum forming the lateral boundary of
Douglas' pouch.
• Douglas line
– The arcuate line of the sheath of the rectus
abdominis muscle.
• Douglas septum
– The septum formed by the union of Rathke's folds,
forming the rectum of the fetus

32. Pantaloon Hernia
(Double/Dual Hernia, Saddle Hernia & Romberg Hernia)
Ipsilateral, concurrent direct and indirect
inguinal hernias

33. Pantaloon Hernia
(Double/Dual Hernia, Saddle Hernia & Romberg
Hernia)
Italian Pantalone
(Pan:all Leone: Lion)
(Greek: Παντελεήμων [Panteleímon], "all-compassionate")
• After San Pantalone (Saint Pantaleon; died 303 AD)
– Roman(venetian) Physician & Martyr
• Character in Commedia Dellarte(16th century)
– Skinny old dotard ( foolish merchant- venetian) who wears
spectacles, slippers & tight fitting combination of trousers
& stockings (Baggy trousers)

34. 13th Century Icon of Saint Panteleimon, including scenes from his life,
from the Monastery of St. Katherine on Mount Sinai.

36. Pantaloon Hernia
(Double/Dual Hernia, Saddle Hernia & Romberg Hernia)
• Buffoon in pantomimes
– Foolish vicious absurd old man
– Stock character
– Accomplice/butt of clown’s jokes/tricks
• Wide breeches worn especially in England
during reign of Charles II
– Extending from waist to ankle

37. Pantaloon Hernia
(Double/Dual Hernia, Saddle Hernia & Romberg Hernia)
• Close fitting trousers usually having straps
passing under instep & worn especially in 19th
century
• Loose fitting usually shorter than ankle length
trousers
• Garment’s brand name

39. Etymology
saddle (n.)
Old English sadol "seat for a rider," from Proto-Germanic *sathulaz (cognates: Old
Norse söðull, Old Frisian sadel, Dutch zadel, zaal, German Sattel "saddle"), from PIE *sed- (1)
"to sit" (cognates: Latin sedere "to sit," Old Church Slavonic sedlo "saddle;" see sedentary)
. Figurative phrase in the saddle "in an active position of management" is attested from
1650s. Saddle stitch (n.) was originally in bookbinding (1887).
saddle (v.)
Old English sadolian "to put a riding saddle on;". The meaning "to load with a burden" is first
recorded 1690s. Related: Saddled; saddling.

40. Moritz Heinrich Romberg
(1795 – 1873)
German Physician

41. Obturator Hernia
• Hernia through the obturator foramen/canal
Obturator comes from the Latin obturare, to close up/obstruct. The obturator foramen of
the os coxa, completely covered by a membrane, was named by the great French surgeon
AmbroiseParé in 1550,
Ambroise Paré
(1510 – 1590)
French barber surgeon

42. Howship–Romberg sign
( Romberg sign)
• Obturator nerve neuropathy due to
compression of it by an obturator hernia
– pain and paresthesia along the inner aspect of the
thigh, down to the knee(referred pain through
geniculate branch of obturator nerve)
– inner thigh pain on internal rotation of the hip
John Howship Moritz Heinrich Romberg
(1781 –1841) (1795-1873)
English surgeon German Physician
(died of leg abscess)

43. Lumbar Hernia
• New Latin lumbaris, from Latin lumbus loin
• In tetrapod anatomy,
– lumbar is an adjective
– that means of or pertaining to the abdominal
segment of the torso, between the diaphragm and
the sacrum (pelvis)

44. Lumbar Triangle for Lumbar Hernia
Border
Inferior Iliac Crest
Anterior External oblique
Posterior Latissimus Dorsi
Floor Internal Oblique
Inferior lumbar (Petit) triangle
Superior lumbar (Grynfeltt-Lesshaft) triangle
Border
Superior 12th rib
Medial Quadratus Lumborum
Lateral Internal Oblique
Floor Transversalis Fascia
Roof External Oblique

45. Jean-Louis Petit
(1674 – 1750)
French surgeon

46. Grynfeltt described a hernia through
the superior lumbar triangle in 1866
Lesshaft independently reported
a similar case in 1870

47. Femoral Hernia
• Hernia through the femoral canal

48. Retrovascular hernia (Narath’s hernia) The hernial sac emerges from the
abdomen within the femoral sheath but
lies posteriorly to the femoral vein and
artery, visible only if the hip is
congenitally dislocated
Velpeau hernia The hernia sac lies in front of the femoral
blood vessels in the groin
External femoral hernia of Hasselbach and
Cloquet
The neck of the sac lies lateral to the
femoral vessels.
Transpectineal femoral hernia of Laugier The hernia sac transverses the lacunar
ligament or the pectineal ligament of
Cooper
Callisen’s or Cloquets hernia The hernial sac descends deep to the
femoral vessels through the pectineal
fascia
Béclard's hernia The h ernia sac emerges through the
saphenous opening carrying the
cribriform fascia with it
De Garengeot's hernia This is a vermiform appendix trapped
within the hernial sac.

49. Retrovascular Hernia
• Narath’s Hernia
– Behind femoral artery in congenital dislocation of
hip
• Serofini’s Hernia
– Behind femoral vessels
Albert Narath
(1864 –1924)
Austrian surgeon & anatomist

50. Velpeau (Prevascular/Teale’s) Hernia
• Hernia in front of femoral vessels
Alfred-Armand-Louis-Marie Velpeau
(1795 – 1867)
French anatomist and surgeon

51. Velpeau
• Provides 1st accurate description of leukemia in 1827
• Velpeau Bandage
– A wrapping used to immobilize the arm to the chest wall
• Velpeau's disease
– Hidradenitis suppurativa
• Velpeau's canal
– Inguinal canal
• Velpeau's fossa
– Ischiorectal fossa

52. External femoral hernia of Hasselbach and Cloquet
(Hesselbach Hernia)
neck of the sac lies lateral to the femoral vessels
Franz Kaspar Hesselbach
(1759 – 1816)
German surgeon & anatomist

53. Hesselbach
• Cribriform fascia
– Hesselbach's fascia
• Interfoveolar ligament
– Hesselbach's ligament
• Inguinal triangle
– Hesselbach's triangle

54. Cloquet’s (Callisen’s) Hernia
femoral hernia perforating the aponeurosis of
the pectineus (Pectineal fascia) and insinuating
itself between this aponeurosis and the muscle,
lying therefore behind the femoral vessels
Jules Germain Cloquet
(1790 –1883)
French physician and surgeon

55. Cloquet’s
– Cloquet canal(Hyaloid Canal)
• minute canal running through the vitreous from the discus
nervi optici to the lens.
– Cloquet's septum(Femoral Septum)
• Fibrous membrane bounding the annulus femoralis at the
base of the femoral canal
– Cloquet's gland/node
• 1 of the deep inguinal lymph nodes located in or adjacent to
the femoral canal
• Also called Rosenmuller node/gland

56. Béclard's hernia
Hernia sac emerges through the saphenous
opening carrying the cribriform fascia with it
Pierre Augustin Béclard
(1785 – 1825)
French anatomist and surgeon

57. Beclard’s
• Béclard's nucleus
– core of ossification in the cartilage of the
distal epiphysis of the femur during the latter part of
fetal life
– Use in forensic medicine to determine the age of
a fetus or newborn infant
• Beclard's anastomosis(arcus raninus)
– Anastomosis between the right and the left end-
branch of the deep lingual artery

58. Beclard’s
• Béclard's triangle
– Area whose boundaries are the posterior border
of the hyoglossus, the posterior belly of
the digastric muscle and the greater horn of
the hyoid bone

59. Transpectineal femoral hernia of Laugier
(Laugier’s Hernia)
Hernia sac transverses the lacunar ligament or
the pectineal ligament of Cooper
Stanislas Laugier
(1799 - 1872)
French surgeon
Laugier sign
In fracture of the lower portion of
the radius, the styloid processes of the
radius and of the ulna are on the same
level

61. Phantom Hernia
• a muscular bulge as a result of local muscular
paralysis due to interference with nerve
supply of the affected muscles, like
poliomyelitis.
– common in lumbar region
– often seen in lower abdomen
Phantom:
Something apparently seen, heard, or sensed, but having no physical reality

62. Phantom
• Phantom limb
– feeling of pain in amputated toe or limb
• Phantom tumour
– tumour like lesion in lung like interlobar pleural
effusion

63. Gluteal & Sciatic Hernia
• protrusion of the peritoneal sac through the greater or
lesser sciatic foramen
• Classified based on their relationship to the pyriformis
muscle and ischial spine.
– 1. Suprapyriformis. Through greater sciatic foramen
– 2. Infrapyriformis. (Gluteal Hernia)
– 3. Subpyriformis.  Sciatic Hernia
• Sac lies deep to gluteus maximus.
– Large hernias protrude below the buttock crease.

64. Interparietal (Interstitial) Hernia
• Herniation through parietal peritoneum into various layers of the
abdominal wall
• Common in Down’s syndrome, Prune Belly syndrome
• Often it can attain large size
• May mimic abdominal wall lipoma; haematoma
• As neck of the sac is often narrow, can present with irreducibility or
obstruction
• Commonly it is deep to external oblique aponeurosis

65. • Types
– Preperitoneal - between peritoneum and transversus
abdominis muscle – 20%
– Interparietal / intermuscular-between external
oblique and internal oblique; commonest – 60%.
• It is commonly associated with inguinal hernia
– Extraparietal (inguino superficial) – herniates through
external oblique aponeurosis into subcutaneous plane
– 20%

66. Spigelian Hernia
(Lateral Ventral Hernia)
• type of interparietal hernia occurring at the
level of arcuate line through spigelian point
• Hernial sac lies either deep to the internal
oblique or between external and internal
oblique muscles
• common between arcuate line to umbilicus

67. Spigelian Hernia
• a hernia through the spigelian fascia, which is
the aponeurotic layer between the rectus
abdominis muscle medially, and the semilunar
line laterally
• occur through spigelian’s line or spigelian’s
fascia which runs along the outside edge of
each of the rectus abdominis (6 pack) muscles

68. Anatomy of abdominal wall.
1: Linea semilunaris (spigelian;
semilunar line/zone)
9th Costal cartilage
pubic tubercle
2: rectus abdominis muscle;
3: transversus abdominal muscle;
4: spigelian aponeurosis/fascia
5: linea semicircularis(arcuate
line; Douglas Line)

69. Spigelian Hernia
• Although named after Adriaan van der
Spieghel (1578 – 1625; Belgian anatomist)
– he only described the semilunar line (linea
Spigeli) in 1645 (publised 20 years after his death)
• It was Josef Klinkosch (name long forgotten!)
in 1764 who first defined the spigelian hernia
as a defect, hole or hernia in the semilunar
line.

70. • common misconception that they protrude below the
arcuate line owing to deficiency of the posterior rectus
sheath at that level, but in fact the defect is almost
always above the arcuate line
• Spigelian Fascia/aponeurosis
– refers either to the combined aponeuroses of the external
abdominal oblique muscle, the internal abdominal oblique
muscle and transversus abdominis muscle, or just the
aponeurosis of the transversus abdominis
• caudate lobe of the liver is also known as Spiegel's lobe

71. Raveenthiran Syndrome
• Raveenthiran described a new syndrome in
which spigelian hernia and cryptorchidism
(undescended testis) occur together

72. Spigelian Hernia Belt
• majority of Spigelian hernias are found in a
transverse band lying 0-6 cm cranial to a line
running between both anterior superior iliac
spines referred to as the Spigelian hernia belt.

73. Epigastric Hernia
(Fatty Hernia of Linea Alba)
• 10% common.
• 20% of epigastric hernias are multiple—Swisscheese like.
• It occurs usually through a defect in the decussation of the fibres of
linea alba, any where between xiphoid process and umbilicus.
• Extraperitoneal fat protrudes through the defect as fatty hernia of
the linea alba presenting like a swelling in the upper midline with an
impulse on coughing.
• It is sacless hernia.
– Later protrusion enlarges and drags a pouch of peritoneum,
presenting as a true epigastric hernia.

74. Epigastric Hernia
• often associated with peptic ulcer and so pain
may be due to peptic ulcer.
– gastroscopy is done to rule out acid peptic
disease.

75. Parameter Epigastric Hernia Para Umbilical Hernia
Site Midline raphe(linea alba) anywhere
between xiphoid process and umbilicus
(usually midway)
Through thinned and atttenuated
linea alba
Pathology Initially transverse split in linea alba-
elliptical defect
Rounded defect with well defined
fibrous margin
Etiology Small BVs pierce linea alba
Abnormal decussation of aponeurtoic
fibres related to heavy physcial activity
Stretching and thinning of linea
alba
Gender Common in muscular men( fit healthy
males 25-40 years)
M:F (1:5) overweighted men or
multipara female
Risk Factors manual labourers • Obesity
• Multiple pregnancies
• Flabby abdominal wall
• Liver Cirrhosis
Number 20 % multiple(swiss cheese like)
It is sacless hernia. Later protrusion
enlarges and drags a pouch of
peritoneum, presenting as a true
epigastric hernia
Overlying dermatitis
Crescent shaped umbilicus

76. Para Umbilical Hernia Epigastric hernia
Incision Transverse Vertical midline
Very small(< 1 cm) Figure-of-eight suture
Darn repair
1-2 cm Mayo’s Repair
>2 cm Mesh Repair

77. Ventral* Hernia
• Hernias of anterior abdominal wall
• EXCEPTIONs to above definition
– Inguinal and femoral hernias not included even
though they are ventral
– Lumbar Hernia included despite being dorsolateral
*Latin "venter" meaning belly

78. Indirect Inguinal Hernia
• Bubonocele
• from Greek boubōn groin + kēlē tumour/swelling
• Funicular
– funicular, also known as an inclined plane or cliff railway, is
a cable railway in which a cable attached to a pair of tram-like
vehicles on rails moves them up and down a steep slope
– the ascending and descending vehicles counterbalance each
other.
OR
– having the form of or associated with a cord usually under
tension

79. Funicular in Hastings,
England
Funicular in Lyon,
(France)
Duquesne Incline, Pittsburgh, Pennsylvania, U.S., with full-length
parallel tracks

80. Sliding inguinal Hernia
( NOT sliding hiatal Hernia)
• posterior wall of the sac is not only formed by the
parietal peritoneum, but also by sigmoid colon on
left side; caecum on right side and often with
portion of the bladder (Both sides)
• Rarely small bowel sliding hernia or sacless sliding
hernia can occur.
• Sliding hernia occurs exclusively in males. Mainly
on the left side

81. Mery’s Hernia
(Perineal Hernia)
Postoperative Perineal Hernia Through perineal scar (excicion of rectum)
Median sliding Perineal Hernia Complete rectal prolapse
Anterolateral Perineal Hernia Swelling of labium majus
Posterolateral Perineal Hernia Pass through levator ani to enter ischiorectal fossa

82. Holthouse’s hernia
Inguinal hernia that has turned outwards into
the groin.
Inguinal hernia with extension of the loop of
intestine along the Poupart ligament.
Carsten Holthouse,
English surgeon
1810-1901

83. Barth’s Hernia
Hernia between abdominal wall and persistent
vitello-intestinal duct.
Jean Baptiste Philippe Barth
French physician (1806-1877)

84. Diaphargmatic Hernia
• Congenital diaphragmatic hernia
– Morgagni's hernia
– Bochdalek hernia
– Diaphragmatic eventration
• Hiatal hernia
• Iatrogenic diaphragmatic hernia
• Traumatic diaphragmatic hernia

85. Morgagni (Retrosternal/parasternal)
Hernia
• rare anterior defect of the diaphragm
• 2% of all CDH cases
• characterized by herniation through
the foramina of Morgagni which are located
immediately adjacent and posterior to
the xiphoid process of the sternum

86. Foramina of Morgagni
• Also called
– sternocostal hiatus/triangle
– Larrey's triangle
• Small zones lying between costal and sternal
attachments of thoracic diaphragm
• Contents
– superior epigastric arteries as terminations of the
internal thoracic arteries, with accompanying veins
and lymphatics.

87. Giovanni Battista Morgagni
(1682 – 1771)
Italian anatomist
Father of modern anatomical pathology
Eponymous structures
• Aortic sinus ("sinus of Morgagni")
• Columns of Morgagni
• Foramina of Morgagni
• Hydatid of Morgagni
• Morgagni's hernia

88. Bochdalek hernia
• also known as a postero-lateral diaphragmatic
hernia
• >95 % of CDH
• 80-85 % left sided
Vincent Alexander Bochdalek
(1801 – 1883)
Bohemian anatomist

89. Associated Eponyms
• Bochdalek's cyst
– congenital cyst at the root of the tongue
• Bochdalek's flower basket
– part of the choroid plexus of the 4th ventricle protruding through the
lateral bursa (recessus lateralis) of the 4th ventricle (Luschka's
foramen).
• Bochdalek's foramen
– congenital defective opening through the diaphragm, connecting
pleural and peritoneal cavities
• Bochdalek's ganglion
– ganglion of dental nerve in the jaw (maxilla) above the root of the
canine teeth.

90. Associated Eponyms
• Bochdalek's hernia
– Congenital diaphragmatic hernia which allows protrusion of abdominal viscera
into the chest.
• Bochdalek's triangle
– Lumbocostal triangle, a triangle-shaped slit in the muscle plate between
lumbar or sternal part in the diaphragm and the 12th rib.
• Bochdalek's valve
– fold of membrane in the lacrimal duct near the punctum lacrimale.
– Also called Foltz' valvule;French ophthalmologist Jean Charles Eugène Foltz
(1822–1876) )
• Vater's duct
– a duct that in the embryo connects the thyroid diverticulum and the posterior
part of the tongue.

91. Hiatus/Hiatal Hernia
• Type I (sliding) hernia
– characterized by an upward herniation of the cardia and GE junction in
the posterior mediastinum. The most common one. (C)
• Type II (rolling or paraesophageal) hernia (PEH)
– characterized by an upward herniation of the gastric fundus alongside
a normally positioned cardia. The GE junction is in its normal place (D).
• Type III (combined sliding-rolling or mixed) hernia
– characterized by an upward herniation of both the cardia and the
gastric fundus.
• Type IV hiatal hernia
– is declared in some taxonomies, when an additional organ, usually the
colon, herniates as well.

92. Parameters Gastroschisis (Belly Cleft) EXOMPHALOS (Omphalocele)
Etiology defect of the anterior abdominal
wall just lateral to the umbilicus
failure of all or a part of the gut to
return to
the coelomic cavity during early
foetal life
Sac coverings Nil
Umbilicus is normal. The defect is
almost always to right of an intact
umbilical cord.
Thin, consists of three
layers—outer amniotic membrane,
middle Wharton’s
jelly and inner peritoneal layer
Non-rotation and intestinal
atresia are common associations.
Cardiac anomaly is not common
as in omphalocele.
often associated with congenital
anomalies
of cardiac and genitourinary system
- 70%.

93. Etymology
• -Schisis
– Ancient Greek σχίσις (schisis)
– breaking up of attachments or adhesions
– Fissure
– denoting a cleft or cleavage
– <gastroschisis> <cranioschisis> <palatoschisis>

94. Etymology
• Gastric(gas-trik)
– Greek gastr-, gastēr, (stomach)
– alteration of *grastēr, from gran to gnaw, eat
• Epi-
– a prefix occurring in loanwords from Greek,
– where it meant “upon,” “on,” “over,” “near,” “at,”
“before,” “after”

95. • Omphalos
– a religious stone artifact, or baetylus
– Greek, means "navel“
• In Greek lore, Zeus (God of sky & thunder) sent two eagles across
the world to meet at its center, the "navel" of the world.
– Omphalos stones marking the centre were erected in several places
about the Mediterranean Sea; the most famous of those was at Delphi
• Omphalos is also the name of the stone given to Cronus
• In the ancient world of the Mediterranean, it was a powerful
religious symbol

96. • Omento-
– Latin for Apron
• Epiploic-
– Related/associated with omentum
• Entero-
– refers to the intestine (from Greek ἔντερον, enteron)

97. –

98. • It is protrusion of abdominal wall muscles
during leg rising test as weak, soft, supple,
swelling,
– signifies poor abdominal muscle tone.
– also concludes that particular hernia requires
mesh repair (hernioplasty)
– Common in old age, obese patient.
Malgaigne bulging
Joseph-François Malgaigne
(1806 – 1865)
French surgeon and medical historian

100. Associated eponyms
• Malgaigne's ( Subastragalar) amputation
– Amputation of the foot in which the astragalus is conserved
• Malgaigne's fracture
– Vertical pelvic fracture with bilateral sacroiliac dislocation and fracture of the
pubic rami
• Malgaigne's hernia
– Infantile inguinal hernia prior to the descent of the testis
• Malgaigne's luxation (Nursemaid’s Elbow)
– Partial dislocation of the head of the radius within the elbow joint
• Malgaigne's triangle/Fossa
– Also known as the superior carotid triangle

101. Rectus abdominis diastasis
(diastasis recti, abdominal separation)
(Divarication of rectus abdominus Muscles-DRAM)
• a separation of the two rectus abdominis muscle
pillars
• results in the characteristic bulging of the
abdominal wall in the epigastrium
• sometimes mistaken for a ventral hernia
– despite the fact that the midline aponeurosis is intact
and no hernia defect is present

102. Rectus abdominis diastasis
(diastasis recti, abdominal separation)
(Divarication of rectus abdominus Muscles-DRAM)
• Congenital
– as a result of a more lateral insertion of the rectus
muscles to the ribs and costochondral junctions
• Acquired
– advancing age
– obesity, or
– Post-partum
• advanced maternal age
• after multiple or twin pregnancies
• high-birth-weight infants Diastasis: Greek Separation

104. Internal Hernia
• Occur when the intestine (the ‘viscus’) passes beneath a constricting band or
through a peritoneal window (the ‘defect’) within the abdominal cavity or in the
diaphragm.
• They present as
– Acute intestinal obstruction, with or without intestinal ischaemia, perforation and peritonitis,
or
– Chronic recurrent abdominal pain and vomiting due to incomplete and intermittent intestinal
obstruction.
• Sites of internal herniation include
– (i) the paraduodenal and paracaecal fossae,
– (ii) the lesser sac through the epiploic foramen (foramen of Winslow) or a defect in the
transverse mesocolon,
– (iii) beneath congenital bands or adhesions,
– (iv) through defects in the small bowel mesentery,
– (v) between the lateral abdominal walls and intestinal stomas, and
– (vi) through defects in the diaphragm (hernias of Bochdalek and Morgagni).

105. Miscellanoeus
• Traumatic Hernia
• Sportman’s Hernia
• Parastomal Hernia
• Incisional Hernia

106. Available at surgicalpresentations