HERNIA

GOVINATHAN
 HERNIA

A HERNIA IS A PROTRUSION OF A VISCUS OR

PART OF A VISCUS THROUGH AN
ABNORMAL OPENING IN THE WALLS OF ITS
CONTAINING CAVITY.
APPROACH TO INGUINAL SWELLING?
-HISTORY
- EXAMINATION
 HERNIA
CAUSES

developmental sharp and blunt

design weakness
failure trauma

weakness due to excessive intra- primary

ageing and abdominal neurological and
pregnancy pressure muscle diseases
 HERNIA

Abdominal Parastomal
Inguinal Femoral
Wall Hernia

Direct

Indirect
 Reducible

Irreducible Occult

Complication
s of hernia

Obstructed Infarcted

Strangulated
INCISIONAL HERNIA
HESSELBACH’S TRIANGLE
 CONTENT OF INGUINAL CANAL??

• MALES: SPERMATIC CORD + ILIOINGUINAL NERVE (ABDOMEN TO TESTIS)

• FEMALES: ROUND LIGAMENT OF THE UTERUS + ILIOINGUINAL NERVE (UTERUS
TO LABIUM MAJUS)
ANATOMY OF INGUINAL CANAL
• INDIRECT INGUINAL HERNIA

• 3 TYPES:
BUBONOCELE
FUNICULAR
COMPLETE ( SCROTAL )
 CLINICAL FEATURES:

- PAIN
- GROIN MASS
- EPIGASTRIC PAIN
- CONSTIPATION

DIFFERENTIAL DIAGNOSIS
HYDROCELE,
ENCYSTED HYDROCELE OF CORD.
SPERMATOCELE,
FEMORAL HERNIA
LIPOMA OF CORD.
 MANAGEMENT

NON-SURGICAL:
• RAISED INTRA-ABDOMINAL PRESSURE
• WEIGHT LOSS, CHANGE JOBS, AVOID HEAVY LIFTING
• TREAT MEDICAL CONDITIONS CAUSING CHRONIC COUGH, CHRONIC CONSTIPATION

• TRUSS: FOR COMPRESSION OF REDUCIBLE HERNIA AT DEEP RING (POOR PICKUP

RATE)
• IF OBSTRUCTED/STRANGULATED: NBM, IV DRIP, NG TUBE ON SUCTION, IV ABX
 SURGICAL TECHNIQUES

• OPEN ANTERIOR REPAIR (BASSINI &

SHOULDICE).
• OPEN POSTERIOR REPAIR (NYHUS,
PREPERITONEAL)
• TENSION-FREE REPAIR WITH
MESH(LIECHTENSTEIN)
• LAPAROSCOPIC (TEP & TAPP)
SURGICAL:
• PRINCIPLES: REDUCE BOWEL, ±EXCISE HERNIA SAC, REINFORCE POSTERIOR WALL
• IMMEDIATELY IF SUSPECT INCARCERATION TO PREVENT ANY BOWEL PERFORATION

• OPEN INGUINAL HERNIA REPAIR (WITH MESH / WITHOUT MESH)

• HERNIOTOMY (REMOVAL OF HERNIA SAC ONLY) – DONE IN KIDS, RARELY IN ADULTS
• HERNIORRHAPHY (HERNIOTOMY + REPAIR OF POSTERIOR WALL OF INGUINAL CANAL)
• I.E. – SHOULDICE REPAIR  NON-MESH TECHNIQUE: 2 CONTINUOUS BACK & FORTH SUTURES WITH
PERMANENT SUTURE MATERIAL
• HERNIOPLASTY (REINFORCEMENT OF THE POSTERIOR INGUINAL CANAL WALL WITH A
SYNTHETIC MESH)
• I.E. – LICHTENSTEIN TENSION-FREE MESH REPAIR -> POLYPROPYLENE MESH INSERTION & SUTURE

• LAPAROSCOPIC INGUINAL HERNIA REPAIR (INTRAPERITONEAL OR EXTRAPERITONEAL)

• TRANS-ABDOMINAL PRE-PERITONEAL (TAPP) REPAIR
• TOTALLY EXTRA-PERITONEAL REPAIR (TEP)
 FEMORAL HERNIA:
- WOMEN: MEN=4:1
- MOST LIABLE TO BECOME
STRANGULATED.

- 40% WILL PRESENT AS

STRANGULATION.
RARE BEFORE PUBERTY
 FEMORAL RING :

ANT. - INGUINAL LIGAMENT

POST - ILEOPECTINEAL LIGAMENT, PUBIC

BONE
MED - LACUNAR LIGAMENT.

LATERAL - FEMORAL VEIN.

• DIFFERENTIAL DIAGNOSIS

INGUINAL HERNIA
FEMORAL ARTERY ANEURYSM
SAPHENA VARIX
PSOAS ABSCESS
INGUINAL LYMPH NODE
RUPTURED ADDUCTOR LONGUS
LIPOMA
 MANAGEMENT (SURGERY)
Low operation (Lockwood) Below inguinal lig Suture inguinal lig to cooper’s lig. Dissect fundus of
sac by direct vision & repair is done from below *only for uncomplicated
cases, not prevent inguinal hernia. *no risk of bowel resection

High operation (McEvedy) *emergency Above inguinal lig. Conjoint tendon to ileopectineal line *Provide good
cases! -irreducible & strangulated hernia access to pre-peritoneal space. Advantage : if need to resect intestine, can
obtain ample room by open the peritoneum Disadv : if infection occur,
may dev incisional hernia

Inguinal operation (Lotheissen)
Through inguinal canal. *open transversalis fascia & identify the neck of
sac in femoral ring. Dissect sac from above, ligate the neck and repair is
done. After herniotomy, suture the conjoint tendon to iliopectineal lig by
interrupted sutures by non-absorable monofilament suture. Advantage:
can prevent inguinal hernia as well
SCROTAL SWELLING
HIRISHEN SIVAKUMAR
 APPROACH TO SCROTAL SWELLINGS

• ANSWER 4 QUESTIONS:
• 1. CAN YOU GET ABOVE THE SWELLING?
• 2. CAN YOU IDENTIFY THE TESTIS AND THE EPIDIDYMIS?
• 3. IS THE SWELLING TRANSILLUMINABLE?
• 4. IS THE SWELLING TENDER?
Cannot  Cough impulse Hernia
get  Reducible
above  Testis palpable
swelling  Opaque
 No cough impulse Infantile hydrocoele
 Not reducible
 Testis not palpable
 Transilluminable
Opaque Tender: TORSION, EPIDYDMO-ORCHITIS, ACUTE
Testis not definable from HEMATOCELE
Can get Epididymis
above Non tender: TUMOUR, GUMMA, CHRONIC
swelling HEMATOCELE

Transilluminable Hydrocoele

Opaque Tender: EPIDYDMO-ORCHITIS

Testis definable from Non tender testis swelling: TUMOUR
Epididymis Non tender epididymis swelling: TB epididymis
Transilluminable Cyst of epididymis
 HYDROCELE

• ASYMPTOMATIC FLUID COLLECTION AROUND THE TESTICLES (PROCESSUS VAGINALIS)

THAT TRANSILLUMINATES.

• HISTORY ?

• POINTS FROM EXAMINATION:

• VERY SWOLLEN SCROTUM; UNIFORMLY ENLARGED
• CANNOT DEFINE TESTIS WELL; NOT SEPARABLE FROM TESTIS
• MAYBE FIRM, TENSE OR LAX
• MAYBE TRANSILLUMINABLE IF ACUTE (LESS IN CHRONIC HYDROCELE)
• CAN GET ABOVE THE MASS; THE SUPERFICIAL RING IS DISTINCT
 CLASSIFICATION

• VAGINAL
• HYDROCELE OF THE CORD
ANATOMIC • CONGENITAL
AL • INFANTILE

• From testicular tumour

SECONDAR •
•
From torsion
From trauma
Y • From orchitis (any inflammation)
• Following inguinal hernia repair
 MANAGEMENT

• NON SURGICAL
- WAIT AND WATCH
- ASPIRATION
- ULTRASOUND OF SCOTUM : TRO SECONDARY CAUSE
 EPIDYDIMO ORCHITIS

•  INFLAMMATION OF THE EPIDIDYMIS

AND/OR TESTICLE (TESTIS)
 URINARY
TRACT
INFECTION

AUTOIMMU CAUS VIRAL

NE
ES INFECTIONS

STD
 HISTORY AND EXAMINATION

• HISTORY ? FEVER AND RIGOR

EPIDIDYMIS & TESTIS BECOME SWELL & PAINFUL
CAUSES?

• EXAMINATION
SCROTAL WALL – RED, EDEMA, SHINY
+VE PREHN’S
 TREATMENT

BED REST 1-3 DAYS DRINK PLENTY FLUID +

ANALGESIC
ELEVATE THE SCROTAL
NO SEX. AVOID URETHRAL INSTRUMENT
 INGUINAL LYMPADENITIS

• SWOLLEN LYMPH NODES IN THE

GROIN AREA.
• LYMPH NODES :
- LESS THAN 1.0 CM IN DIAMETER
-MAJOR SITES OF LYMPHOCYTES THAT INCLUDE B AND T CELLS
-ACTING AS FILTERS FOR FOREIGN PARTICLES INCLUDING CANCER CELLS
 HIV

infective TB

STD
causes
LYMPHOM
A,
neoplastic
METATASE
S
TESTICULAR TORSION
IZZAT
 ACUTE SCROTUM
• TESTICULAR TORSION
• TESTICULAR APPENDAGES
• EPIDIDYMO-ORCHITIS
 PATHOPHYSIOLOGY
• TESTICULAR TORSION OCCURS WHEN A TESTICLE ROTATES,
TWISTING THE SPERMATIC CORD THAT BRINGS BLOOD TO THE
SCROTUM.
• TESTICULAR SALVAGE IS MOST LIKELY IF THE DURATION OF TORSION
IS LESS THAN 6 HOURS (GOLDEN HOUR).
• IF 24 HOURS OR MORE, TESTICULAR NECROSIS DEVELOPS IN MOST
PATIENTS.
 CAUSES
CONGENITAL FACTORS
• THIS MAY BE CAUSED BY A CONGENITAL
TRAIT KNOWN AS A “BELL CLAPPER”
DEFORMITY.
OTHER CAUSES
• SPONTANEOUS, EVEN BEFORE BIRTH
• AFTER AN INJURY TO THE GROIN,
• DURING PUBERTY
 TYPES OF TORSION
Extravaginal Intravaginal
 SYMPTOM & SIGN
• PAIN DURATION OF LESS THAN 24 HOURS
• NAUSEA OR VOMITING
• HIGH POSITION OF THE TESTICLE
• TRANSVERSE LIE OF THE AFFECTED TESTIS
• ABNORMAL CREMASTERIC REFLEX
• ENLARGEMENT AND EDEMA OF THE TESTICLE; EDEMA INVOLVING THE
ENTIRE SCROTUM
• SCROTAL ERYTHEMA
• FEVER (UNCOMMON)
 DIAGNOSIS
• IF CLINICALLY SUGGESTED, PERFORM IMMEDIATE SURGICAL
EXPLORATION, REGARDLESS OF LABORATORY STUDIES
• IMAGING STUDIES (ULTRASONOGRAPHY, NUCLEAR SCANS) MAY BE
USEFUL WHEN A LOW SUSPICION OF TESTICULAR TORSION EXISTS.
• THE TWIST SCORE (TESTICULAR WORKUP FOR ISCHEMIA AND
SUSPECTED TORSION)
 DIAGNOSIS
• SCORE 0-2: LOW RISK
• 100% NEGATIVE PREDICTIVE VALUE FOR
TORSION
• GENERALLY NO ULTRASOUND REQUIRED

• SCORE 3-4: INTERMEDIATE RISK

• ULTRASOUND WARRANTED

• SCORE 5 OR ABOVE: HIGH RISK

• 100% POSITIVE PREDICTIVE VALUE FOR
TORSION
• ULTRASOUND NOT REQUIRED, URGENT
SURGERY REQUIRED TO SALVAGE TESTICLE
 ULTRASONOGRAPHY
ULTRASONOGRAPHIC FINDINGS :
• ABSENT OR DECREASED BLOOD FLOW IN THE AFFECTED TESTICLE
• DECREASED FLOW VELOCITY IN THE INTRATESTICULAR ARTERIES
• INCREASED RESISTIVE INDICES IN THE INTRATESTICULAR ARTERIES
• HYPERVASCULARITY WITH A LOW RESISTANCE FLOW PATTERN (AFTER
PARTIAL TORSION-DETORSION)
 MANAGEMENT
• IMMEDIATE SURGICAL EXPLORATION IS INDICATED. FOR
RELIABLE SALVAGE OF THE TESTICLE, SURGICAL REPAIR
MUST OCCUR WITHIN 6 HOURS OF SYMPTOM ONSET.
• IF DELAYED, THE PATIENT MAY EXPERIENCE DECREASED
FERTILITY OR MAY REQUIRE ORCHIECTOMY.
• SURGICAL DETORSION IS THE DEFINITIVE TREATMENT
FOR TESTICULAR TORSION.
 SURGICAL DETORTION
• NEONATAL TORSION IS CONTROVERSIAL, BUT IS MOST OFTEN TREATED WITH
ELECTIVE EXPLORATION.
• IN AN OLDER PATIENT, FOR URGENT SCROTAL EXPLORATION, REGARDLESS
OF THE NUMBER OF HOURS SINCE THE ONSET OF PRESENTING SYMPTOMS.
INTRAOPERATIVE DETAILS
• ONCE EXPLORED, THE SPERMATIC CORD IS THEN UNTWISTED. EVALUATE THE
TESTIS FOR VIABILITY. IF VIABILITY IS IN QUESTION, PLACE THE TESTICLE IN
WARM SPONGES AND REEVALUATE AFTER SEVERAL MINUTES.
• SIGNS OF A VIABLE TESTIS (RETURN OF COLOR, RETURN OF DOPPLER FLOW,
AND ARTERIAL BLEEDING).
• IF THE TESTIS IS NECROTIC, PERFORM AN ORCHIECTOMY.
 MEDICATION
ANALGESIC
• MORPHINE IS THE DRUG OF CHOICE.
ANTIEMETICS
ANTIANXIETY AGENTS
SUMMARY
TESTICULAR
APPENDAGES
IZZAT
 PATHOPHYSIOLOGY
• TORSION OF TESTICULAR APPENDAGES CAN RESULT IN THE CLINICAL
PRESENTATION OF ACUTE SCROTUM.
• TORSION OF AN APPENDAGE LEADS TO ISCHEMIA AND INFARCTION.
• NECROSIS OF APPENDICES CAUSES PAIN AND LOCAL INFLAMMATION
OF SURROUNDING THE TUNICA VAGINALIS AND EPIDIDYMIS (ACUTE
HEMISCROTUM).
• CAB PRESENCE AS THICKENED SCROTAL WALL, REACTIVE
HYDROCELE, AND ENLARGEMENT OF THE HEAD OF THE EPIDIDYMIS.
 SYMMPTOM
• PAIN IN ONE TESTICLE, ON ONE SIDE OF THE SCROTUM
• SWELLING AND REDNESS OF THE SCROTUM
• SCROTUM THAT’S SORE TO THE TOUCH
• A HARD LUMP AT THE TOP OF THE SCROTUM
• A BLUE DOT AT THE TOP OF THE SCROTUM. THIS SHOWS THAT THE
TWIST IS IN THE APPENDAGE, NOT THE TESTICLE.
 DIAGNOSIS
URINE TEST. 
• THIS IS TO CHECK FOR OTHER POSSIBLE CAUSES OF SCROTAL PAIN
SUCH AS INFECTION.
ULTRASOUND.
• TESTICULAR APPENDAGE TORSION APPEARS AS A LESION OF LOW
ECHOGENICITY WITH A CENTRAL HYPOECHOGENIC AREA.
.
 TREATMENT
TREATED CONSERVATIVELY. PAIN USUALLY RESOLVES WITHIN 1 WEEK
TREATMENT FOR TESTICULAR APPENDAGE TORSION INCLUDES:
• REST
• ICE
• RAISING THE AREA TO HELP EASE SWELLING
• OVER-THE-COUNTER PAIN MEDICINE
TESTICULAR TUMOR
SHENBA
PREDISPOSING FACTORS
PATHOLOGICAL CLASSIFICATION
SEMINOMA
SEMINOMA
SPREAD
SPREAD
SPREAD
CLINICAL FEATURES
CLINICAL FEATURES
CLINICAL FEATURES
TUMOUR MARKERS
STAGING WORK UP
DIAGNOSTIC RADIOLOGY
MANAGEMENT
THANK YOU