Prof C M K Reddy

A TRIBUTE TO A GREAT TEACHER AND SOCIAL WORKER - Prof RNR

Prof R Nanjunda Rao CME Program for Undergraduates INGUINAL HERNIA

Prof R Nanjunda Rao & A S I – Chennai City Branch Prof D Nagarajan, President Dr G Chandrasekar, Secretary Dr Ravindran Kumeran, Treasurer

BY Prof C M K REDDY DSc (Hon) FRCS (Glas) FRCS (Ire) Emeritus Professor, TN Dr MGR Med University General & Vascular Surgeon Apollo Hospitals & Halsted Surgical Clinic C H E N N A I

President TN Medical Practitioners’ Association (TAMPA) Indian Chapter, Royal College of Surgeons in Ireland Core Committee for Hosp. Waste Mgmt. of Chennai

Formerly Medical Director, Sri Jayendra Saraswathi Inst of Med Sciences Honorary Professor of Surgery Stanley Medical College President, Tamil Nadu Medical Council

Receiving Dr B C Roy National Award as Eminent Medical Teacher from the President of India (2000)

Honorary Doctorate (DSc) conferred by the TN Dr MGR Medical University (2007)

INGUINAL HERNIA HERNIA IS DEFINED AS AN ABNORMAL PROTRUSION OF A VISCUS THROUGH NORMAL OR ABNORMAL OPENING LINED BY A SAC IF A VISCUS FORMS A PART OF THE SAC, IT IS CALLED A SLIDING HERNIA IF THERE IS NO SAC, IT IS A PROLAPSE

SLIDING HERNIA (Hernie-en-glissade) PROPLASE RECTUM & UTERUS

INGUINAL HERNIA PROLAPSE OF BOWEL (TRAUMA)

INGUINAL HERNIA GROIN IS A COLLOQUIAL TERM TO INCLUDE THE FOLLOWING REGIONS : INGUINAL FEMORAL ROOT OF SCROTUM or LABIA MAJORA WHILE DESCRIBING A MASS, THE PARTICULAR AREA TO BE SPECIFIED

INGUINAL HERNIA ANATOMY OF INGUINAL CANAL IT IS AN OBLIQUE CANAL, 6cm LONG, EXTENDS FROM DEEP TO SUPERFICIAL RING PARALLEL TO THE MEDIAL HALF OF THE INGUINAL (POUPART) LIGAMENT

INGUINAL ANATOMY

INGUINAL HERNIA EXTERNAL (SUPERFICIAL) RING A TRIANGULAR OPENING IN THE EXTERNAL OBLIQUE APONEUROSIS 2cm ABOVE & MEDIAL TO PUBIC TUBERCLE IT DOESN’T NORMALLY ADMIT TIP OF A FINGER. FORCIBLE ATTEMPT IS RESISTED DUE TO DISCOMFORT

INGUINAL HERNIA INTERNAL (DEEP) INGUINAL RING IT IS A ‘U’ SHAPED DEFECT IN THE TRANSVERSALIS FASCIA, 2cm ABOVE THE MIDPOINT OF INGUINAL LIGT (MIDWAY BETWEEN ANT SUP ILIAC SPINE & PUBIC TUBERCLE)

INGUINAL HERNIA BOUNDARIES OF ING CANAL FLOOR : INGUINAL LIGT POST WALL : TRANSVERSALIS FASCIA & MEDIALLY CONJOINT TENDON ROOF : ARCHING FIBRES OF CONJOINT TENDON ANT WALL : EXT OBLIQ APONEUROSIS & INT OBLIQ MUSCLE LATERALLY

INGUINAL HERNIA HESSELBACH’S TRIANGLE WEAK AREA IN POSTERIOR WALL THROUGH WHICH DIR HERNIA PRESENTS BOUNDARIES LATERAL : INF EPIGASTRIC VESSELS RAISING LATERAL UMBILICAL LIGT (FOLD) MEDIAL : LATERAL BORDER OF RECTUS INFERIOR : MEDIAL THIRD OF ING LIGT FLOOR BISECTED BY MEDIAL UMB LIGT, FORMED BY OBLITERATED UMB ARTERY

INGUINAL HERNIA EXTERNAL DISSECTION HESSELBACH’S TRIANGLE Laparoscopic view from inside

INGUINAL HERNIA • AS WE GO FROM OUTSIDE • SKIN • TWO LAYERS OF SUPERFICIAL FASCIA SUPERFICIAL (FATTY) : CAMPER’S FASCIA DEEP (MEMBRANOUS) : SCARPA’S FASCIA A THIN AREOLAR LAYER IMMEDIATELY OVER THE EXT OBLIQ APONEUROSIS : FASCIA INNOMINATUM (OF GALLAUDET) EXT OBLIQ APONEUROSIS & EXT RING INGUINAL CANAL & SPERMATIC CORD

INDIRECT DIRECT FEMORAL INGUINAL HERNIA Laparoscopic Anatomy INFERIOR EPIGAST VESSELS

INGUINAL HERNIA Myopectineal Orifice of Fruchaud Boundaries Medial : Rectus muscle Lateral : Iliopsoas Superior : Conjoint tendon Inferior : Pectin pubis

INGUINAL HERNIA INGUINAL HERNIA MAY BE DIRECT – THRO’ THE H’ TRIANGLE INDIRECT – THRO’ THE INT RING SADDLE or PANTALOON (ROMBERG) WITH BOTH COMPONENTS SADDLED BY INF EPIGAST VESSELS • ALL OF THEM ULTIMATELY COME OUT THRO’ THE EXTERNAL RING

INGUINAL HERNIA DIRECT TYPE ACQUIRED SAC LIES SEPARATE FROM AND POSTERIOMEDIAL TO THE CORD STRANGULATION IS RARE SINCE THE NECK OF THE SAC IS WIDE IT IS GLOBULAR AND DOESN’T READILY DESCEND INTO SCROTUM

INGUINAL HERNIA INDIRECT TYPE CONSIDERED TO BE CONGENITAL DUE TO IMPERFECT OBLITERATION OF PROCESSUS VAGINALIS COMES OUT THRO’ BOTH RINGS RETORT SHAPED DESCENDS READILY INTO SCROTUM DUE TO THE ‘READY MADE’ SAC SAC LIES WITH IN AND ANTEROSUPERIOR TO THE CORD STRUCTURES

Diff between Ind. & Dir. Ing Hernia

INGUINAL HERNIA HOW DO WE SAY IF AN IRREDUCIBLE HERNIA IS DIRECT OR INDIRECT ?

SHAPE WHETHER DESCENDED INTO SCROTUM THE FACT IT IS IRREDUCIBLE, IS IN FAVOR OF INDIRECT HERNIA BUT IT IS ONLY OF ACADEMIC INTEREST, SINCE EARLY SURGERY IS NECESSARY & IT COULD BE DECIDED AT THAT TIME

INGUINAL HERNIA TOPOGRAPHIC TYPES BUBONOCELE (Boubon : Groin) FUNICULAR TYPE (UPTO THE TOP OF TESTIS) COMPLETE or CONGENITAL ENTIRE PROCESSUS IS PATENT TESTIS BECOMES A CONTENT OF THE HERNIAL SAC

INGUINAL HERNIA Bubonocele Funicular Complete

INGUINAL HERNIA BILATERAL BUBONOCELES

INGUINAL HERNIA GIBBON’S HERNIA LARGE INGUINAL HERNIA PRODUCING SECONDARY HYDROCELE, DUE TO COMPRESSION OF VENOUS AND LYMPHATIC CHANNELS

INGUINAL HERNIA INTERPARIETAL or INTERSTITIAL TYPE DOWN’S or PRUNE BELLY SYND UNDESCENDED TESTIS SAC DISSECTS INTO THE LAYERS OF ABDOMINAL WALL PREPERITONEAL INTERPARIETAL or INTERMUSCULAR (COMMONEST) EXTRAPARIETAL or INGUINO-SUPERFICIAL

LARGE RIGHT INGUINAL INTERSTITIAL HERNIA

INGUINAL HERNIA RIGHT INGUINAL INTERSTITIAL HERNIA

INGUINAL HERNIA CLASSIFICATION REDUCIBLE (UNCOMPLICATED) IRREDUCIBLE OBSTRUCTED STRANGULATED INFLAMED

INGUINAL HERNIA COMPRESSIBLE Vs REDUCIBLE COMPRESSIBLE SWELLING REFILLS IMMEDIATELY (SPONTANEOUSLY) AS SOON AS THE PRESSURE IS RELEASED Eg : HEMANGIOMA, LYMPHANGIOMA, ANEURYSM, MENINGOCELE ETC REDUCIBLE SWELLING MAY REQUIRE SOME MANEUVERING TO BRING IT OUT AFTER REDUCTION

INGUINAL HERNIA PREDISPOSING / PRECIPITATING FACTORS CHRONIC COUGH / COPD (SMOKING) CHRONIC CONSTIPTION OBSTRUCTIVE UROPATHY BPH or STRICTURE URETHRA STRENUOUS PHYSICAL ACTIVITY PREVIOUS SURGERY

INGUINAL HERNIA HISTORY OF PREVIOUS SURGERY IN LINE WITH ILIOHYPOGASTRIC & ILIOINGUINAL (L-1) NERVES APPENDECTOMY THRO’ McBURNEY’S DRAINAGE OF PSOAS ABSCESS LUMBAR SYMPATHECTOMY URETERIC or RENAL SURGERY EXTENDED PFANNENSTEIL INCN

INGUINAL HERNIA SYMPTOMS ASYMPTOMATIC, MAY BE DISCOVERED DURING ROUTINE EXAM A MASS APPEARING / DISAPPEARING VAGUE LOCAL DISCOMFORT IRREDUCIBLE or PAINFUL LUMP FEATURES OF INTEST OBSTRUCTION FEATURES OF SEPTICEMIA (LATE CASES OF STRANGULATION)

INGUINAL HERNIA SIGNS SHOULD BE EXAMINED BOTH IN STANDING & SUPINE POSITIONS TWO CLASSICAL SIGNS OF UNCOMPLICATED HERNIA : EXPANSILE COUGH IMPULSE & REDUCIBILITY

INGUINAL HERNIA WHY SHOULD IT BE EXAMINED IN ERECT POSITION ?

IN SUPINE POSITION, NORMAL PROTECTIVE MECHANISMS COME TO PLAY BEFORE THE VISCERA ENTER THE DEEP RING

INGUINAL HERNIA SIGNS …..

POSITION SCROTAL or INGUINOSCROTAL COUGH IMPULSE (EXPANSILE) CONSISTENCY (DOUGHY or ELASTIC) REDUCIBILITY OMENTOCELE : INITIALLY EASY ENTEROCELE : INITIALLY DIFFICULT & REDUCES WITH A GURGLE

INGUINAL HERNIA BUBONOCELE, LEFT

INGUINAL HERNIA LARGE LEFT INGUINAL HERNIA IN A CHILD

INGUINAL HERNIA SIGNS ….

INTERNAL RING OCCLUSION TEST 2cm ABOVE THE MIDPOINT OF ING LIGT DON’T SAY POSITIVE or NEGATIVE THIS TEST IS NOT POSSIBLE IF THE HERNIA IS IRREDUCIBLE

INGUINAL HERNIA SIGNS ….

EXTERNAL RING INVAGINATION TEST NORMLLY PAINFUL SIZE OF EXTERNAL RING (IMPORTANT) STRENGTH OF POSTERIOR WALL IMPULSE TOUCHING THE TIP or PULP OF THE FINGER (UNRELIABLE)

INGUINAL HERNIA EXT RING INVAGINATION TEST NOTE : PATIENT EXPERIENCS DISCOMFORT

INGUINAL HERNIA EXT RING INVAGINATION IS NOT POSSIBLE IN WOMEN ASSOCIATED WITH LARGE HYDROCELE or FILARIAL SCROTUM IRREDUCIBLE HERNIA

INGUINAL HERNIA SIGNS ….

THREE FINGER TEST (ZIEMAN’S) DIFFICULT TO ELICIT NEVER DONE BY SENIORS BETTER TO EXAMINE INDIVIDUAL AREAS FOR COUGH IMPULSE

INGUINAL HERNIA DIFF DIAGNOSIS (COMMON CONDITIONS) HYDROCELE – VAGINAL – ENCYSTED – INFANTILE – BILOCULAR – OF CANAL OF NUCK (in females) RARE FEMORAL HERNIA VARICOCELE CANALICULAR (UNDESCENDED) TESTIS DIFFUSE LIPOMA OF THE CORD

INGUINAL HERNIA DD : Types of Hydrocele Vaginal Congenital Infantile Encysted ( communicating) YOU MAY NOT GET ABOVE THE SWELLING IN B, C & D TYPES and BILOCULAR TYPE

INGUINAL HERNIA INGUINAL Vs FEMORAL HERNIA

INGUINAL HERNIA DD : Testicular descent

INGUINAL HERNIA DD : Varcocele, left

INGUINAL HERNIA DIFF DIAGNOSIS (RARE) FUNCULITIS LYMPH VARIX PSOAS ABSCESS

INGUINAL HERNIA HOW TO DIFFERENTIATE A LARGE SCROTAL HERNIA FROM A HYDROCELE

INGUINAL HERNIA VAGINAL HYDROCELE LEFT

INGUINAL HERNIA Diff between Hydrocele & Scrotal Hernia NOTE : BOTH CONDITIONS MAY COEXIST

INGUINAL HERNIA IS IT CONGENITAL (COMMUNICATING) HYDEROCELE OR CONGENITAL HERNIA ?

DEPENDS UPON THE SIZE OF THE NECK OF THE SAC WHETHER IT ALLOWS ONLY FLUID OR VISCERA

INGUINAL HERNIA HERNIA OF A HYDROCELE LOCALIZED THINNING OF TUNICA LEADING TO PSEUDOPODIUM-LIKE PROJECTION, USUALLY SEEN WHEN THE SAC IS THICK AND FLUID IS UNDER TENSION

INGUINAL HERNIA HYDROCELE OF A HERNIA FLUID SEQUESTRATION IN A LOCULUS OF THE HERNIAL SAC, RESEMBLING HYDROCELE. THIS IS SEEN IN LONG STANDING CASES WITH ADHESIONS WITHIN THE SAC MORE COMMON IN VENTRAL HERNIA CONTAING OMENTUM

INGUINAL HERNIA MALGAIGNE BULGING IT IS A PHANTOM HERNIA, LOCATED JUST ABOVE THE INGUINAL LIGT, MEDIAL TO ANT SUP ILIAC SPINE MAY BE SEEN IN NORMAL THIN ELDERLY INDIVIDUALS DENOTES LOSS OF TONE OF CONJOINT TENDON (WHICH IS MORE MUSCULAR)

INGUINAL HERNIA MALGAIGNE BULGES ….

SEEN IN STANDING POSITION or HEAD RISING (CARNETT’S) MANEUVER VALSALVA MANEUVER THEY ARE NOT DIAGNOSTIC OF HERNIA THEIR PRESENCE DOES NOT IMPLY A GOOD HERNIORRHAPHY CAN’T BE DONE

INGUINAL HERNIA LEG RAISING (CARNETT) TEST TO LOOK FOR MALGAIGNE BULGES

INGUINAL HERNIA MAYDL’S HERNIA (HERNIA-en-W)

‘NORMAL’ LOOKING LOOPS MAYDL’S HERNIA HERNIA-en-W or RETROGRADE STRNGULATION NECROZED LOOP

INGUINAL HERNIA INVESTIGATIONS NO SPECIFIC INVESTIGATIONS REQUIRED FOR THE DIAGNOSIS ONLY TO ASSESS THE FITNESS FOR ANESTHESIA / SURGERY SCREEN PRECIPITATING CONDITIONS COPD, BPH, COLORECTAL LESIONS

INGUINAL HERNIA INVESTIGATIONS - BASIC ROUTINE BLOOD, URINE, CXR, ECG IN AN ELDERLY PATIENT USG ABDOMEN IF BPH IS SUSPECTED COLONOSCOPY IF COLORECTAL LESION IS SUSPECTED

HERNIOGRAPHY CONTRAST STUDY OF THE PERITONEAL SAC (RARELY DONE)

SLIDING HERNIA WITH BLADDER (SCROTAL CYSTOCELE) PELVIC PART URINARY BLADDER SCROTAL PART

INGUINAL HERNIA TREATMENT NO MEDICAL TREATMENT ONLY FOR PREOPERATIVE OPTIMIZATION TRUSS SHOULD NOT BE PRESCRIBED SURGERY IS THE ONLY TREATMENT

INGUINAL HERNIA TRUSS SHOULD NOT BE ADVISED

INGUINAL HERNIA TREATMENT TREAT THE PREDISPOSING CONDITIONS BEFORE ELECTIVE SURGERY STOP SMOKING (AT LEAST 10 DAYS) TREATMENT OF CHRONIC COUGH IF BPH WITH SIGNIFICANT OUTFLOW OBSTRUCTION PRESENT, IT SHOULD BE APPROPRIATELY TREATED CONSTIPATION SHOULD BE CORRECTED

INGUINAL HERNIA Not only it can cause hernia, it may increase its postoperative morbidity

INGUINAL HERNIA SURGERY HERNIOTOMY HERNIORRHAPHY HERNIOPLASTY OPEN (CONVENTIONAL) LAPAROSCOPIC CARDINAL PRINCIPLES NO TENSION NONABSORBABLE SUTURES

INGUINAL HERNIA HERNIOTOMY HIGH LIGATION IS IMPORTANT IN CHILDREN AS THE ONLY PROCEDURE DONE BEFORE OTHER PROCEDURES DIRECT SAC MAY BE INVERTED BY A PURSE-STRING SUTURE

INGUINAL HERNIA HERNIORRHAPHY BASSINI REPAIR (& MODIFICATION) HALSTED REPAIR SHOULDICE REPAIR WILLI MEYER REPAIR (& MODIFICATION) LA ROQUE REPAIR (FOR SLIDING TYPE)

INGUINAL HERNIA ADJUVANT PROCEDURES RELAXING INCISION (TANNER) RESECTION OF SPER CORD (KOONTZ) ORCHIDECTOMY OMENTECTOMY ARTIFICIAL TENSION PNEUMOPERITONEUM

INGUINAL HERNIA Very Large, reaching the Knees NOTE THE SUPRAPUBIC POLYTHENE TUBE TO CREATE ARTIFICIAL PNEUMOPERITONEUM

INGUINAL HERNIA HERNIOPLASTY AUTOLOGOUS TISSUE SYNTHETIC MESH (MORE COMMON) POLYPROPYLENE (PROLENE) (MOST COMMON) PTFE (GORE-TEX) MARLEX DACRON

INGUINAL HERNIA HERNIOPLASTY …… OPEN : LICHTENSTEIN REPAIR (TENSION-FREE) LAPAROSCOPIC : (ALWAYS MESH USED) T RANS A BDOMINAL P RE P ERITONEAL (TAPP) T OTALLY E XTRA P ERITONEAL (TEP)

INGUINAL HERNIA LICHTENSTEIN’S MESH REPAIR

INGUINAL HERNIA TRILAMINAR HERNIA SYSTEM (PROLENE)

INGUINAL HERNIA LAPAROSCOPIC SURGERY

INGUINAL HERNIA STRANGULATION IS IT OBSTRUCTED or STRANGULATED SYMPTOMS IRREDUCIBILITY LOCAL PAIN FEATURES OF INT OBSTRUCTION VOMITING (EVEN IN OMENTOCELE) ABDOMINAL DISTENTION COLICKY ABD PAIN ABSOLUTE CONSTIPATION

INGUINAL HERNIA SIGNS OF STRANGLATION INGUINO-SCROTAL SWELLING TENSELY CYSTIC IN CONSISTENCY IRREDUCIBLE NO COUGH IMPULSE MAY BE SIGNS OF INT OBSTRUCTION IN LATE CASES SIGNS OF PERITONITIS FEATURES OF SEPTICEMIA

INGUINAL HERNIA STRANGULATION …… URGENT SURGERY ONLY ESSENTIAL INVESTIGATIONS IF FEATURES OF INT OBSTRUCTION IV FLUIDS ANTIBIOTICS NASOGASTRIC ASPIRATIONS

INGUINAL HERNIA SURGERY FOR STRANGULATION INGUINO-SCROTAL INCISION OPEN THE SAC FIRST (BEFORE CUTTING THE EXT RING) SUCK OUT THE TOXIC FLUID HAVE A HOLD ON THE BOWEL LOOP THEN DIVIDE THE CONSTRICTING BAND DRAW MORE BOWEL LOOPS INTO THE FIELD ASCERTAIN THE VIABILITY OF THE LOOP BEFORE REDUCTION

INGUINAL HERNIA SURGERY FOR STRANGULATION …… IF THE BOWEL IS VIABLE : REST OF THE PROCEDURE IS SIMILAR TO AN ELECTIVE CASE IF THE BOWEL IS NONVIABLE : BOWEL RESECTION & ANASTOMOSIS CONTINUE IV FLUIDS, ANTIBIOTICS & NG ASPIRATIONS, TILL THE RETURN OF BOWEL ACTIVITY (48-72 HRS) AVOID MESH PLASTY- FEAR OF INFECTION

INGUINAL HERNIA Gangrenous loops of bowel due to Strangulation (delayed)

INGUINAL HERNA CAUSES OF RECURRENCE PREOPERATIVE OPERATIVE POSTOPERATIVE COMMON CAUSES INFECTION TECHNICAL REASONS UNRESOLVED PREDISPOSING FACTORS EARLY RETURN TO ACTIVITY

INGUINAL HERNIA WHAT TO DO IF AFTER GOOD COUNSELING THE PATIENT REFUSES SURGERY ?

LET HIM GO TO

130 CHAPTERS 800 PAGES 1000 PICTURES

CHARLES DARWIN 1809 - 82 “It is not the strongest nor the most intelligent species that survives, but only the one capable of adopting to the changed environment”

Prof R Nanjunda Rao & A S I – Chennai City Branch Prof D Nagarajan, President Dr G Chandrasekar, Secretary Dr Ravindran Kumeran, Treasurer

IF I COVER TOO MUCH YOU MAY LOSE INTEREST

C M K Reddy