Various types of hernia are dealt by a general or laparoscopic surgeon For details plz visit - https://drnitinjha.com/ https://drnitinjha.com/inguinal-hernia-surgery-noida/

2. ESOPHAGEAL CANCER SURGERY
Dr Nitin Jha
(MBBS,MS,FIAGES)
Consultant
Laparoscopic,MIS and Bariatric surgeon
FORTIS Hospital, Noida. INDIA
drnitinjha@yahoo.com

3. What is a hernia?
 A hernia is an abnormal weakness or hole in an
anatomical structure which allows something inside to
protrude through.
 It is commonly used to describe a weakness in the
abdominal wall.

5. Common types

7. NOMENCLATURE
Incomplete hernia
 Bubonocele—limited within the inguinal canal
 Funicular—limited just above the epididymis
Complete hernia
 traverses to the bottom of the scrotum
Littre”s hernia
Richters hernia
Irreducible hernia
Obstructed
Strangulated hernia
Hernia of hydrocele
Hydrocele of hernia

8. Nyhus Classification
 Type I: Indirect inguinal hernia Internal inguinal
ring normal (simple pediatric hernia)
 Type II: Indirect inguinal hernia
Internal inguinal ring dilated but posterior inguinal
wall intact (inferior deep epigastric vessels not
displaced)

9. Nyhus Classification
 Type III: Posterior wall defect
 A. Direct inguinal hernia
 B. Indirect inguinal hernia- internal inguinal ring
dilated (massive scrotal or sliding hernia)
 C. Femoral hernia
 Type IV: Recurrent hernia
 A. Direct
 B. Indirect
 C. Femoral
 D. Combined

10. Gilbert’s Classification
Types 1, 2 and 3 are indirect hernias; types 4 and 5 are direct.
 Type 1 hernias with an intact internal ring that will not admit 1
fingerbreadth (<1 cm); the posterior wall is intact.
 Type 2 hernias (the most common indirect hernia) have a peritoneal sac
coming through a 1-fingerbreadth internal ring (≤2 cm.); the posterior wall
is intact.
 Type 3 hernias with 2-fingerbreadth or wider internal ring (>2 cm.)
 Type 3 hernias begin to break down a portion of the posterior wall just
medial to the internal ring. Often have a sliding component.
 Type 4 hernias have a full floor posterior wall breakdown or multiple
defects in the posterior wall. The internal ring is intact, and there is no
peritoneal sac.
 Type 5 hernias are pubic tubercle recurrence or primary diverticular
hernias. No peritoneal sac and the internal ring remains intact. In cases
where double hernias exist, both types are designated (ex. Types 2/4).
Descriptors such as L, Sld., Inc., Strang. Fem. are used to designate lipoma, sliding component,
incarceration, strangulation and femoral components.

11. Gilbert’s Classification
 In 1993, Rutkow and Robbins added
 type 6 to designate double inguinal hernias
 type 7 to designate a femoral hernia.

12. Pelvic & Inguinal Anatomy
Both the ilioinguinal
nerve and the
genitofemoral nerve
traverse the usual
hernia-repair operative
field. The femoral vein
also runs just deep to
the inguinal floor
laterally.

13. Myopectineal Orifice of Fruchaud
The MPO is bordered:
 Above by the arching fibers of the internal
oblique and transversus abdominus Muscles,
 Medially (towards the center or to the right) by
the Rectus Abdominus Muscle and its fascial
Rectus Sheath
 Inferiorly by Coopers Ligament, and
 Laterally by the Ileopsoas Muscle
 Running diagonally thru the MPO is the inguinal
ligament

14. Myopectineal Orifice of Fruchaud

15. Ingiunal canal Contents
Ilioinguinal nerve.
Spermatic cord, which contains:
3 arteries:
Testicular a.
Ductus deferens a.
Cremasteric a.
3 nerves:
Cremasteric n.
Genital branch of the GF n.
Autonomics
3 other things:
Ductus deferens
Pampiniform plexus
Lymphatics

16. Hesselbach's triangle
Boundaries:
Medial:
Rectus abdominis
muscle medially,
Inferiorly:
Inguinal ligament
Laterally:
Inf. Epigastrics

17. Groin Anatomy--Nerves

19. ANATOMY

20. Etiology of Hernias
 Congenital
 Hydrocele vs. indirect hernia
 Patency rate of processus vaginalis
 60% at 2mo; 40% at 2yo; 20% in adults
 Connective tissue abnomalities
 Smoking (collagen metabolism)
 Malnutrition, Vitamin deficiency
 Increased intra-abdominal pressure
 COPD, dialysis, ascites, BPH
 Chronic constipation
 Strenuous labor ?

21. Composition of hernia
1.Sac: a folding of peritoneum
consisting of a mouth, neck,
body and fundus.
2.Body: which varies in size and
is not necessarily occupied.
3.Coverings: derived from
layers of the abdominal wall.
4.Contents: which could be
anything from the omentum,
intestines, ovary or urinary
bladder.

22. Symptoms
1…Swelling in inguinoscrotal region
Increasing on coughing,straining,walking
Decreasing on lying down
2…h/o irreducibility
3…h/o obstruction
pain, vomiting,obstipation
distension of abdomen.
4…h/o Strangulation
redness,shock,sepsis

23. Clinical Diagnosis
1. Can you get above it?
2. Reducibility test
3. Expansile Cough Impulse;
4. Invagination test
5. Three finger test
Zieman’s technique
6. Ring occlusion test

24. Relation to Pubic Tubercle
INGUINAL HERNIA; The neck above and medial to
the pubic tubercle
FEMORAL HERNIA; The neck below and lateral to
pubic tubercle

25. 1-Cough Impulse
•Pt. coughs to highlight hernia.
•May not ;if the neck is blocked by adhesions
•Visible & Palpable cough impulse.
•Reappear on straining,
standing or coughing

26. 2-Reducibility test
 Ask pt. to reduce hernia himselves
 In lying position.
 Thigh of the affected side should be flexed, adducted and
internally rotated.
 Finger guard of the inguinal canal by thumb and index finger and
then the scrotum is gently squeezed.

27. 3-Get above the swelling test
• Done in standing position
• At the root of the scrotum place the thumb in front and the index
behind
•Try to reach above the swelling.
• Inguinal hernia; cannot get above
• Pure scrotal swelling; will get above

28. 4-Invagination test
•The scrotum on each side is inverted
with the examining index finger
•Entering the inguinal canal along
the course of the cord structures.
•The size of the external ring.
•The finger push up to the
superf inguinal ring.
•The pulp should feel the ring.
•Pat is asked to cough,
•A palpable impulse will confirm the hernia;
felt on the pulp then direct
felt on the tip then indirect hernia.

29. 5-Three finger test /
Zieman’s technique
Index finger; deep inguinal ring
(indirect hernia)
Middle finger; superficial ing. Ring
(direct hernia)
Ring finger; saphenous opening
(femoral hernia)
The patient is asked to cough.

30. 6-Ring occlusion test
•Reduce the hernia
•Occlusion of the deep ring by thumb.
•Then holding the thumb in position ask
The pt to stand
then cough
•If no bulging;
indirect
•If bulging;
direct .

31. PRE-OP WORK UP
 USG abdomen to r/o BHP,
 All routine blood investigation for PAC
 X Ray Chest,ECG
 Written informed Consent
 Part preparation
 Antibiotic after induction of anaesthesia
 Bladder emptying just before surgery

32. Open Inguinal Hernia Repairs
 Bassini
 McVay
 Shouldice
 Lichtenstein
 Plug & patch
 LAPAROSCOPIC REPAIR
TEP (Totally Extra Peritoneal)
TAPP(Trans Abdominal Pre Peritoneal)

33. Lichtenstein Repair
 Popularized the use of polypropylene mesh in primary
hernia repairs
 Mesh is laid over the undisturbed inguinal floor,
posterior to the spermatic cord sutured to the shelving
edge of the inguinal ligament, internal oblique fascia
and the pubis

35. Bassini Repair
 Is frequently used for indirect inguinal hernias and
small direct hernias
 The conjoined tendon of the transversus abdominis
and the internal oblique muscles is sutured to the
inguinal ligament

36. Bassini Repair

37. Shouldice Repair
 AKA: Canadian Repair
 A primary repair of the hernia defect with
4 overlapping layers of tissue.
 Two continuous back-and-forth sutures of
permanent suture material are employed.
The closure can be under tension, leading
to swelling and patient discomfort.

38. Shouldice Repair

39. When is laparoscopy
appropriate?
 Recurrent hernias - avoid a previously operated field
 Bilateral hernias - one set of incisions better than two
inguinal incisions; one mesh to cover both overlay
bladder

40. Types of Laparoscopic Inguinal Hernia
Repair
 IPOM (IntraPeritoneal On-lay Mesh) repair. A mesh is placed intra-
abdominally covering the hernia defect and then secured to the
abdominal wall. Very popular at the beginning of laparoscopic
experience, it has since been abandoned.
 TAPP (Trans Abdominal Pre-Peritoneal) repair. With this technique,
the pre-peritoneal space is accessed from the abdominal cavity and a
mesh is then placed and secured. This is procedure of choice for
recurrent inguinal hernias or in case of incarcerated bowel – visualized.
 TEP (Totally ExtraPeritoneal) repair. The mesh is again placed in the
retroperitoneal space, but in this case, the space is accesed without
violating the abdominal cavity. This is probably the most physiological
repair although technically more demanding. The procedure of choice
for bilateral inguinal hernia repairs

41. Laparoscopic
techniques versus
open techniques for
inguinal hernia repair.
There is no apparent difference in recurrence between laparoscopic and open mesh
methods of hernia repair.
The data suggests less persisting pain and numbness following laparoscopic repair
Return to usual activities is faster.
However, operation times are longer and there appears to be a higher risk of serious
complication rate in respect of visceral (especially bladder) and vascular injuries
Cochrane Database Syst Rev. 2003;(1):CD001785

42. Dangers/Areas to be Avoided
 Triangle of pain
 Contains cutaneous
nerves  neuralgia
 Major arteries and
spermatic vessels
 Epigastric vessels
 Specific example:
tension on vas
deferens

43. Lap TAPP Repair----
VIDEO

44. Lap TEP Repair
VIDEO