management of direct and indirect hernia high yield

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Searching PubMed

"inguinal hernia" AND repair

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I now have comprehensive data. Let me compile the high-yield summary.

Inguinal Hernia Management - High Yield

1. Anatomy Quick Review

Feature	Indirect (Lateral/Oblique)	Direct (Medial)
Location relative to inferior epigastric vessels	Lateral	Medial
Site of origin	Deep (internal) inguinal ring	Hesselbach's triangle
Hesselbach's triangle boundaries	-	Medially: rectus abdominis; Laterally: inferior epigastric vessels; Floor: inguinal ligament
Type	Congenital (patent processus vaginalis)	Always acquired
Can descend to scrotum?	Yes	No
Risk of strangulation	Higher (narrow neck)	Lower (broad base)
Bladder involvement	Rare	Can be pulled in (sliding)
Age group	Young (also elderly)	Elderly
Coverings	All 3 layers of spermatic cord	Only external spermatic fascia

Memory aid: "MDs don't lie" - Direct hernias are Medial and Don't descend to scrotum.

2. Clinical Examination

Invaginated finger test: Finger introduced via scrotum into inguinal canal
- Cough impulse felt at tip of finger = indirect hernia
- Cough impulse felt at pulp/side of finger = direct hernia
Zieman's technique (three-finger test): Examiner's index finger over deep ring (indirect), middle finger over Hesselbach's triangle (direct), ring finger over femoral canal (femoral)
Occlusion test: Pressure over deep ring controls indirect hernia but not direct hernia

3. Classification - Nyhus System (High-Yield for Exams)

Type	Description
I	Indirect, normal internal ring (pediatric/infant)
II	Indirect, enlarged internal ring, floor intact, does NOT extend to scrotum
IIIA	Direct hernia (any size)
IIIB	Indirect, dilated internal ring encroaching on inguinal floor; includes scrotal and sliding hernias
IIIC	Femoral hernia
IV	Recurrent hernia (A=direct, B=indirect, C=femoral, D=combination)

European Hernia Society classification: Primary/Recurrent + Lateral/Medial/Femoral + defect size in fingerbreadths (e.g., PL2 = primary lateral, 2 fingerbreadths).

4. Indications for Surgery

All inguinal hernias in children - surgical repair is mandatory (no spontaneous resolution)
Adults:
- Symptomatic hernias: elective repair recommended
- Watchful waiting is acceptable for asymptomatic or minimally symptomatic hernias in males (low risk of acute incarceration ~0.2%/year)
- Emergency repair: incarceration, strangulation, obstruction

5. Surgical Repair - Open Techniques

A. Tissue (Non-Mesh) Repairs

Repair	Key Feature	Notes
Bassini	Conjoint tendon sutured to inguinal ligament	Historical; higher recurrence
Shouldice	4-layer running suture of transversalis fascia (tension-free tissue)	Best pure tissue repair; ~1% recurrence at specialized centers; higher in general settings
McVay (Cooper's ligament)	Conjoint tendon to Cooper's ligament	Used for femoral hernia repair too
Desarda	External oblique aponeurosis autogenous patch	Tension-free tissue repair; promising early data

When to use tissue repair (no mesh):

Contaminated field (strangulation with bowel resection, mesh infection risk)
Pediatric repair (high ligation of sac only, no floor repair needed)
Patient preference / mesh contraindication

B. Open Mesh Repair

Lichtenstein "Tension-Free" Repair (gold standard open repair, most common worldwide):

Polypropylene mesh placed over posterior wall of inguinal canal
Fixed to pubic tubercle medially, inguinal ligament inferiorly, internal oblique superiorly
Keyhole slit cut for spermatic cord
Recurrence rate ~0.5-1%
Identifies and preserves ilioinguinal, iliohypogastric, and genital branch of genitofemoral nerves

Other open mesh:

Plug and patch (Rutkow-Robbins): Mesh plug into defect + flat mesh overlay
PHS (Prolene Hernia System): Bilayer device, pre-peritoneal and flat onlay components

6. Laparoscopic / Minimally Invasive Repair

Approach	Description	Best for
TAPP (TransAbdominal PrePeritoneal)	Enter peritoneal cavity, then dissect preperitoneal space, place mesh, close peritoneum	Bilateral hernias, diagnostic laparoscopy needed, recurrent after open
TEP (Totally ExtraPeritoneal)	Enter preperitoneal space directly, never breach peritoneum	Bilateral hernias (no peritoneal closure needed); prior pelvic surgery relative contraindication
Robotic TAPP	Preferred robotic platform approach	Increasing adoption, ergonomic advantage

Key technical point: Wide exposure of the myopectineal orifice (MPO) is critical; mesh must cover the entire MPO (deep ring, direct space, femoral space).

Comparison (Lichtenstein vs. Laparoscopic):

Laparoscopic = less post-op pain, faster return to work, better for bilateral/recurrent hernias
Open Lichtenstein = simpler, lower cost, lower learning curve
Recurrence rates are equivalent when performed by experienced surgeons
Chronic pain is higher with open approach
TAPP vs TEP (Cochrane 2024, PMID 38963034): No significant difference in outcomes; choice based on surgeon experience and patient factors

7. Special Situations

Situation	Management
Incarcerated hernia (reducible)	Attempt manual reduction (Trendelenburg + gentle pressure from below toward internal ring); if successful, elective repair within 24-48h
Strangulated hernia	Emergency surgery; may need bowel resection; use tissue repair if contaminated field
Pediatric hernia	High ligation of sac at internal ring; no floor repair needed; contralateral exploration controversial (laparoscopic assessment via hernia sac reasonable)
Sliding hernia	Part of sac formed by viscera (sigmoid on left, cecum on right, bladder in direct); extra care during dissection
Pantaloon hernia	Combined direct + indirect on same side (straddles inferior epigastric vessels)
Recurrent hernia	Use posterior approach (laparoscopic) if initial repair was anterior, and vice versa
Female hernia	Higher recurrence rate; occult femoral hernia common - laparoscopic approach preferred
Bilateral hernia	Laparoscopic (single access, both sides) preferred

8. Nerve Anatomy (Critical to Avoid Chronic Pain)

Three nerves at risk during inguinal hernia repair:

Ilioinguinal nerve - travels within inguinal canal on anterior surface of cord
Iliohypogastric nerve - runs along internal oblique above the canal
Genital branch of genitofemoral nerve - travels within deep spermatic cord

Identification and preservation reduces chronic pain to <1%. If injury suspected intraoperatively, neurectomy proximal to injury site (implant cut end into muscle).

9. Complications

Complication	Notes
Chronic pain (most common overall)	11-18%; higher with open/mesh/tack fixation; related to nerve injury
Recurrence	Lichtenstein ~0.5-1%; tissue repairs 1-3% (general surgeons)
Wound infection / seroma	More common with mesh
Ischemic orchitis	Damage to testicular artery during dissection
Vas deferens injury	Especially in pediatric repair
Bladder injury	In direct hernias (sliding bladder) or preperitoneal dissection
Femoral vessel injury	Sutures too deep into inguinal ligament

10. Key Differentiators (Exam Focus)

Direct hernia = always acquired, never congenital, Hesselbach's triangle, elderly, medial to inferior epigastric vessels, broad base = low strangulation risk
Indirect hernia = congenital or acquired, through deep ring lateral to inferior epigastric vessels, can descend to scrotum, all pediatric hernias are indirect
Lichtenstein = gold standard open repair (mesh, tension-free)
Shouldice = gold standard tissue repair (4-layer, specialized centers)
Laparoscopic TEP = no peritoneal entry (true extra-peritoneal); TAPP = enters peritoneum then goes pre-peritoneal
Recurrent after open anterior = use posterior (laparoscopic) approach and vice versa

Sources:

Bailey & Love's Short Practice of Surgery, 28th Edition
Current Surgical Therapy, 14th Edition
Schwartz's Principles of Surgery, 11th Edition
Cochrane review: TAPP vs TEP (PMID 38963034), 2024

surgical approaches available for abdominal[direct/indirect] hernia with their core procedure steps in flowchart

Reading File

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Running Command

ls -la /home/daytona/workspace/ && mkdir -p /home/daytona/workspace/hernia-flowchart

Writing File

~/hernia-flowchart/build.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3 x 7.5

// ─── PALETTE ───────────────────────────────────────────────────────────────
const C = {
  darkBg:   "0D1B2A",  // deep navy - title/section bg
  midBg:    "1B2838",  // slightly lighter navy
  accentA:  "00B4D8",  // cyan - open mesh
  accentB:  "06D6A0",  // teal-green - tissue
  accentC:  "FFB703",  // amber - laparoscopic
  accentD:  "FB5607",  // orange-red - emergency
  accentE:  "9B5DE5",  // violet - robotic
  boxBg:    "1E3A5F",  // medium blue box bg
  boxBg2:   "122A40",  // darker box
  stepBg:   "0A2540",  // step card bg
  white:    "FFFFFF",
  offWhite: "E0F0FF",
  lightGray:"A8C8E8",
  arrow:    "4FC3F7",
  decBg:    "1A3A5C",
  decText:  "FFB703",
};

// ─── HELPER: Flowchart box (rounded rect) ──────────────────────────────────
function fcBox(slide, x, y, w, h, text, color, textColor, fontSize, bold) {
  slide.addShape(pres.ShapeType.roundRect, {
    x, y, w, h,
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    fontSize: fontSize || 11,
    bold: bold !== undefined ? bold : true,
    align: "center",
    valign: "middle",
    wrap: true,
    margin: 4,
  });
}

// ─── HELPER: Diamond decision shape ───────────────────────────────────────
function diamond(slide, x, y, w, h, text, bgColor, textColor, fontSize) {
  slide.addShape(pres.ShapeType.diamond, {
    x, y, w, h,
    fill: { color: bgColor || C.decBg },
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    fontSize: fontSize || 9.5,
    bold: true,
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    wrap: true,
    margin: 4,
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}

// ─── HELPER: Arrow ────────────────────────────────────────────────────────
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    x: x1, y: y1, w: x2 - x1, h: y2 - y1,
    line: { color: C.arrow, width: 1.5, endArrowType: "triangle" },
  });
}

// ─── HELPER: Section header bar ────────────────────────────────────────────
function sectionBar(slide, x, y, w, h, label, color) {
  slide.addShape(pres.ShapeType.rect, {
    x, y, w, h,
    fill: { color },
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    x, y, w, h,
    color: C.white,
    fontSize: 9,
    bold: true,
    align: "center",
    valign: "middle",
    charSpacing: 2,
  });
}

// ─── HELPER: numbered step card ────────────────────────────────────────────
function stepCard(slide, x, y, num, text, accentColor) {
  const W = 1.95, H = 0.52;
  // accent circle
  slide.addShape(pres.ShapeType.ellipse, {
    x: x, y: y, w: 0.3, h: 0.3,
    fill: { color: accentColor },
    line: { color: accentColor, width: 0 },
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  slide.addText(String(num), {
    x: x, y: y, w: 0.3, h: 0.3,
    color: C.darkBg, fontSize: 8, bold: true,
    align: "center", valign: "middle",
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  slide.addText(text, {
    x: x + 0.33, y: y + 0.03, w: W - 0.36, h: H - 0.06,
    color: C.offWhite, fontSize: 7.8, bold: false,
    align: "left", valign: "top", wrap: true,
  });
}

// ════════════════════════════════════════════════════════════════════════════
//  SLIDE 1 — TITLE
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  // Full-bleed dark bg
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:7.5, fill:{color:C.darkBg}, line:{color:C.darkBg} });

  // Accent bars top/bottom
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:0.18, fill:{color:C.accentA}, line:{color:C.accentA} });
  s.addShape(pres.ShapeType.rect, { x:0,y:7.32,w:13.3,h:0.18, fill:{color:C.accentC}, line:{color:C.accentC} });

  // Left vertical accent
  s.addShape(pres.ShapeType.rect, { x:0,y:0.18,w:0.22,h:7.14, fill:{color:C.accentB}, line:{color:C.accentB} });

  // Title
  s.addText("SURGICAL APPROACHES FOR INGUINAL HERNIA", {
    x:0.5, y:1.6, w:12.4, h:1.1,
    color: C.accentA, fontSize: 38, bold: true, align: "center",
    charSpacing: 3,
  });
  s.addText("Direct & Indirect — Core Procedure Steps Flowchart", {
    x:0.5, y:2.75, w:12.4, h:0.65,
    color: C.offWhite, fontSize: 22, bold: false, align: "center",
  });

  // Divider
  s.addShape(pres.ShapeType.line, { x:1.5, y:3.55, w:10.3, h:0, line:{ color:C.accentC, width:1.5 } });

  // Legend row
  const legendItems = [
    { color: C.accentA, label: "Open Mesh Repair" },
    { color: C.accentB, label: "Tissue (Non-Mesh) Repair" },
    { color: C.accentC, label: "Laparoscopic Repair" },
    { color: C.accentE, label: "Robotic-Assisted" },
    { color: C.accentD, label: "Emergency/Urgent" },
  ];
  legendItems.forEach((item, i) => {
    const lx = 1.2 + i * 2.2;
    s.addShape(pres.ShapeType.ellipse, { x:lx, y:3.85, w:0.25, h:0.25, fill:{color:item.color}, line:{color:item.color} });
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  });

  // Subtitle note
  s.addText("Based on: Schwartz's Principles of Surgery 11e  |  Mulholland & Greenfield Surgery 7e  |  Bailey & Love 28e  |  Current Surgical Therapy 14e", {
    x:0.5, y:6.9, w:12.4, h:0.35,
    color: "4A6A8A", fontSize: 7.5, align:"center", italic: true,
  });

  // Type boxes
  const typeW = 3.2, typeH = 1.4, typeY = 4.5;
  // Direct
  s.addShape(pres.ShapeType.roundRect, { x:1.0, y:typeY, w:typeW, h:typeH, fill:{color:C.boxBg}, line:{color:C.accentA, width:1.5}, rectRadius:0.1 });
  s.addText("DIRECT HERNIA", { x:1.0, y:typeY+0.08, w:typeW, h:0.28, color:C.accentA, fontSize:11, bold:true, align:"center" });
  s.addText([
    { text: "• Medial to inferior epigastric vessels\n", options:{} },
    { text: "• Through Hesselbach's triangle\n", options:{} },
    { text: "• Always acquired\n", options:{} },
    { text: "• Broad base → low strangulation risk", options:{} },
  ], { x:1.05, y:typeY+0.38, w:typeW-0.1, h:typeH-0.5, color:C.offWhite, fontSize:9.2, align:"left", wrap:true });

  // Indirect
  s.addShape(pres.ShapeType.roundRect, { x:5.05, y:typeY, w:typeW, h:typeH, fill:{color:C.boxBg}, line:{color:C.accentB, width:1.5}, rectRadius:0.1 });
  s.addText("INDIRECT HERNIA", { x:5.05, y:typeY+0.08, w:typeW, h:0.28, color:C.accentB, fontSize:11, bold:true, align:"center" });
  s.addText([
    { text: "• Lateral to inferior epigastric vessels\n", options:{} },
    { text: "• Through deep (internal) inguinal ring\n", options:{} },
    { text: "• Congenital or acquired\n", options:{} },
    { text: "• Can descend to scrotum", options:{} },
  ], { x:5.1, y:typeY+0.38, w:typeW-0.1, h:typeH-0.5, color:C.offWhite, fontSize:9.2, align:"left", wrap:true });

  // Shared repairs
  s.addShape(pres.ShapeType.roundRect, { x:9.1, y:typeY, w:3.0, h:typeH, fill:{color:"1A3020"}, line:{color:C.accentC, width:1.5}, rectRadius:0.1 });
  s.addText("SHARED REPAIRS", { x:9.1, y:typeY+0.08, w:3.0, h:0.28, color:C.accentC, fontSize:11, bold:true, align:"center" });
  s.addText([
    { text: "• Lichtenstein (mesh)\n", options:{} },
    { text: "• Shouldice / Bassini (tissue)\n", options:{} },
    { text: "• Laparoscopic TEP / TAPP\n", options:{} },
    { text: "• Robotic TAPP", options:{} },
  ], { x:9.15, y:typeY+0.38, w:2.9, h:typeH-0.5, color:C.offWhite, fontSize:9.2, align:"left", wrap:true });
}

// ════════════════════════════════════════════════════════════════════════════
//  SLIDE 2 — DECISION FLOWCHART (Master Overview)
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:7.5, fill:{color:C.darkBg}, line:{color:C.darkBg} });
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:0.42, fill:{color:C.boxBg}, line:{color:C.boxBg} });
  s.addText("SURGICAL DECISION FLOWCHART — Inguinal Hernia", {
    x:0.2, y:0, w:13, h:0.42, color:C.accentA, fontSize:16, bold:true, align:"center", valign:"middle", charSpacing:1,
  });

  // Start
  fcBox(s, 5.45, 0.55, 2.4, 0.42, "INGUINAL HERNIA DIAGNOSED", C.boxBg, C.accentA, 9, true);
  arrow(s, 6.65, 0.97, 6.65, 1.38);

  // Acute?
  diamond(s, 5.45, 1.38, 2.4, 0.72, "Acute presentation?\n(Incarcerated / Strangulated)", C.decBg, C.decText, 8.5);

  // YES branch
  arrow(s, 5.45, 1.74, 3.5, 1.74); // left
  s.addText("YES", { x:4.0, y:1.55, w:0.5, h:0.25, color:C.accentD, fontSize:8, bold:true, align:"center" });
  fcBox(s, 1.9, 1.46, 1.55, 0.56, "Attempt Manual\nReduction", "2D1010", C.accentD, 8.5, true);
  arrow(s, 2.68, 2.02, 2.68, 2.42);

  diamond(s, 1.82, 2.42, 1.72, 0.7, "Successful?", "2D1010", C.accentD, 8.5);
  // yes -> elective
  arrow(s, 1.82, 2.77, 1.0, 3.35);
  s.addText("YES", { x:0.85, y:2.98, w:0.55, h:0.22, color:C.accentB, fontSize:7.5, bold:true });
  fcBox(s, 0.18, 3.35, 1.6, 0.5, "Elective repair\nwithin 24–48 h", "0D2D18", C.accentB, 7.5, false);
  // no -> emergency
  arrow(s, 3.54, 2.77, 4.1, 3.35);
  s.addText("NO", { x:3.6, y:2.98, w:0.55, h:0.22, color:C.accentD, fontSize:7.5, bold:true });
  fcBox(s, 3.55, 3.35, 1.85, 0.5, "EMERGENCY\nSURGERY", C.accentD, C.darkBg, 8.5, true);
  // emergency note
  s.addText("± Bowel resection\n→ Tissue repair (no mesh)", {
    x:3.55, y:3.9, w:1.85, h:0.45, color:"FFAA44", fontSize:7.2, align:"center", italic:true,
  });

  // NO branch → elective
  arrow(s, 6.65, 2.1, 6.65, 2.5); // down from diamond
  s.addText("NO", { x:6.7, y:2.18, w:0.5, h:0.22, color:C.accentB, fontSize:7.5, bold:true });
  diamond(s, 5.42, 2.5, 2.46, 0.72, "Symptomatic?", C.decBg, C.decText, 9);
  // Asymptomatic
  arrow(s, 7.88, 2.86, 9.4, 2.86);
  s.addText("NO (asymptomatic)", { x:7.9, y:2.62, w:1.45, h:0.28, color:C.lightGray, fontSize:7, align:"center" });
  fcBox(s, 9.4, 2.62, 1.85, 0.48, "Watchful Waiting\n(acceptable in males)", "1A2A1A", C.accentB, 7.5, false);

  // Symptomatic → elective
  arrow(s, 6.65, 3.22, 6.65, 3.62);
  s.addText("YES", { x:6.7, y:3.3, w:0.5, h:0.22, color:C.accentA, fontSize:7.5, bold:true });
  diamond(s, 5.2, 3.62, 2.9, 0.72, "Open vs Laparoscopic?", C.decBg, C.decText, 9);

  // ── Open branch ──────────────────────────────────────────────────────────
  arrow(s, 5.2, 3.98, 3.3, 4.5);
  s.addText("OPEN", { x:3.7, y:4.1, w:0.8, h:0.22, color:C.accentA, fontSize:8, bold:true });

  diamond(s, 2.1, 4.5, 2.4, 0.72, "Mesh\nContraindicated?", C.decBg, C.decText, 8.5);
  // mesh yes → tissue
  arrow(s, 2.1, 4.86, 0.8, 5.5);
  s.addText("YES", { x:0.82, y:5.05, w:0.5, h:0.22, color:C.accentB, fontSize:7.5, bold:true });
  fcBox(s, 0.12, 5.5, 1.8, 0.5, "TISSUE REPAIR\n(Shouldice / Bassini)", C.accentB, C.darkBg, 7.5, true);

  // mesh no → lichtenstein
  arrow(s, 4.5, 4.86, 4.9, 5.5);
  s.addText("NO", { x:4.55, y:5.05, w:0.4, h:0.22, color:C.accentA, fontSize:7.5, bold:true });
  fcBox(s, 3.85, 5.5, 2.1, 0.5, "LICHTENSTEIN\n(Tension-Free Mesh)", C.accentA, C.darkBg, 8, true);
  // plug note
  s.addText("Alt: Plug & Patch / PHS", {
    x:3.85, y:6.05, w:2.1, h:0.3, color:C.lightGray, fontSize:7.2, align:"center", italic:true,
  });

  // ── Laparoscopic branch ──────────────────────────────────────────────────
  arrow(s, 8.1, 3.98, 9.6, 4.5);
  s.addText("LAPAROSCOPIC /\nROBOTIC", { x:8.5, y:4.08, w:1.1, h:0.4, color:C.accentC, fontSize:7.5, bold:true, align:"center" });

  diamond(s, 8.5, 4.5, 2.3, 0.72, "Approach\nPreference / History?", C.decBg, C.decText, 8.5);

  // TAPP
  arrow(s, 8.5, 4.86, 7.2, 5.5);
  s.addText("TAPP", { x:7.1, y:5.08, w:0.7, h:0.22, color:C.accentC, fontSize:7.5, bold:true });
  fcBox(s, 6.1, 5.5, 2.0, 0.5, "TAPP\n(Transabdominal\nPreperitoneal)", C.accentC, C.darkBg, 7.5, true);

  // TEP
  arrow(s, 10.8, 4.86, 10.8, 5.5);
  s.addText("TEP", { x:10.85, y:5.05, w:0.5, h:0.22, color:C.accentC, fontSize:7.5, bold:true });
  fcBox(s, 9.85, 5.5, 2.0, 0.5, "TEP\n(Totally\nExtraperitoneal)", C.accentC, C.darkBg, 7.5, true);

  // Robotic
  arrow(s, 9.65, 4.86, 9.0, 5.5);
  fcBox(s, 12.15, 5.5, 1.0, 0.5, "Robotic\nTAPP", C.accentE, C.darkBg, 7.5, true);
  arrow(s, 10.8, 4.86, 12.2, 5.5);

  // ── Bottom legend ────────────────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x:0,y:7.1,w:13.3,h:0.4, fill:{color:C.boxBg2}, line:{color:C.boxBg2} });
  s.addText("Preferred for bilateral/recurrent: Laparoscopic  |  Contaminated field: Tissue repair (no mesh)  |  Pediatric: High ligation of sac only  |  Chronic pain risk: Higher with open", {
    x:0.2, y:7.1, w:12.9, h:0.4, color:C.lightGray, fontSize:7.5, align:"center", valign:"middle",
  });
}

// ════════════════════════════════════════════════════════════════════════════
//  SLIDE 3 — LICHTENSTEIN (Open Mesh) Flowchart
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:7.5, fill:{color:C.darkBg}, line:{color:C.darkBg} });
  sectionBar(s, 0, 0, 13.3, 0.45, "OPEN MESH REPAIR — LICHTENSTEIN TENSION-FREE HERNIOPLASTY  |  Gold Standard", C.accentA);

  // Sub-header
  s.addText("Indications: Symptomatic inguinal hernia (direct or indirect) in adults  |  Standard first-line open repair", {
    x:0.3, y:0.5, w:12.7, h:0.28, color:C.lightGray, fontSize:8.5, align:"center", italic:true,
  });

  // Steps as a vertical flowchart in 2 columns
  const col1 = [
    { n:1, t:"Incision: 6–8 cm oblique\nbelow ASIS to symphysis pubis" },
    { n:2, t:"Divide Scarpa's fascia;\nligate superficial epigastric veins" },
    { n:3, t:"Open external oblique aponeurosis\nalong fiber direction → expose inguinal canal" },
    { n:4, t:"Identify & preserve 3 nerves:\nilioinguinal, iliohypogastric,\ngenital branch of genitofemoral" },
    { n:5, t:"Isolate spermatic cord\n(Penrose drain retraction)" },
    { n:6, t:"Dissect indirect sac\nfrom cord → ligate/reduce at deep ring" },
    { n:7, t:"Assess posterior wall\nfor direct hernia defect" },
  ];
  const col2 = [
    { n:8,  t:"Cut polypropylene mesh ~15×7 cm;\nround medial end" },
    { n:9,  t:"Fix medial edge to aponeurosis\n2 cm medial to pubic tubercle" },
    { n:10, t:"Running suture: inferior mesh edge\nto inguinal ligament (medial → lateral)" },
    { n:11, t:"Interrupted sutures: superior mesh edge\nto internal oblique aponeurosis" },
    { n:12, t:"Slit lateral mesh → create 2 tails;\nencircle cord → shutter valve stitch\nat lateral inguinal ligament" },
    { n:13, t:"Tuck tails under ext oblique\nto ASIS" },
    { n:14, t:"Close external oblique\n→ reconstruct external ring\n→ Subcuticular skin closure" },
  ];

  const bx1 = 0.25, bx2 = 6.85, startY = 0.9, stepH = 0.74, gap = 0.08;

  col1.forEach((item, i) => {
    const y = startY + i * (stepH + gap);
    s.addShape(pres.ShapeType.roundRect, { x:bx1, y, w:6.35, h:stepH, fill:{color:C.stepBg}, line:{color:C.accentA, width:0.8}, rectRadius:0.07 });
    // number badge
    s.addShape(pres.ShapeType.ellipse, { x:bx1+0.08, y:y+0.16, w:0.4, h:0.4, fill:{color:C.accentA}, line:{color:C.accentA} });
    s.addText(String(item.n), { x:bx1+0.08, y:y+0.16, w:0.4, h:0.4, color:C.darkBg, fontSize:10, bold:true, align:"center", valign:"middle" });
    s.addText(item.t, { x:bx1+0.56, y:y+0.07, w:5.72, h:stepH-0.14, color:C.offWhite, fontSize:9.5, align:"left", valign:"middle", wrap:true });
    if (i < col1.length - 1) arrow(s, bx1+3.18, y+stepH, bx1+3.18, y+stepH+gap);
  });

  col2.forEach((item, i) => {
    const y = startY + i * (stepH + gap);
    s.addShape(pres.ShapeType.roundRect, { x:bx2, y, w:6.35, h:stepH, fill:{color:C.stepBg}, line:{color:C.accentA, width:0.8}, rectRadius:0.07 });
    s.addShape(pres.ShapeType.ellipse, { x:bx2+0.08, y:y+0.16, w:0.4, h:0.4, fill:{color:C.accentA}, line:{color:C.accentA} });
    s.addText(String(item.n), { x:bx2+0.08, y:y+0.16, w:0.4, h:0.4, color:C.darkBg, fontSize:10, bold:true, align:"center", valign:"middle" });
    s.addText(item.t, { x:bx2+0.56, y:y+0.07, w:5.72, h:stepH-0.14, color:C.offWhite, fontSize:9.5, align:"left", valign:"middle", wrap:true });
    if (i < col2.length - 1) arrow(s, bx2+3.18, y+stepH, bx2+3.18, y+stepH+gap);
  });

  // connector: col1 bottom → col2 top
  const col1LastY = startY + (col1.length - 1) * (stepH + gap) + stepH;
  s.addShape(pres.ShapeType.line, { x:bx1+3.18, y:col1LastY, w:3.67+3.18, h:0, line:{color:C.accentA, width:1.2, dashType:"dash"} });
  arrow(s, bx2+3.18, col1LastY, bx2+3.18, startY);
  s.addText("Continue →", { x:6.2, y:col1LastY-0.18, w:1.3, h:0.22, color:C.accentA, fontSize:7, align:"center" });

  // Recurrence note
  s.addShape(pres.ShapeType.rect, { x:0,y:7.1,w:13.3,h:0.4, fill:{color:C.boxBg2}, line:{color:C.boxBg2} });
  s.addText("Recurrence: ~0.5–1%  |  Most common complication: Chronic inguinodynia (11–18%)  |  Can be done under local/spinal/general anesthesia", {
    x:0.2, y:7.1, w:12.9, h:0.4, color:C.lightGray, fontSize:7.5, align:"center", valign:"middle",
  });
}

// ════════════════════════════════════════════════════════════════════════════
//  SLIDE 4 — TISSUE REPAIRS (Shouldice, Bassini, McVay)
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:7.5, fill:{color:C.darkBg}, line:{color:C.darkBg} });
  sectionBar(s, 0, 0, 13.3, 0.45, "TISSUE (NON-MESH) REPAIRS — Shouldice · Bassini · McVay", C.accentB);

  s.addText("Use when: Contaminated field  |  Strangulation with bowel resection  |  Mesh contraindicated  |  Patient preference", {
    x:0.3, y:0.5, w:12.7, h:0.28, color:C.lightGray, fontSize:8.5, align:"center", italic:true,
  });

  // ── Shouldice (Best tissue repair) ──────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x:0.2, y:0.88, w:4.15, h:6.15, fill:{color:"0A2210"}, line:{color:C.accentB, width:1.5} });
  s.addText("SHOULDICE REPAIR", { x:0.2, y:0.88, w:4.15, h:0.38, color:C.accentB, fontSize:12, bold:true, align:"center", valign:"middle" });
  s.addText("Gold standard tissue repair | ~1% recurrence at specialist centers", { x:0.25, y:1.28, w:4.05, h:0.28, color:C.lightGray, fontSize:7.5, align:"center", italic:true });

  const shouldiceSteps = [
    { n:1, t:"Incision & dissection identical to Lichtenstein up to cord isolation" },
    { n:2, t:"Divide transversalis fascia from pubic tubercle to deep inguinal ring" },
    { n:3, t:"Develop preperitoneal space; reduce indirect sac; ligate at deep ring" },
    { n:4, t:"LAYER 1: Running suture — deep flap of transversalis fascia to undersurface of superior flap (medial → lateral)" },
    { n:5, t:"LAYER 2: Same suture returns (lateral → medial) approximating superior flap to inguinal ligament" },
    { n:6, t:"LAYER 3: Running suture — internal oblique / conjoined tendon to inguinal ligament" },
    { n:7, t:"LAYER 4: Same suture returns approximating ext oblique aponeurosis over cord" },
    { n:8, t:"Reconstruct external ring; skin closure" },
  ];
  shouldiceSteps.forEach((item, i) => {
    const y = 1.6 + i * 0.63;
    s.addShape(pres.ShapeType.roundRect, { x:0.28, y, w:4.0, h:0.59, fill:{color:C.stepBg}, line:{color:C.accentB, width:0.6}, rectRadius:0.06 });
    s.addShape(pres.ShapeType.ellipse, { x:0.33, y:y+0.12, w:0.33, h:0.33, fill:{color:C.accentB}, line:{color:C.accentB} });
    s.addText(String(item.n), { x:0.33, y:y+0.12, w:0.33, h:0.33, color:C.darkBg, fontSize:9, bold:true, align:"center", valign:"middle" });
    s.addText(item.t, { x:0.73, y:y+0.04, w:3.48, h:0.52, color:C.offWhite, fontSize:8.2, align:"left", valign:"middle", wrap:true });
    if (i < shouldiceSteps.length - 1) arrow(s, 2.28, y+0.59, 2.28, y+0.65);
  });

  // ── Bassini ──────────────────────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x:4.6, y:0.88, w:4.0, h:3.55, fill:{color:"0A1A2A"}, line:{color:"5599CC", width:1.2} });
  s.addText("BASSINI REPAIR", { x:4.6, y:0.88, w:4.0, h:0.38, color:"5599CC", fontSize:12, bold:true, align:"center", valign:"middle" });
  s.addText("Historical; higher recurrence (10–15% in general practice)", { x:4.65, y:1.28, w:3.9, h:0.28, color:C.lightGray, fontSize:7.2, align:"center", italic:true });

  const bassiniSteps = [
    { n:1, t:"Incision, open ext oblique aponeurosis, expose inguinal canal" },
    { n:2, t:"Isolate cord; dissect & reduce indirect hernia sac; high ligation" },
    { n:3, t:"Assess direct defect (posterior wall weakness)" },
    { n:4, t:"Triple layer reconstruction: conjoined tendon (transversus abdominis + internal oblique) sutured to inguinal ligament posterior to cord" },
    { n:5, t:"Recreate external ring; layer closure" },
  ];
  bassiniSteps.forEach((item, i) => {
    const y = 1.62 + i * 0.56;
    s.addShape(pres.ShapeType.roundRect, { x:4.68, y, w:3.84, h:0.52, fill:{color:C.stepBg}, line:{color:"5599CC", width:0.5}, rectRadius:0.06 });
    s.addShape(pres.ShapeType.ellipse, { x:4.73, y:y+0.1, w:0.3, h:0.3, fill:{color:"5599CC"}, line:{color:"5599CC"} });
    s.addText(String(item.n), { x:4.73, y:y+0.1, w:0.3, h:0.3, color:C.darkBg, fontSize:8, bold:true, align:"center", valign:"middle" });
    s.addText(item.t, { x:5.1, y:y+0.03, w:3.35, h:0.46, color:C.offWhite, fontSize:8, align:"left", valign:"middle", wrap:true });
    if (i < bassiniSteps.length - 1) arrow(s, 6.6, y+0.52, 6.6, y+0.6);
  });

  // ── McVay ────────────────────────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x:4.6, y:4.6, w:4.0, h:2.45, fill:{color:"1A0A2A"}, line:{color:"BB88FF", width:1.2} });
  s.addText("McVAY (COOPER'S LIGAMENT) REPAIR", { x:4.6, y:4.6, w:4.0, h:0.38, color:"BB88FF", fontSize:10, bold:true, align:"center", valign:"middle" });
  s.addText("Use for: Femoral hernia repair  |  Large direct defects", { x:4.65, y:5.0, w:3.9, h:0.22, color:C.lightGray, fontSize:7.2, align:"center", italic:true });

  const mcvaySteps = [
    { n:1, t:"Standard inguinal dissection; open inguinal floor down to Cooper's ligament" },
    { n:2, t:"Suture conjoined tendon to Cooper's ligament (pectineal ligament) medially" },
    { n:3, t:"Transition sutures to inguinal ligament laterally over femoral vessels (transition stitch)" },
    { n:4, t:"Relaxing incision in anterior rectus sheath to relieve tension" },
  ];
  mcvaySteps.forEach((item, i) => {
    const y = 5.26 + i * 0.42;
    s.addShape(pres.ShapeType.roundRect, { x:4.68, y, w:3.84, h:0.38, fill:{color:C.stepBg}, line:{color:"BB88FF", width:0.5}, rectRadius:0.05 });
    s.addShape(pres.ShapeType.ellipse, { x:4.73, y:y+0.04, w:0.28, h:0.28, fill:{color:"BB88FF"}, line:{color:"BB88FF"} });
    s.addText(String(item.n), { x:4.73, y:y+0.04, w:0.28, h:0.28, color:C.darkBg, fontSize:7.5, bold:true, align:"center", valign:"middle" });
    s.addText(item.t, { x:5.08, y:y+0.02, w:3.37, h:0.34, color:C.offWhite, fontSize:7.8, align:"left", valign:"middle", wrap:true });
  });

  // ── Comparison box ───────────────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x:8.8, y:0.88, w:4.3, h:6.15, fill:{color:C.boxBg2}, line:{color:C.lightGray, width:0.8} });
  s.addText("COMPARISON", { x:8.8, y:0.88, w:4.3, h:0.38, color:C.lightGray, fontSize:12, bold:true, align:"center", valign:"middle" });

  const compRows = [
    ["Repair", "Recurrence", "Key Advantage"],
    ["Shouldice", "~1%*", "Best tissue; 4-layer"],
    ["Bassini", "10–15%†", "Simple technique"],
    ["McVay", "Variable", "Covers femoral space"],
    ["Desarda", "Similar to\nShoulce", "Autogenous, tension-free"],
    ["Lichtenstein", "0.5–1%", "GOLD STANDARD"],
  ];
  compRows.forEach((row, i) => {
    const ry = 1.32 + i * 0.75;
    const isHeader = i === 0;
    const isGold = i === 5;
    const rowColor = isHeader ? C.boxBg : (isGold ? "1A2800" : C.stepBg);
    const textColor = isHeader ? C.accentA : (isGold ? C.accentC : C.offWhite);
    [0,1,2].forEach((ci) => {
      const cx = 8.85 + ci * 1.43;
      s.addShape(pres.ShapeType.rect, { x:cx, y:ry, w:1.4, h:0.72, fill:{color:rowColor}, line:{color:"2A4A6A", width:0.5} });
      s.addText(row[ci], { x:cx, y:ry, w:1.4, h:0.72, color:textColor, fontSize: isHeader ? 8.5 : 8, bold:isHeader||isGold, align:"center", valign:"middle", wrap:true });
    });
  });
  s.addText("* Shouldice Hospital; †General practice\nDesarda: autogenous ext oblique patch", {
    x:8.85, y:5.85, w:4.2, h:0.4, color:"6688AA", fontSize:6.8, align:"center", italic:true,
  });

  s.addShape(pres.ShapeType.rect, { x:0,y:7.1,w:13.3,h:0.4, fill:{color:C.boxBg2}, line:{color:C.boxBg2} });
  s.addText("Shouldice 4-layer: transversalis fascia → internal oblique → external oblique (4 running sutures, same continuous stitch folds back on each pass)", {
    x:0.2, y:7.1, w:12.9, h:0.4, color:C.lightGray, fontSize:7.5, align:"center", valign:"middle",
  });
}

// ════════════════════════════════════════════════════════════════════════════
//  SLIDE 5 — LAPAROSCOPIC: TAPP
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:7.5, fill:{color:C.darkBg}, line:{color:C.darkBg} });
  sectionBar(s, 0, 0, 13.3, 0.45, "LAPAROSCOPIC REPAIR — TAPP (TransAbdominal PrePeritoneal)", C.accentC);

  s.addText("Indications: Bilateral hernia  |  Recurrent after open anterior  |  Diagnostic laparoscopy needed  |  Prior mesh plug recurrence", {
    x:0.3, y:0.5, w:12.7, h:0.28, color:C.lightGray, fontSize:8.5, align:"center", italic:true,
  });

  const tappSteps = [
    { n:1,  t:"Position: Trendelenburg, tilted to contralateral side\n(gravity moves viscera cephalad)" },
    { n:2,  t:"Port placement: 10–12 mm umbilical camera port;\ntwo 5 mm working ports (~6 cm lateral to umbilicus)" },
    { n:3,  t:"Inspect peritoneal cavity;\nconfirm hernia type & bilaterality" },
    { n:4,  t:"Incise peritoneum ≥4 cm above internal ring\n(from ASIS medially to medial umbilical ligament)" },
    { n:5,  t:"Develop preperitoneal space in avascular plane\njust deep to transversalis fascia" },
    { n:6,  t:"Medial dissection: parietal transversalis fascia\n→ expose retropubic (Retzius) space, Cooper's ligament" },
    { n:7,  t:"Lateral dissection: preserve visceral/parietal fascia\nover nerve area to avoid neuropathy\n(Triangle of Pain / Triangle of Doom)" },
    { n:8,  t:"Reduce hernia sac completely;\nligate indirect sac at deep ring if cannot reduce" },
    { n:9,  t:"Place large polypropylene mesh (≥15×10 cm)\ncovering entire myopectineal orifice (MPO)" },
    { n:10, t:"Tack mesh medially (Cooper's lig, above iliopubic tract)\nAvoid tacks below iliopubic tract (nerve injury risk)" },
    { n:11, t:"Close peritoneum over mesh completely\n(running suture or tacker) to prevent adhesions" },
    { n:12, t:"Deflate pneumoperitoneum; close port sites ≥10 mm" },
  ];

  const col1 = tappSteps.slice(0,6);
  const col2 = tappSteps.slice(6,12);
  const bx1 = 0.2, bx2 = 6.8, sy = 0.88, sh = 0.97, sg = 0.06;

  col1.forEach((item, i) => {
    const y = sy + i*(sh+sg);
    s.addShape(pres.ShapeType.roundRect, { x:bx1, y, w:6.4, h:sh, fill:{color:C.stepBg}, line:{color:C.accentC, width:0.8}, rectRadius:0.07 });
    s.addShape(pres.ShapeType.ellipse, { x:bx1+0.08, y:y+0.28, w:0.38, h:0.38, fill:{color:C.accentC}, line:{color:C.accentC} });
    s.addText(String(item.n), { x:bx1+0.08, y:y+0.28, w:0.38, h:0.38, color:C.darkBg, fontSize:9.5, bold:true, align:"center", valign:"middle" });
    s.addText(item.t, { x:bx1+0.54, y:y+0.06, w:5.78, h:sh-0.12, color:C.offWhite, fontSize:9, align:"left", valign:"middle", wrap:true });
    if (i < col1.length-1) arrow(s, bx1+3.2, y+sh, bx1+3.2, y+sh+sg);
  });

  col2.forEach((item, i) => {
    const y = sy + i*(sh+sg);
    s.addShape(pres.ShapeType.roundRect, { x:bx2, y, w:6.4, h:sh, fill:{color:C.stepBg}, line:{color:C.accentC, width:0.8}, rectRadius:0.07 });
    s.addShape(pres.ShapeType.ellipse, { x:bx2+0.08, y:y+0.28, w:0.38, h:0.38, fill:{color:C.accentC}, line:{color:C.accentC} });
    s.addText(String(item.n), { x:bx2+0.08, y:y+0.28, w:0.38, h:0.38, color:C.darkBg, fontSize:9.5, bold:true, align:"center", valign:"middle" });
    s.addText(item.t, { x:bx2+0.54, y:y+0.06, w:5.78, h:sh-0.12, color:C.offWhite, fontSize:9, align:"left", valign:"middle", wrap:true });
    if (i < col2.length-1) arrow(s, bx2+3.2, y+sh, bx2+3.2, y+sh+sg);
  });

  // connector line col1→col2
  const joinY = sy + (col1.length-1)*(sh+sg) + sh + 0.03;
  s.addShape(pres.ShapeType.line, { x:bx1+3.2, y:joinY, w:3.6+3.2, h:0, line:{color:C.accentC, width:1, dashType:"dash"} });
  arrow(s, bx2+3.2, joinY, bx2+3.2, sy);
  s.addText("Continue →", { x:6.3, y:joinY-0.18, w:1.3, h:0.2, color:C.accentC, fontSize:7, align:"center" });

  s.addShape(pres.ShapeType.rect, { x:0,y:7.1,w:13.3,h:0.4, fill:{color:C.boxBg2}, line:{color:C.boxBg2} });
  s.addText("Key danger zones: Triangle of Doom (iliac vessels) & Triangle of Pain (lateral cutaneous + femoral branch genitofemoral nerves) — NO tacks lateral to vas deferens or below iliopubic tract", {
    x:0.2, y:7.1, w:12.9, h:0.4, color:"FF8888", fontSize:7.2, align:"center", valign:"middle",
  });
}

// ════════════════════════════════════════════════════════════════════════════
//  SLIDE 6 — TEP Flowchart
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:7.5, fill:{color:C.darkBg}, line:{color:C.darkBg} });
  sectionBar(s, 0, 0, 13.3, 0.45, "LAPAROSCOPIC REPAIR — TEP (Totally ExtraPeritoneal)", C.accentC);

  s.addText("Best for: Bilateral hernias (no peritoneal closure needed)  |  Recurrent after TAPP  |  Avoid if: prior pelvic surgery (relative CI), scrotal/massive hernia", {
    x:0.3, y:0.5, w:12.7, h:0.28, color:C.lightGray, fontSize:8.5, align:"center", italic:true,
  });

  const tepSteps = [
    { n:1,  t:"Infraumbilical incision; open anterior rectus sheath\n(do NOT enter peritoneum)" },
    { n:2,  t:"Insert 10–12 mm blunt trocar (balloon or direct)\ninto preperitoneal space beneath rectus abdominis" },
    { n:3,  t:"Balloon expansion of preperitoneal space\n(or blunt dissection with laparoscope) under direct vision" },
    { n:4,  t:"Place 2 additional 5 mm trocars in midline\n(infraumbilical / suprapubic)" },
    { n:5,  t:"CO₂ insufflation of preperitoneal space\n(pressure ~8–12 mmHg)" },
    { n:6,  t:"Identify landmarks: pubic symphysis, Cooper's lig,\nepigastric vessels, vas deferens, iliac vessels" },
    { n:7,  t:"Dissect direct and/or indirect sac;\nreduce completely into abdomen" },
    { n:8,  t:"Ligate indirect sac at deep ring if large;\ncream-pot rule: reduce contents before dividing" },
    { n:9,  t:"Place large mesh (≥15×10 cm) covering entire MPO:\ndeep ring, direct space, femoral canal" },
    { n:10, t:"Tack mesh to Cooper's ligament and above iliopubic tract\n(NO tacks in triangle of pain / triangle of doom)" },
    { n:11, t:"No peritoneal closure required\n(key advantage over TAPP)" },
    { n:12, t:"Deflate CO₂ gradually (allows mesh to lie flat);\nclose anterior rectus sheath; skin closure" },
  ];

  const col1 = tepSteps.slice(0,6);
  const col2 = tepSteps.slice(6,12);
  const bx1 = 0.2, bx2 = 6.8, sy = 0.88, sh = 0.97, sg = 0.06;

  col1.forEach((item, i) => {
    const y = sy + i*(sh+sg);
    s.addShape(pres.ShapeType.roundRect, { x:bx1, y, w:6.4, h:sh, fill:{color:C.stepBg}, line:{color:C.accentC, width:0.8}, rectRadius:0.07 });
    s.addShape(pres.ShapeType.ellipse, { x:bx1+0.08, y:y+0.28, w:0.38, h:0.38, fill:{color:C.accentC}, line:{color:C.accentC} });
    s.addText(String(item.n), { x:bx1+0.08, y:y+0.28, w:0.38, h:0.38, color:C.darkBg, fontSize:9.5, bold:true, align:"center", valign:"middle" });
    s.addText(item.t, { x:bx1+0.54, y:y+0.06, w:5.78, h:sh-0.12, color:C.offWhite, fontSize:9, align:"left", valign:"middle", wrap:true });
    if (i < col1.length-1) arrow(s, bx1+3.2, y+sh, bx1+3.2, y+sh+sg);
  });

  col2.forEach((item, i) => {
    const y = sy + i*(sh+sg);
    s.addShape(pres.ShapeType.roundRect, { x:bx2, y, w:6.4, h:sh, fill:{color:C.stepBg}, line:{color:C.accentC, width:0.8}, rectRadius:0.07 });
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// ════════════════════════════════════════════════════════════════════════════
//  SLIDE 7 — COMPARISON TABLE + Special Situations
// ════════════════════════════════════════════════════════════════════════════
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    ["Shouldice\n(Tissue)", "~1%*\n(3× higher†)", "Lower than\nmesh", "Local / Spinal\n/ GA", "Contaminated\nfield; mesh CI", "Requires expert\ntechnique"],
    ["Bassini\n(Tissue)", "10–15%†", "Low", "Local / GA", "Developing world;\nno mesh available", "High recurrence\nin general practice"],
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    { icon:"⚠", title:"Incarcerated", body:"Attempt reduction → Elective repair 24–48 h\nFailed → Emergency surgery" },
    { icon:"🚨", title:"Strangulated", body:"Emergency surgery\n± bowel resection\nTissue repair (no mesh in contaminated field)" },
    { icon:"👶", title:"Pediatric", body:"High ligation of sac only\nNo floor repair needed\nAll are indirect type" },
    { icon:"🔄", title:"Recurrent", body:"Use opposite approach:\nOpen anterior → Laparoscopic posterior\nLaparoscopic → Open anterior" },
    { icon:"♀", title:"Female", body:"Higher recurrence;\nOccult femoral hernia common\nLaparoscopic preferred" },
    { icon:"⬅➡", title:"Bilateral", body:"Single laparoscopic\napproach covers both\nsides (TEP/TAPP)" },
    { icon:"🩸", title:"Pantaloon", body:"Both direct + indirect\n(straddles inf. epigastric v.)\nTreat both components" },
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// ─── Write file ──────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/hernia-flowchart/Inguinal_Hernia_Surgical_Approaches_Flowchart.pptx" })
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Running Command

cd /home/daytona/workspace/hernia-flowchart && node build.js 2>&1

Running Command

ls -lh /home/daytona/workspace/hernia-flowchart/

Your presentation is ready:

Inguinal Hernia Surgical Approaches Flowchart
Presentation · PPTX

What's inside (7 slides, dark navy theme):

Slide	Content
1 - Title	Direct vs Indirect hernia type comparison boxes + color-coded legend for all repair categories
2 - Decision Flowchart	Master algorithm: Acute? → Incarcerated/Strangulated → Manual reduction → Emergency vs Elective; Symptomatic? → Watchful waiting vs Open vs Laparoscopic branch
3 - Lichtenstein	14 numbered step-by-step flowchart cards (2 columns) for the gold standard open mesh repair
4 - Tissue Repairs	Side-by-side flowcharts for Shouldice (8 steps - 4-layer), Bassini (5 steps), McVay/Cooper's ligament (4 steps) + comparison table
5 - TAPP	12-step laparoscopic TAPP flowchart including Triangle of Doom / Triangle of Pain danger zones
6 - TEP	12-step TEP flowchart; highlights key difference - no peritoneal entry/closure needed
7 - Comparison + Specials	Head-to-head table (Recurrence / Chronic Pain / Anesthesia / Best indication) + 7 special situation boxes (Incarcerated, Strangulated, Pediatric, Recurrent, Female, Bilateral, Pantaloon)

All steps sourced from Schwartz's 11e, Mulholland & Greenfield Surgery 7e, Bailey & Love 28e, and Current Surgical Therapy 14e.

cant open...just give me as text

Here is the complete flowchart as text:

SURGICAL APPROACHES FOR INGUINAL HERNIA

Direct & Indirect — Core Procedure Steps

MASTER DECISION FLOWCHART

                    ┌─────────────────────────┐
                    │  INGUINAL HERNIA         │
                    │  DIAGNOSED               │
                    └────────────┬────────────┘
                                 │
                    ┌────────────▼────────────┐
                    │  Acute presentation?    │
                    │  (Incarcerated /        │◄── YES ──► Attempt Manual Reduction
                    │   Strangulated?)        │                    │
                    └────────────┬────────────┘         ┌─────────┴────────┐
                                 │ NO                   YES                NO
                                 │                       │                  │
                    ┌────────────▼────────────┐    Elective repair    EMERGENCY
                    │    Symptomatic?         │    within 24–48 h     SURGERY
                    └────────────┬────────────┘                       ± bowel
                          │             │                              resection
                         YES            NO                            → Tissue
                          │             │                              repair
                          │      Watchful Waiting                     (no mesh)
                          │      (acceptable in
                          │       asymptomatic males)
                          │
           ┌──────────────┴──────────────┐
           │                             │
          OPEN                    LAPAROSCOPIC /
           │                          ROBOTIC
           │                             │
    ┌──────┴──────┐             ┌────────┼────────┐
   Mesh CI?     Mesh OK        TAPP     TEP    Robotic
    │              │                              TAPP
    ▼              ▼
TISSUE         LICHTENSTEIN
REPAIR         (Tension-Free)
(Shouldice /   Alt: Plug & Patch
 Bassini /          PHS
 McVay)

Key routing rules:

Bilateral hernia → Laparoscopic (TEP/TAPP) preferred
Recurrent after open anterior → Laparoscopic posterior
Recurrent after laparoscopic → Open anterior
Contaminated field → Tissue repair (no mesh)
Pediatric → High ligation of sac only

A. LICHTENSTEIN TENSION-FREE REPAIR

(Open Mesh — Gold Standard | Recurrence ~0.5–1%)

STEP 1
Incision: 6–8 cm oblique, below ASIS → just lateral to symphysis pubis
         │
         ▼
STEP 2
Divide Scarpa's fascia
Ligate/cauterize superficial epigastric veins
         │
         ▼
STEP 3
Open external oblique aponeurosis along fiber direction
→ Incision extended through external inguinal ring medially
→ Exposes inguinal canal
         │
         ▼
STEP 4
Identify & PRESERVE all 3 nerves:
  • Ilioinguinal nerve (anterior surface of cord)
  • Iliohypogastric nerve (along internal oblique above canal)
  • Genital branch of genitofemoral nerve (within deep cord)
         │
         ▼
STEP 5
Bluntly dissect internal oblique from overlying external oblique flap
Reveal shelving edge of inguinal ligament
         │
         ▼
STEP 6
Isolate spermatic cord with Penrose drain
         │
         ▼
STEP 7
Dissect INDIRECT sac from cord anterolateral surface
Separate from cremasteric fibers
→ Reduce or ligate at deep ring
         │
         ▼
STEP 8
Assess posterior wall for DIRECT hernia defect
(broad weakness of Hesselbach's triangle)
         │
         ▼
STEP 9
Cut polypropylene mesh ~15×7 cm
Round the medial end to fit medial canal corner
         │
         ▼
STEP 10
Fix medial edge: single suture to aponeurotic tissue overlying
pubic tubercle, ~2 cm medial overlap
         │
         ▼
STEP 11
Running suture (baseball stitch):
Inferior mesh edge → inguinal ligament (medial to lateral)
         │
         ▼
STEP 12
Interrupted sutures:
Superior mesh edge → internal oblique aponeurosis
(avoid iliohypogastric nerve)
         │
         ▼
STEP 13
Slit lateral mesh → create 2 tails:
  • Wide tail (2/3 width) — superior
  • Narrow tail (1/3 width) — inferior
Encircle cord between tails
→ Shutter valve stitch at inguinal ligament lateral to cord
→ Tuck tails under ext oblique to ASIS level
         │
         ▼
STEP 14
Close external oblique aponeurosis
→ Recreate external ring
→ Subcuticular skin closure

Note: For direct hernia - posterior wall weakness does NOT require separate repair; mesh covers and reinforces Hesselbach's triangle automatically.

B. SHOULDICE REPAIR

(Best Tissue Repair | ~1% recurrence at specialist centers | 4-layer running suture)

STEP 1
Incision → Scarpa's fascia → open external oblique aponeurosis
→ Isolate spermatic cord (identical to Lichtenstein up to this point)
         │
         ▼
STEP 2
Dissect indirect sac from cord → reduce → high ligation at deep ring
         │
         ▼
STEP 3
Divide transversalis fascia from pubic tubercle → to deep inguinal ring
→ Develop preperitoneal space
→ Reduce any direct protrusion / lipoma
         │
         ▼
STEP 4  ── LAYER 1 ──
Running suture starts at pubic tubercle
Deep flap of transversalis fascia sutured to
undersurface of superior flap  (medial → lateral)
         │
         ▼
STEP 5  ── LAYER 2 ──
Same suture returns (lateral → medial)
Superior flap approximated to inguinal ligament
(Suture tied back at pubic tubercle)
         │
         ▼
STEP 6  ── LAYER 3 ──
New suture: internal oblique / conjoined tendon
approximated to inguinal ligament  (medial → lateral)
         │
         ▼
STEP 7  ── LAYER 4 ──
Same suture returns (lateral → medial)
External oblique aponeurosis edges approximated over cord
         │
         ▼
STEP 8
Reconstruct external ring
→ Layer closure → Skin

Memory: 4 layers = 2 sutures, each folding back — transversalis fascia (deep, then returned) + internal oblique/ext oblique (then returned).

C. BASSINI REPAIR

(Historical | 10–15% recurrence in general practice)

STEP 1
Incision → open external oblique aponeurosis
→ Expose inguinal canal
         │
         ▼
STEP 2
Isolate cord
→ Dissect & reduce indirect sac
→ High ligation at internal ring
         │
         ▼
STEP 3
Assess posterior wall for direct defect
         │
         ▼
STEP 4
Triple-layer reconstruction:
Conjoined tendon (transversus abdominis + internal oblique)
sutured POSTERIOR to cord to inguinal ligament
→ Interrupted non-absorbable sutures
         │
         ▼
STEP 5
Reconstruct external ring
→ Layer closure → Skin

D. McVAY (COOPER'S LIGAMENT) REPAIR

(Use for: femoral hernia | large direct defects)

STEP 1
Standard inguinal dissection
→ Open inguinal floor down to Cooper's (pectineal) ligament
         │
         ▼
STEP 2
Suture conjoined tendon → Cooper's ligament (medially)
         │
         ▼
STEP 3
Transition stitch: sutures shift from Cooper's ligament
→ inguinal ligament laterally, passing OVER femoral vessels
(this closes the femoral canal)
         │
         ▼
STEP 4
Relaxing incision in anterior rectus sheath
(relieves tension on repair)
→ Close in layers

E. LAPAROSCOPIC TAPP

(TransAbdominal PrePeritoneal | GA required | Recurrence ~1%)

Best for: Bilateral hernia | Recurrent after open | Diagnostic laparoscopy needed

STEP 1
Position: Trendelenburg, tilted to contralateral side
(gravity moves bowel cephalad)
         │
         ▼
STEP 2
Port placement:
  • 10–12 mm umbilical camera port
  • Two 5 mm working ports (~6 cm lateral to umbilicus)
  Bilateral: both ports at umbilical level
  Unilateral: ipsilateral port higher, contralateral lower
         │
         ▼
STEP 3
Enter peritoneal cavity
→ Visual inspection of both inguinal regions
→ Confirm hernia type and bilaterality
         │
         ▼
STEP 4
Incise peritoneum ≥4 cm above internal ring
(from lateral to ASIS → medial umbilical ligament)
         │
         ▼
STEP 5
Develop preperitoneal space in AVASCULAR plane
just deep to transversalis fascia
         │
         ▼
STEP 6
MEDIAL dissection:
→ Parietal transversalis fascia layer
→ Expose retropubic (space of Retzius)
→ Identify Cooper's ligament, pubic symphysis
         │
         ▼
STEP 7
LATERAL dissection:
→ Preserve visceral/parietal fascia over nerve area
→ Avoid Triangle of Pain and Triangle of Doom (see below)
         │
         ▼
STEP 8
Reduce hernia sac completely into abdomen
(Indirect: separate from cord; divide if cannot fully reduce)
(Direct: reduce preperitoneal fat, invert pseudosac)
         │
         ▼
STEP 9
Place large polypropylene mesh (≥15×10 cm)
→ Must cover entire MYOPECTINEAL ORIFICE (MPO):
  deep ring + direct space + femoral canal
         │
         ▼
STEP 10
Fix mesh:
  • Tacks to Cooper's ligament (medially)
  • Tacks ABOVE iliopubic tract (laterally)
  ⚠ NO tacks below iliopubic tract (nerve injury)
  ⚠ NO tacks in Triangle of Doom (vascular injury)
         │
         ▼
STEP 11
Close peritoneum COMPLETELY over mesh
(running suture or tacker)
→ Prevents mesh-bowel adhesions
         │
         ▼
STEP 12
Deflate pneumoperitoneum
→ Close port sites ≥10 mm
→ Skin closure

Danger Zones:

Triangle of Doom (between vas deferens and gonadal vessels): external iliac artery & vein — no tacks
Triangle of Pain (lateral to gonadal vessels, below iliopubic tract): lateral cutaneous nerve of thigh + femoral branch of genitofemoral nerve — no tacks

F. LAPAROSCOPIC TEP

(Totally ExtraPeritoneal | GA required | Recurrence ~1%)

Best for: Bilateral hernia | No peritoneal entry required | Recurrent after TAPP

STEP 1
Infraumbilical incision
→ Open anterior rectus sheath
→ DO NOT enter peritoneal cavity
         │
         ▼
STEP 2
Insert 10–12 mm blunt trocar into preperitoneal space
(beneath rectus abdominis, anterior to posterior sheath)
         │
         ▼
STEP 3
Balloon dissector / blunt laparoscope expansion
→ Creates working space in preperitoneal plane
→ Under direct vision to avoid peritoneal breach
         │
         ▼
STEP 4
Place 2 additional 5 mm trocars in midline
(infraumbilical + suprapubic)
         │
         ▼
STEP 5
CO₂ insufflation of preperitoneal space
(~8–12 mmHg)
         │
         ▼
STEP 6
Identify anatomical landmarks:
  • Pubic symphysis
  • Cooper's ligament
  • Inferior epigastric vessels
  • Vas deferens
  • Iliac vessels
         │
         ▼
STEP 7
Dissect direct and/or indirect sac
→ Reduce completely into abdomen
         │
         ▼
STEP 8
Ligate large indirect sac at deep ring if needed
(Cream-pot rule: reduce contents before dividing)
         │
         ▼
STEP 9
Place large mesh (≥15×10 cm)
→ Covers entire MPO (deep ring + direct space + femoral canal)
         │
         ▼
STEP 10
Fix mesh:
  • Cooper's ligament medially
  • Above iliopubic tract laterally
  ⚠ Same danger zones as TAPP apply
         │
         ▼
STEP 11
NO peritoneal closure needed
(key advantage over TAPP)
         │
         ▼
STEP 12
Deflate CO₂ GRADUALLY
(allows mesh to lie flat against abdominal wall)
→ Close anterior rectus sheath → Skin

G. EMERGENCY REPAIR (Strangulated / Irreducible)

STEP 1
Resuscitate: IV fluids, NGT, Foley catheter, antibiotics
         │
         ▼
STEP 2
Incision: Inguinal approach ± extend to laparotomy if needed
         │
         ▼
STEP 3
Open hernial sac; assess bowel viability
  ├── Viable bowel → reduce into abdomen
  └── Non-viable → resect + primary anastomosis or stoma
         │
         ▼
STEP 4
Repair hernia defect:
  CONTAMINATED / bowel resection → TISSUE REPAIR (no mesh)
  CLEAN field → Mesh acceptable
         │
         ▼
STEP 5
Close in layers; consider drain if contaminated

HEAD-TO-HEAD COMPARISON

Approach	Recurrence	Chronic Pain	Anesthesia	Best Indication	Key Limitation
Lichtenstein	0.5–1%	11–18% (highest)	Local/Spinal/GA	Standard adult, first-time	Highest chronic pain
Shouldice	~1% (specialist) / 3× higher†	Lower than mesh	Local/Spinal/GA	Contaminated field, mesh CI	Needs expert technique
Bassini	10–15%†	Low	Local/GA	No mesh available	High recurrence
McVay	Variable	Low	Local/GA	Femoral hernia, large direct	Relaxing incision needed
Lap TAPP	~1%	Lower than open	GA required	Bilateral, recurrent after open	Peritoneal entry, adhesion risk
Lap TEP	~1%	Lower than open	GA required	Bilateral, no peritoneal entry	Steep learning curve
Robotic TAPP	~1%	Similar to lap TAPP	GA required	Surgeon preference	Cost ↑↑, OR time ↑↑

†General surgical practice (not specialist centers)

QUICK REFERENCE — SPECIAL SITUATIONS

Situation	Approach
Incarcerated (reducible)	Reduce → Elective repair 24–48 h
Strangulated	Emergency surgery; tissue repair if bowel resected
Pediatric	High ligation of sac only; no floor repair; all are indirect
Recurrent after open	Laparoscopic (posterior approach)
Recurrent after laparoscopic	Open anterior approach
Bilateral	Single laparoscopic session (TEP/TAPP)
Female	Laparoscopic preferred; exclude occult femoral hernia
Pantaloon	Direct + indirect combined; treat both components
Sliding hernia	Caution: bowel forms part of sac (sigmoid left, cecum right, bladder in direct)

Sources: Schwartz's Principles of Surgery 11e · Mulholland & Greenfield Surgery 7e · Bailey & Love 28e · Current Surgical Therapy 14e

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