A brief outline of classification of hernias, workup & management with a greater focus on the in-depth description of inguinal hernia.

1. HERNIAS
PRESENTED BY: BATCH F
SURGICAL UNIT 1,
SIR GANGA RAM HOSPITAL, LAHORE

2. DEFINITION
A hernia (Latin: rupture) is defined as:
An abnormal protrusion of a cavity’s contents (an organ
part of it (such as the intestine)
through a defect or weakness in the connective tissue or a
wall of the cavity (as of the abdomen),
beyond the normal confines of the cavity in which it is
normally enclosed,
taking with it all the linings of the cavity.

3. COMPOSITION OF A HERNIA
The Sac
A diverticulum of peritoneum
consisting of
1. Mouth
2. Neck (usually well-defined,
diameter is significant, narrow neck
 strangulation)
3. Body (may not be occupied)
4. Fundus
The Coverings
Derived from the layers of
the abdominal wall through
which the sac passes.
Contents
Structures of the cavity from
which the hernia is formed.
>Omentum(Omentocoele)
>Intestine (Enterocoele)
>Portion of circumference of
intestine (Richter’s)
> Appendix (Amyands’)
>Meckel’s diverticulum
(Littre’s)
>Prevesical fat, portion of a
bladder or a diverticulum
>Ovary

4. HERNIA COVERINGS:
ANTERIOR ABDOMINAL WALL LAYERS

6. EPIDEMIOLOGY & DEMOGRAPHIC STATISTISTICS
According to American Hernia Society,
As much as 10% of the population develops some type of hernia during life. Over 1 million abdominal hernia
repairs are performed each year, with inguinal hernia repairs constituting nearly 770,000 of these cases.
 Approximately 75% of all hernias are inguinal:
50% indirect (male-to-female ratio, 7:1), with a right-side predominance, young adults
25% are direct, incidence increases with increasing age
3% have sliding hernias (men >> women) Female infants have a high incidence of sliding tube, ovary or broad ligament
hernias.
 Umbilical (14%)
 Incisional or ventral (10%) (female-to-male ratio, 2:1)
 Femoral (3-5%)
 Inter-parietal, supra-vesical, lumbar, sciatic, and perineal hernias are rare
 Spigelian hernias (rare): around the age of 50 years; no sex or side predilection is reported
 Obturator hernias (thin, elderly women, >> right side)
 The incidence of incarcerated or strangulated hernias in pediatric patients is 10-20%; 50% of these occur in infants
younger than 6 months

7. Anatomical
Epigastric
Umbilical/ Praumbilical (14%)
Groin: Inguinal (75%) & Femoral (3-5%)
Incisional/ Recurrent (10%)
Rare (Spigelian, lumbar, obturator, gluteal
sciatic)
Depending upon contents
Enterocoele
Omentocoele
Richter’s
Littre’s
Maydl’s
Clinical Classification
Other
Aetiologic
(Congenital/ Acquired)
Internal/ External
According to severity
(Complete/Incomplete)
Classification

8. NATURAL
HERNIAL ORIFICES

9. CLINICAL CLASSIFICATION OF HERNIA
Reducible Irreducible
Obstructed/
Incarcerated
Strangulated

10. • Can be returned to abdomen by
patient, surgeon (manual
manipulation) or reduced
spontaneously on lying supine
• Expansile impulse on coughing
Reducible
Hernia
• Hernia Contents cannot be returned to
abdomen
• Hernia is too large/ defect is too narrow
• Overcrowding of contents --> Adhesions
between contents & sac.
• Warning sign for strangulation (ANY
DEGREE)
Irreducible
Hernia

11. • SURGICAL EMERGENCY
• Irreducible
• Bowel is obstructed in sac
• No interference with blood supply of bowel
• Imminent strangulation
• Incarcerated: Irreducible hernia with adhesions but no
obstruction
Obstructed
• Blood supply of contents is compromised
• Herniated intestine becomes twisted or edematous leading
to intestinal obstruction
• Most likely O/A narrow neck of the sac
• Gangrene my take 4-5 hours since inception of symptoms
(Colicky abdominal pain, nausea & vomiting)
• O/E: Tense, tender hernia with no expansile cough impulse
Strangulated

12. Occult Hernia:
• Not detectable
clinically
• May cause severe
pain
Infarcted Hernia:
• When contents of the
hernia have become
gangrenous
• High mortality

14. RISK FACTORS
Any condition that increases the pressure in the intra-abdominal cavity may contribute to the formation of
a hernia, including the following:
• Marked obesity
• Coughing (Smoking, COPD)
• Straining with defecation or urination
• Pregnancy
• Heavy lifting (unclear risk association with groin hernias)
• Collagen Vascular Diseases
• Previous open appendectomy
• Ascites (increase in size of existing sac)
• Peritoneal dialysis
• Ventriculo-peritoneal shunt
• Family history of hernias
Pathogenesis
Inguinal Hernia 25 times more
likely in men (Larger size of
inguinal canal that transmits testes
& spermatic cord)
Strength of the posterior wall of
the inguinal canal
An aponeurotic extensions from
the transversus abdominis
aponeurotic arch

15. Laboratory studies for
general medical
evaluation
All baseline
investigations
Imaging Studies
Evaluation for potential
reversal of provocative
factors (eg: prostatism,
chronic cough, severe
constipation, rectal
cancer, and ascites) is
important
• Radiography
Plain Xrays are of
little value
CXR: Hiatus hernia
• Ultrasonography
 Nature of content is dubious
 Narrows the differential on both
scrotal masses and masses below
the inguinal ligament.
 May be indicated when a
spigelian or obturator hernia is
suspected
 When the patient’s body habitus
hinders physical examination
 Post op period to differentiate
between early recurrence &
hematoma/ seroma
• CT
Complex incisional hernia to
determine the size & no. of muscle
defects, identifying contents,
adhesions, ascites
.
Workup  Clinical Diagnosis
• Contrast (barium) radiology
help to define most hidden hernias
 Small recurrent hernias)
 Occult inguinal hernia
• MRI
Diagnosis of sportsman’s groin
• Laparoscopy
Incisional hernia (occult
contralateral)
Suspected incarcerated or
strangulated hernia
Upright chest radiograph to
exclude free air
Flat and upright abdominal
films
to diagnose a small bowel
obstruction (neither sensitive or
specific)

16. Inguinoscrotal USG
Young male presented with right
inguinal swelling. On clinical
examination, it was irreducible
hernia. Ultrasound was
requested to check bowel / fat
content. Ultrasound shows
peritoneal fat reaching upto
scrotum.
Surgery was done with few hrs
showing odematous peritoneal
fat as hernia content.
Case courtesy of Dr Maulik S
Patel, Radiopaedia.org, rID:
13126

17. Peritoneography & Herniography
 Intraperitoneal injection of non-
ionic contrast by dermatotomy &
insertion of micropuncture needle
 Radiographs on prone &
prone-oblique positions at rest &
on provocative maneuvers
 Selectively for evaluation of
inguinal region  Herniography
 Diagnostic modality in children
 bilateral congenital hernias
 Useful adjunct for obese patients
 Occult inguinal hernias 
Chronic inguinal pain
(inguinodynia), no clinical
evidence of hernia
(A) Normal study on a standard peritoneogram. In contrast, a
positive study reveals an obvious indirect inguinal hernia on both
the posteroanterior (B) and oblique (C) images (arrows).

18. Management Principles:
• Not all hernias require surgical repair  Watchful waiting
• In elderly with asymptomatic, small in size & reducible hernia  Use of truss
European Hernia Guidelines:
• All male (>30 years) patients with a symptomatic inguinal hernia should be operated on using a mesh technique.
• Non-mesh repair  the Shouldice’ technique.
• The open Lichtenstein and endoscopic inguinal hernia techniques  the best evidence-based options for the
repair of a primary unilateral hernia.
• Recurrent hernias after conventional open repair, endoscopic inguinal hernia techniques are recommended.
• When only considering chronic pain, endoscopic surgery is superior to open mesh.
• In inguinal hernia tension-free repair, synthetic non-absorbable flat meshes (or composite meshes with a non-
absorbable component) should be used.
• It is recommended that an extraperitoneal approach (TEP) is used for endoscopic inguinal hernia operations.
• A mesh technique is used for inguinal hernia correction in young men (aged 18–30 years and irrespective of the
type of inguinal hernia
• In female patients, the existence of a femoral hernia should be excluded in all cases of a hernia in the groin.
• A preperitoneal (endoscopic) approach should be considered in female hernia repair

19. European Hernia
Guidelines:
Flow chart of
treatment approach
considerations

20. INGUINAL HERNIA is the
protrusion of abdominal cavity
contents through the inguinal
canal
Clinical Presentation:
 Bulge in the groin area that
can become more prominent
when coughing, straining, or
standing up, disappears on
lying down. (In complete)
 May extend into the scrotum
(complete)
 Unilateral/ Bilateral
 Rarely painful
 Mild discomfort
 Irreducibility, incarceration
 Risk of strangulation (0.25%)

21. Types of
Inguinal
Hernia

22. Type Description
Relationship
to inferior
epigastric vessels
Covered
by internal
spermatic
fascia?
Usual onset
Indirect
(More
common)
(Persistent patency of processus vaginalis
even after the passage of testes
Enters inguinal canal through deep ring
Sac lies within spermatic cord
Contents: (Omentum/ Bowel commonly)
Lateral Yes
Congenital ,
Children & Young
Adult
Direct
(Less
Common)
O/AAbdominal wall weakness, enters
through Hesselbach triangle into the inguinal
canal then through superficial ring
Sac lies parallel to the spermatic cord
Contents: Retroperitoneal fat, less commonly
peritoneal sac containing bowel)
Medial No Middle Age

23. Types of Indirect Inguinal Hernia
Bubonocele
Hernia limited to the inguinal
canal
Funnicular
The processus vaginalis is
closed just above the
epididymis
Contents of the sac can be felt
just above the testes
Complete
Hernia reaches to the
bottom of the scrotum
Testes is felt just below
the lower part of hernia

25. Hesselbach’s Triangle
Boundaries
Medial Border:
Lateral margin of rectus sheath (linea
semilunaris)
Superolateral Border:
Inferior epigastric vessels
Inferior border:
Inguinal ligament also referred to as Poupart’s
ligament

26. INGUINAL CANAL
 Situated just above the medial half of
the inguinal ligament
 Transmits spermatid cord in male &
round ligament of uterus in females
 Approximately 3.75 to 4 cm long
 Angled antero-inferiorly and medially.
BOUNDARIES:
Anterior wall:
Aponeurosis of the external oblique, and
reinforced by the internal oblique muscle
laterally.
Posterior wall:
transversalis fascia.
Roof: transversalis fascia, internal
oblique and transversus abdominis.
Floor: inguinal ligament (a ‘rolled up’
portion of the external oblique aponeurosis)
and thickened medially by the lacunar
ligament.
1.25 cm

27. Surgical Anatomy
(Boundaries of Inguinal
Canal)

30. Triangle of Doom
The Triangle of Doom is an anatomical triangle defined by
the vas deferens medially,
spermatic vessels laterally
and external iliac vessels inferiorly.
Contents: external iliac artery and vessels, the deep circumflex iliac vein, the
genital branch of genitofemoral nerve and hidden by fascia, the femoral
nerve.
It bears significance in laparoscopic repair of groin hernia. Surgical staples
are avoided here.

32. Vaginal Hydrocele
Testes is impalpable
Upper limit is reachable
Swelling not reduced on lying down
Transillumination +ve
Expansile Cough impulse (-ve)
Encysted Hydrocele of Cord
Testes palpable
To get above the swelling (+ve)
Fluctuation +ve
Transillumination +ve
Cough impulse -ve
Femoral Hernia
Swelling below &
lateral to pubic tubercle
Undescended Testes
Scrotum empty or
undeveloped
Cord Lipoma
Soft lobulated
swelling
Irreducible in
inguinal region
DDx of
Inguinal
Hernia
in Males

33. Hydrocoele of the Canal of Nuck
• Cyst in relation to round ligament
• Always lies within inguinal canal
Femoral Hernia
• Swelling below & lateral to the pubic
tubercle
DDx
of Inguinal
Hernia in
Females

34. Irreducibility Obstruction Strangulation
Intestinal
obstruction
Intestinal
perforation
Peritonitis
Complications
of Inguinal
Hernia

35. Pertinent Examination
Inspection:
• Abdominal distension (Obstruction/
incarceration)
• Prominent scar-marks (Recurrent/ incisional
hernia)
• All natural hernial orifices
• Location, size & shape of the swelling
• Skin changes
• Expansile cough impulse

36. Pertinent
Examination
Palpation
• Temperature
• Tenderness +
Tension
• Palpable Cough
impulse
• Reducibility
• Palpable Edges
DRE:
• Blood/ Rectal mass
• BPH
Cough impulse
• Patient is asked
to cough to
highlight the
hernia
• Visible &
palpable cough
impulse if neck
is not blocked by
adhesions
Reducibility Test
• Usually done in supine position
• Ask the patient to reduce the
swelling
To get above the swelling test

38. RING OCCLUSION TEST

39. Herniotomy (Excision of the hernia sac)
Open Inguinal Hernia Suture Repair
(Herniorraphy)
• Open Anterior Repair
Lytl’s
Bassini’s
Desarda’s
Shouldice’
Modified Shouldice’
McVay’s
• Open Posterior Repair
Nyhus’
Preperitoneal
• Open Tension-free flat mesh repair (Hernioplasty)
Lichtenstein
• Open Complex Mesh Repair
Kugel patch
Plug and patch [mesh-plug]
Hernia Systems
Rutkow
• Open Preperitoneal Repair
Stoppa (wrapping the lower part of parietal
peritoneum with prosthetic mesh placed at Fruchauds
myopectinel orifice)
Laparoscopic Hernia Repair
 Transabdominal pneumoperitoneal (TAPP)
 Total Extraperitoneal Approach (TEP)
Surgical Approaches

40.  Oblique incision parallel to & 1.25 cm above the medial two thirds
of the inguinal ligament
 Skin, SC tissue & fascia scarpa incised
 External oblique aponeurosis & superficial inguinal ring are
identified
 Inguinal Canal is opened by incising External oblique aponeurosis
in the line of its fibers
 Cord visualized, lifted with its contents sac separated from cord
coverings, freed all around till deep ring
 Neck is transfixed, sac excised
 Herniotomy completes the procedure for infants & young adults
 External oblique is closed in continuous manner, fascia scarpa
closed, skin closed with interrupted silk sutures
Herniotomy: Excision of hernia sac without any repair of the inguinal
canal

41. OPEN HERNIORRAPHY
Required in older
individuals O/A
 Direct inguinal
hernia
 Weaker posterior
wall of the
inguinal
Strengthening of
the posterior wall of
inguinal canal by
way of
 Sutured Repair
 Prosthetic Mesh
Lytle’s Method
Narrowing of weak &
patulous internal ring with
bulging transversalis by
few interrupted non-
absorbable sutures
Modified Bassini’s Repair
The conjoined tendon is
sutured with inguinal ligament
with interrupted sutures

43. Desarda’s Tension Free Non-mesh
Repair:
 Posterior wall strengthening by use of a strip
of External Oblique Aponeurosis strip
 Superior lip sutured with Conjoint tendon
 The inferior lip with inguinal ligament

44. SHOULDICE HERNIA REPAIR
 Gold standard for the prosthesis-free treatment of inguinal hernias
 Internationally recognized as one of the safest and most effective techniques
 Tension-free natural tissue repair eliminates repeat hernias (recurrences)
Anaesthesia:
 Preoperative sedation
Local subcutaneous infiltration of 1% procaine hydrochloride begins 2 cm medial and
inferior to the ASIS and proceeds to the pubic tubercle
 Patient is able to strain upon request to aid in the search for occult hernias
 Normal abdominal wall muscle tone Accurate judgement of the amount of tension
created by the reconstruction
Inguinal dissection: A comprehensive intraoperative examination of the inguinal region
should include the direct, indirect, interstitial and femoral spaces
 Frequency of secondary hernias at the time of surgery is 15.4%
Opening of posterior wall of the inguinal canal: beginning at the internal ring in
parallel to the internal oblique muscle fibers
Rule Out presence of Interstitial & femoral Hernias:
 Preperitoneal examination of the internal oblique muscle and fascia cephalad to
the internal ring and the inguinal canal  Rule out an interstitial hernia
 Dissection below inguinal ligament Identification of Cooper’s ligament Rule out
femoral hernia

46. Right inguinal hernia
repair:
Dissection of
cremasteric muscle.
Mobilization of the
spermatic cord
through the
cremasteric muscle
and creation of
medial and lateral
flaps for transection

47. 4-layered tissue Reconstruction: A
continuous repair with 32–34 gauge stainless steel
wire may be substituted with a 3–0 polypropylene
suture.
The first layer:
A) Starting at the pubic tubercle, the lateral flap of
transversalis fascia is taken to the edge of rectus
sheath underneath the medial flap
B) The layer is completed with the reconstruction of
internal ring. The lateral stump of cremasteric
muscle is taken with the bite of transversalis to
buttress its medial edge of the new internal ring,
prior to emerging with a full thickness bite of
internal oblique.

48. The second layer
Using the same suture, it is
continued from the internal ring
back, taking the medial flap of
transversalis fascia to the shelving
portion of the inguinal ligament.
Overlapping layers are created.
The third layer
Starting at the medial side of the
internal ring, the external and internal
oblique are used to imbricate the first
two layers. Small bites of external
oblique are taken just above the
inguinal ligament.
The fourth layer
The second layer of imbrication
using the external and internal
oblique. The mobilized lateral flap
of external oblique remains after
the four layers is used to
reconstruct the inguinal canal and
restore the natural anatomic
position of the cord structures.

49. Maloney Darn
(Abrahamson’s) Repair
(Darning Hernia Repair)
 Re-enforcement of the
posterior wall by
monofilament nylon darn,
made in a crisscross (figure
of 8) fashion between the
conjoint tendon & inguinal
ligament
 The first suture is passed
through the periosteum of
the pubic tubercle
 Excellent results
 Most commonly performed
in countries where mesh is
too expensive

50. Fascia transversalis is
incised from deep
inguinal ring to pubic
tubercle
The upper leaf & lower
leaf of this fascia are
overlapped & double-
breast suturing done
Conjoint tendon is
sutured to inguinal
ligament in a
continuous fashion
unlike that in Bassini’s
repair
SHOULDICE
HERNIA REPAIR
(SUMMARY)
Modified Shouldice’ Hernia
Repair
• Lasers are used for a more precise
dissection and to minimize pain.
• A mesh screen is bonded to the
repaired fascia.
• A nylon suture with excellent
elastic properties is incorporated
in a continuous stitch technique
along with small titanium staples
that are used to anchor the mesh
to the fascia. This has many
advantages over the stiff wire in
terms of post operative comfort.
Dr. Edward Earle
Shouldice

51. Complications of
Herniotomy or Open
Herniorraphy
Immediate:
 Bleeding & Hematoma
 Bladder injury/ urinary retention
 Femoral Nerve Blockade/
Inability to move leg
Intermediate (1 week)
 Seroma
 Wound Infection
 Hydrocele of hernia sac (if distal
sac is left as such)
Late/ Delayed
 Recurrence
 Chronic pain (pain present 3
months after surgery)
 Testicular Atrophy
Laparoscopic Herniorraphy (Minimally invasive)
Transabdominal Pneumoperitoneum Approach (TAPP)
• Pneumoperitoneum is created
• A mesh is placed pre-peritoneally
• Dissection of peritoneum off the hernia orifices
• Positioning the mesh beneath the peritoneum before
closing the peritoneum over the mesh
Total Extra-Peritoneal Approach (TEP)
• Paraumbilical incision
• Preperitoneal plane is opened by balloon or direct
dissection
• Hernial orifice identified & sac reduced
• Mesh placed over the hernia orifice in the pre peritoneal
plane

52. The Lichtenstien Tension-free Open Inguinal
Hernia “Mesh” Repair:
• After herniotomy, the posterior wall is cleared
off the cremasteric muscle
• A polypropylene mesh is cut to cover the
whole posterior wall of the inguinal canal &
extends around the deep ring
• Tension-free suture fixation of the mesh is
done, anchoring its lower edge to the inguinal
ligament & the upper edge with the conjoint
tendon
• No suture is placed through the periosteum of
the pubic tubercle
• External oblique aponeurosis is closed by
continuous sutures leaving the superficial ring
• Skin is closed in subcuticular fashion

53. DIRECT INGUINAL
HERNIA (Treatment)
• Sac is identified,
dissected free &
simply inverted
• Tension-free
Lichtenstein Mesh
Hernia repair done
• Plication done

55. STRANGULATED INGUINAL HERNIA
Inguinal Hernia with compromised blood supply
 Indirect Inguinal Hernia >> Direct inguinal hernia because of narrower sac neck
 Strangulation of small intestine >> omentum
 Rare for large intestine to strangulate
 Infants 4% risk of strangulation
Clinical Presentation
Symptoms: Sudden pain over hernia Generalized colicky abdominal pain (mainly around
the umbilicus) Vomiting
Signs: Tense, tender, irreducible, no expansile cough impulse
Management
Adequate resuscitation  Urgent Surgical Repair
Intravenous fluid resuscitation
Antibiotic cover
Nasogastric aspiration
Urine Output Monitoring

56. Operation:
1. Incision is made over the most prominent part of the
swelling
2. External oblique aponeurosis is exposed & the sac is
identified & delivered to the surface.
3. Each layer covering the sac is incised & stripped off
4. Sac is incised & any infective fluid is drained
5. External oblique aponeurosis & the external ring are divided
6. Sac is opened upto constriction over a finger & the
constriction is divided
7. Devitalized omentum is excised, viable gut is returned,
doubtful & gangrenous part is resected & end to end
anastomosis done
8. Sac excised & closed by purse string sutures
9. Hernioraphy done
10. Mesh is avoided because of high risk of infection
HAZARDS OF REDUCTION
IN STRANGULTED HERNIA
 Contusion & rupture of the
intestine wall
 Reduction en-mass: sac with
strangulated bowel is pushed
back
 Reduction into the loculus of
sac
 Rupture of sac with
extraperitoneal reduction of
contents

57. Sliding Inguinal Hernia:
Posterior wall is not only formed by peritoneum but by sigmoid colon & its
mesentery on the left & caecum to the right & sometimes on either side by a portion
of the bladder.
Presentation:
 Mostly Men
 5 out of 6 on left side
 Bilateral Rare
 Nearly always over 40 years
Treatment:
 Surgical Repair
 No attempt should be made to dissect caecum or colon free from peritoneum
owing to high risk of perforation

58. Umbilical Hernia:
The umbilical defect present at birth closes as the umbilical stump heals within a week of birth.
Umbilical Hernia in Children:
• Higher incidence in premature babies
• Asymptomatic, appearing within a few weeks
• Increases in size on crying, assuming a classical
conical appearance
• Treatment
• <2 years  Conservative treatment
• Operation
• A small curved incision is made below the
umbilicus
• The neck of the sac is defined, opened & any
contents returned back to peritoneum
• Sac closed, redundant sac excised
• The defect in linea alba is closed by interrupted
sutures
Umbilical Hernia in Adults:
Thinning & stretching of midline raphe (linea alba)
 Pregnancy
 Obesity
 Liver cirrhosis
Paraumbilical hernia is external bulging of the navel with
a well-defined rounded, fibrous margin with a crescent-
shaped bulge containing abdominal fat, omentum or
rarely bowel contents in larger ones.
Clinical Features:
• F>>M
• Pain & features of intermittent bowel obstruction
Treatment
• High risk of strangulation
• Surgery is required (Open or laparoscopically)

60. Open Umbilical Hernia Repair
Defects <1cm in size:
• Simple figure-of-eight suture (Purse-string)
• Repaired by Darn Technique: A non-absorbable monofilament suture is criss-crossed across
the defect & anchored firmly to the fascia all around
Defects 1-2cm:
• Mayo’s repair (Classical)
• Transverse elliptical/ infra-umbilical incision  Dissection  the hernia sac dissected,
opened & contents reduced  non-viable tissue removed  peritoneum closed
• Defect in anterior rectus sheath is extended laterally & elevated to create upper & lower
flaps  Double-breasting done  Row of mattress sutures, overlapped upper margin
stitched to the sheath of the rectus
Defects> 2cm/ Recurrent:
Prosthetic material recommended
Lipectomy/ Panniculectomy: Fashioning the incisions to remove the fat-laden superficial
layer of abdominal wall in large, pendulous PUH

61. Incisional Hernia
Protrusion through a scar caused by previous surgery or trauma
Presentation:
• Mostly asymptomatic
• Diffuse bulging through the whole length of the scar
• Gradual increase in size
• Strangulate rarely
Treatment:
Palliative:
• Asymptomatic
Surgery:
Simple apposition
• Full-length incision.
• All layers are repaired with absorbable suture
Complex apposition Layered Closure
Mesh/ Net closure
Onlay: Placed anterior to the
anterior rectus sheath. Overlap
of 5cm is made all around
Sublay: Between anterior &
posterior rectus sheath
Inlay:
• Defect too large to close by
apposition of rectus sheath.
• Sewing the mesh to the
fascia on either side of the
defect, 4 cm overlap of
fascial edges with mesh

63. Epigastric Hernia
• Between the xiphoid process & umbilicus
• Protrusion of extraperitoneal fat (Fatty
hernia of the linea alba )
• Pouch of peritoneum (True epigastric hernia)
• Surgical approach:
• A vertical / Transverse incision is made over
the swelling
• Gauze/ blunt dissection in order to clear the
hernia orifice off the pedicle fat which is
ligated
• If sac present  Identified, opened, contents
reduced, sac neck transfixed, opened &
excised
• Repair of the defect in linea alba
• If defect is large >4cm, Mesh recommended
Ultrasound
- “ Findings of epigastric hernia containing fat and
fluid. ”

64. Femoral hernia
Protrusion of contents below the
inguinal ligament through a naturally
occurring weakness called femoral
canal
• 3rd most common type
• Female>>Male
• Incidence of strangulation high
(narrow neck)
Femoral Canal
• The most medial compartment of
femoral sheath
• Extends from femoral ring above
to saphenous opening below
• 1.25 cm long & 1.25 cm wide
• Contents: Fat, lymphatic vessels,
lymph nodes of cloquet

68. Presentation:
 Usually after 20 years of
age
 Prevalence increases with
increasing age
 Right side>> Left side
 Less pronounced
symptoms
Differential Diagnosis
 Saphena Varix
 Enlarged femoral lymph
nodes
 Inguinal Hernia
 Lipoma
 Femoral aneurysm
 Psoas abscess
Surgical repair is the treatment of choice
 The low/ infra-inguinal (Lockwood) operation
 Trans-inguinal approach (Lotheissen’s) operation
 The high operation or (McEvedy’s) operation

70. Spigelian Hernia:
Protrusion through the linea semilunaris at the outer border of rectus muscle usually at
the level of arcuate line
Arcuate/ Douglas' line is a horizontal line that demarcates the lower limit of the
posterior layer of the rectus sheath. It is also where the inferior epigastric vessels
perforate the rectus abdominis.
Linea Semilunaris/ Spigelian line is a curved tendinous intersection found on either side
of the rectus abdominis muscle.

71. Presentation:
• No gender predilection
• After 50 years of age
• Soft reducible mass lateral to
rectus muscle & below the
umbilicus
• Strangulation can occur
Diagnosis: by CT or USG
scanning
Treatment: Surgical
Intervention

73. The obturator canal is a
passageway formed in the
obturator foramen by part
of the obturator
membrane. It connects
the pelvis to the thigh.
The obturator artery,
obturator vein, and
obturator nerve all travel
through the canal.

74. Lumbar Hernia:
A flank hernia, also
known as a lumbar
hernia, results from
defects in the
postero-lateral
abdominal wall that
allows the tissues
inside the abdomen
to protrude.

77. Surgical Repair (Prone to increase in size)
Gluteal
Hernia:
Through
Greater
Sciatic
Foramen
Sciatic
Hernia:
Through
Lesser
Sciatic
Foramen
Sportsmann’s
Hernia:
Groin injury
leading to
chronic groin
pain is
referred to as
the
Sportsman’s
Hernia
Divarication of Recti:
A gap can be seen
between the rectus
abdominis while straining
Fingers can be introduced
when abdomen relaxed.
Elderly Multiparous
women
Treatment: Abdominal
Belt

78. THANK YOU!