CLINICAL INFORMATION OF (GROIN) INGUINAL HERNIA
Dr. Desarda’s theory – Transversalis fascia can not give and never gives protection from the herniation process as believed today or stated in the text books or various research articles. Transversalis fascia is papery thin and is an extension of the endo-abdominal fascia. Posterior wall of the inguinal canal is not only a single layer wall composed of the transversalis fascia as believed today but is composed of two layers. Transversalis fascia is a posterior layer and in front of it is another layer composed of the aponeurotic extensions from the Transversus Abdominis Aponeurotic Arch also called as the "Dessidious part of the Transversus Abdominis Aponeurotic Arch" These aponeurotic extensions in the posterior wall of the inguinal canal gives real protection from the herniation process. The inguinal hernia formation can take place only if these aponeurotic extensions are absent or deficient. Loss of strength and physiologically a-dynamic nature of the posterior wall of the inguinal canal due to absent aponeurotic extensions in the posterior wall and loss of strength of cremasteric fascia and musculo-aponeurotic structures around the inguinal canal are the real factors or the cause of hernia formation. Read our research article: Surgical physiology of inguinal hernia repair - a study of 200 cases Mohan P Desarda BMC Surgery 2003, 3:2 doi:10.1186/1471-2482-3-2 http://www.biomedcentral.com/1471-2482/3/2/
Bubonocele / Inguinal Hernia
Bubon = groin
Bubonocele is a type of inguinal hernia which is limited in its extent to the inguinal canal.
v Occurs at all ages; M > F
v In 1st decade - right > left ( because of late descent of right testis)
v After that R = L
v Bilateral in 1/3 of cases
v Etiology :
1) Increased Intra Abdominal Pressure due to straining :-
v In children - Measles, whooping cough
v In adults - Smoking, chronic bronchitis, emphysema, hard physical labor, Intra Abdominal malignancy,
v Stricture urethra, chronic constipation
2) Increased Intra Abdominal Pressure due to stretching muscles :-
Ø dull dragging pain referred to the testis - increases on work
Ø If obstructed may have constipation, vomiting, pain
Ø If strangulated may have severe pain, shock, collapse.
v Clinical Findings
Ø piriform swelling - in the inguinal canal
Ø bubonocele does not come into scrotum
Ø Cough impulse + Reducibility +
Ø Neck of the hernia is supero-medial to pubic tubercle
v Special tests
Ø Deep ring occlusion - hernia does not appear
Ø Finger Invagination - impulse at tip of finger
Ø Dr.Desarda's test - Sliding of contents from ring finger to index finger indicates indirect and from middle to index finger indicates direct hernia
v Types :
2. Irreducible (complication of (1))
3. Obstructed -------"---------
4. Strangulated ------"----------
5. Inflamed (the viscus in the hernia is inflamed - e.g. appendicitis, salpingitis)
v Differential Diagnosis:
1. Femoral hernia
2. Direct inguinal
3. Vaginal hydrocele
4. encysted hydrocele of cord
5. Undescended testis
8. Diffuse lipoma of cord.
9. Femoral hernia
10. Hydrocele of canal of Nuck
 Principles of treatment :
1. Restore the disrupted anatomy
2. Repair using fascia / aponeurosis NOT muscle
3. NO tension
4. Suture material used should hold until natural support is formed over it. ( i.e. monofilament nylon or polyethylene)
1. Resuscitation - in case of strangulated hernia with gangrene with shock or with intestinal obstruction.
2. Reduction of hernia - includes taxis, & reduction under anesthesia.
3. Repair - of the defect - may be herniorrhaphy or hernioplasty.
v Strangulated hernia -
Ø treat as emergency
Ø treat shock if any. Start IV antibiotics
Ø Incision over the most prominent part of swelling - sac carefully identified & dissected out. Sac opened.
Ø Aspirate all fluid ( highly infectious)
Ø Resect any unviable intestine or omentum
Ø EO aponeurosis & external ring divided. Sac opened throughout the length upto deep ring & a little inside.
Ø Viable contents reduced. Definite repair carried out - any prosthetic repair is contra-indicated.
- Non - Operative approach - in elderly, unfit / unwilling for surgery.
- Use of truss is advised in such cases- Truss must be applied with hernia reduced. Must prevent reappearance of the hernia on straining.
- Surgery - treatment modality of choice.
1 - Herniotomy - may be sufficient in young, muscular individuals and in children.
2 - Herniorrhaphy - in adults with good muscular tone.
3 - Hernioplasty - in elderly with poor muscular tone.
C/I in strangulated hernia - may get infected leading to wound sinuus.
v Herniorrhaphy -
o Dr. Desarda's repair: Giving physiologically dynamic and strong posterior wall should be the principle of any type of inguinal hernia repair to give 100% success rate. Undetached strip of the external oblique aponeurosis is sutured between the muscle arch and the inguinal ligament to give a strong posterior wall which is kept physiologically dynamic by the additional muscle strength provided by the external oblique muscle to the weakened muscle arch.
Ø Lytle's repair (syn : Marcie's repair)- narrowing of the deep ring by suturing medial wall - Tight enough so that cord & little finger just fit in.
Ø Bassini's repair - Suturing of conjoint tendon to the incurved part of inguinal ligament - medial most stitch through the pubic periosteum - sutures taken with non-absorbable sutures - originally done by Bassini using black silk - now monofilament nylon used. - Chances of femoral hernia increased.
Ø Shouldice repair - Double breasting of transversalis fascia - best tissue repair - at the Shouldice clinic in Toronto, stainless steel wire used for darning.
Ø Ogilvie's repair - plication of transversalis fascia
Ø McVay's repair / Cooper's repair - Conjoint tendon sutured to the Cooper's ligament - also prevents Femoral hernia formation - closes off the Fruchaud's orifice.
Ø Condon's repair - Conjoint tendon sutured to the ilio-pubic tract.
Ø Halsted's repair - repaired at 3 levels (6 layer repair) - Bassini's + Shouldice + double breasting of external oblique - cord becomes subcutaneous
Ø NYHUS / Cheatle - Henry repair - pre-peritoneal repair - may be combined with prostatectomy. Used for large double hernias (direct + indirect), bilateral hernias, & Recurrent hernias.
Ø Inguinoclysis - only in elderly men with recurrent / very large hernias - obliteration of the inguinal canal with bilateral orchidectomy.
Ø Pantaloon hernia - Treated by 1st converting the hernia into one giant indirect hernia & then treating it as indirect hernia
1] Of the hernia -
v Toxic shock
2] Of the surgery -
v Sepsis ( most common ) - may lead to formation of incisional hernia.
v 2ndary hydrocele - damage to lymphatics
v Testicular ischemia & atrophy
v Division of the vas deferens - especially in children
v Sinus formation - use of non-absorbable sutures
v Nerve entrapment - ilioinguinal N.
v Lymphocele - common after operations for femoral hernia
v Recurrence of hernia.
Hernia - General information
Hernia - General
v Common Hernias : Inguinal, Incisional, Femoral, Umbilical
v Acquired Hernia - Incisional
v Hernias due to obesity - Direct inguinal, Para umbilical, Hiatus hernia.
v Diaphragmatic hernia - congenital or acquired
v Duodenum herniating in the Para duodenal pouch
v Intestine herniating into the lesser sac or hole in mesentery or hole in transverse mesocolon or defect in the broad ligament or Ileocaecal fossae - superior & inferior or retrocaecal fossa
Ø Inguinal - indirect, direct, pantaloon
Ø Umbilical - Exomphalos (major & minor), & child umbilical hernia.
Ø Para umbilical
Ø Divarication of Rectii
Ø Spigelian-occurs at lateral border of rectus sheath at level of arcuate line.
Ø Interstitial / Interparietal - 4 types
§ Pro-peritoneal - diverticulum from inguinal or femoral hernia.
§ Intermuscular - common in obese patients - spreads between External Oblique & Internal Oblique - narrow neck - tendency to strangulation.
§ Inguinosuperficial - hernia into the superficial inguinal pouch - associated commonly with an ectopic testis in the pouch.
Ø Lumbar - superior & inferior. May be a phantom hernia - due to local muscular paralysis e.g. polio.
Ø Gluteal - through greater sciatic foramen.
Ø Sciatic - through lesser sciatic foramen.
v Perineal hernia - 4 types
Ø Post - operative - after AP resection of rectum.
Ø Median sliding hernia - complete rectal prolapse.
Ø Antero-lateral - in females - swelling of one side labium majus.
Ø Postero-lateral - through levator ani muscle into the ischiorectal fossa.
v Para-ileostomy hernia
v Para-colostomy hernia
Theories for Hernia formation