🏥 HERNIA - RGUHS FINAL YEAR MBBS SURGERY NOTES

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import mm, cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import ListFlowable, ListItem

OUTPUT = "/home/daytona/workspace/hernia-notes/Hernia_RGUHS_MBBS_Notes.pdf"

doc = SimpleDocTemplate(
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    pagesize=A4,
    rightMargin=18*mm,
    leftMargin=18*mm,
    topMargin=18*mm,
    bottomMargin=18*mm,
    title="Hernia - RGUHS Final Year MBBS Surgery Notes",
    author="Orris Medical"
)

W = A4[0] - 36*mm  # usable width

# ── Colour palette ─────────────────────────────────────────────────────────
NAVY   = colors.HexColor("#1a3a5c")
TEAL   = colors.HexColor("#0d6e6e")
AMBER  = colors.HexColor("#e67e22")
LIGHT  = colors.HexColor("#eaf4fb")
MLIGHT = colors.HexColor("#fef9e7")
GREEN  = colors.HexColor("#196f3d")
RED    = colors.HexColor("#922b21")
LGREY  = colors.HexColor("#f4f6f7")
MGREY  = colors.HexColor("#d5d8dc")

# ── Styles ──────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def S(name, **kw):
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TITLE_STYLE = S("DocTitle",
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# ── Helpers ──────────────────────────────────────────────────────────────────
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def b(text): return Paragraph(text, BULLET)
def p(text): return Paragraph(text, BODY)
def h2(text): return Paragraph(text, H2)
def h3(text): return Paragraph(text, H3)
def sp(n=4): return Spacer(1, n)
def hr(): return HRFlowable(width=W, thickness=0.5, color=MGREY, spaceAfter=4, spaceBefore=4)

def make_table(headers, rows, col_widths=None, alt=True):
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    tbl.setStyle(TableStyle(ts))
    return tbl

# ═══════════════════════════════════════════════════════════════════════════
# BUILD CONTENT
# ═══════════════════════════════════════════════════════════════════════════
story = []

# ── COVER ──────────────────────────────────────────────────────────────────
cover = Table([
    [Paragraph("HERNIA", TITLE_STYLE)],
    [Paragraph("RGUHS Final Year MBBS Surgery", SUBTITLE_STYLE)],
    [Paragraph("Exam-Oriented Notes with Mnemonics", SUBTITLE_STYLE)],
    [Spacer(1, 6)],
    [Paragraph("Based on: Bailey & Love 28th Ed | S Das 13th Ed | Schwartz 11th Ed", SUBTITLE_STYLE)],
], colWidths=[W])
cover.setStyle(TableStyle([
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    ("LEFTPADDING",   (0,0), (-1,-1), 20),
    ("RIGHTPADDING",  (0,0), (-1,-1), 20),
    ("ROUNDEDCORNERS", [6]),
]))
story.append(cover)
story.append(sp(10))

# ── RGUHS QUESTIONS ─────────────────────────────────────────────────────────
story.append(section_header("⭐  FREQUENTLY ASKED RGUHS QUESTIONS", AMBER))
story.append(sp(4))
story.append(h2("Long Questions (10 marks)"))
lq = [
    "Classify hernias. Describe anatomy, clinical features and management of inguinal hernia.",
    "Differences between indirect and direct inguinal hernia.",
    "Anatomy of femoral canal. Clinical features and management of femoral hernia.",
    "Complications of inguinal hernia – management of strangulated hernia.",
    "Describe various types of umbilical hernia and their management.",
    "Incisional hernia – causes, clinical features, management.",
    "Surgical anatomy of inguinal canal.",
]
for q in lq:
    story.append(b("• " + q))
story.append(sp(4))
story.append(h2("Short Notes (5 marks)"))
sn = [
    "Richter's hernia | Littre's hernia | Maydl's hernia | Pantaloon hernia",
    "Spigelian hernia | Sliding hernia",
    "Hesselbach's triangle",
    "Herniotomy vs Herniorrhaphy vs Hernioplasty",
    "TEP / TAPP laparoscopic repair",
    "Causes of recurrent hernia | Femoral canal anatomy",
]
for s in sn:
    story.append(b("• " + s))
story.append(sp(8))

# ── SECTION 1 ───────────────────────────────────────────────────────────────
story.append(section_header("1.  DEFINITION & COMPONENTS"))
story.append(sp(4))
story.append(p("<b>Definition:</b> Protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity."))
story.append(sp(4))
story.append(mnemonic_box('Mnemonic – Parts of Hernia: "SNC Covered"'))
parts_data = [
    ["S – Sac", "Peritoneum lining the hernial sac (has neck, body, fundus)"],
    ["N – Neck", "Junction of sac with peritoneal cavity (most important clinically)"],
    ["C – Contents", "Omentum (most common), small bowel, colon, bladder"],
    ["Coverings", "Layers overlying the sac (fasciae, skin)"],
]
story.append(sp(3))
story.append(make_table(["Component", "Description"], parts_data, [60*mm, W-60*mm]))
story.append(sp(8))

# ── SECTION 2 ───────────────────────────────────────────────────────────────
story.append(section_header("2.  CLASSIFICATION OF HERNIA"))
story.append(sp(4))
story.append(h2("By Site"))
story.append(mnemonic_box('Mnemonic: "I Feel Unusual Pain Every Single Day"'))
story.append(sp(2))
story.append(b("Inguinal (most common) • Femoral • Umbilical/Para-umbilical • Para-stomal • Epigastric • Spigelian • Diaphragmatic/Hiatal"))
story.append(sp(6))
story.append(h2("By Clinical State"))
story.append(mnemonic_box('Mnemonic: "ROIS"'))
state_data = [
    ["Reducible",     "Contents can be returned to cavity manually or spontaneously"],
    ["Obstructed",    "Hollow viscus obstructed; blood supply INTACT; causes intestinal obstruction"],
    ["Irreducible",   "Cannot return to cavity; blood supply intact; no obstruction"],
    ["Strangulated",  "Blood supply COMPROMISED → ischemia → gangrene within ~6 hours"],
]
story.append(sp(3))
story.append(make_table(["State", "Features"], state_data, [50*mm, W-50*mm]))
story.append(sp(8))

# ── SECTION 3 ───────────────────────────────────────────────────────────────
story.append(section_header("3.  INGUINAL HERNIA  (Most High-Yield)", TEAL))
story.append(sp(4))
story.append(h2("Anatomy of Inguinal Canal"))
story.append(p("Length: 4 cm | Direction: downward, medially, anteriorly | Connects deep inguinal ring to superficial inguinal ring"))
story.append(sp(4))
wall_data = [
    ["Anterior", "External oblique aponeurosis (whole length) + Internal oblique (lateral 1/3)"],
    ["Posterior", "Transversalis fascia (whole) + Conjoint tendon (medial 1/3)"],
    ["Roof",      "Arching fibres of Internal oblique + Transversus abdominis"],
    ["Floor",     "Inguinal ligament + Lacunar ligament (medially)"],
]
story.append(make_table(["Wall", "Structure"], wall_data, [30*mm, W-30*mm]))
story.append(sp(4))
story.append(mnemonic_box('Wall mnemonic: "2A2P" – 2 Anterior structures, 2 Posterior structures'))
story.append(sp(4))
story.append(h3("Rings"))
story.append(b("• <b>Deep inguinal ring:</b> Defect in transversalis fascia | Midpoint between ASIS and pubic tubercle | Inferior epigastric vessels lie just <b>medial</b>"))
story.append(b("• <b>Superficial inguinal ring:</b> Inverted-V defect in external oblique aponeurosis | Above and medial to pubic tubercle"))
story.append(sp(4))
story.append(h3("Contents of Inguinal Canal (Male)"))
story.append(mnemonic_box('Mnemonic: "I Get Goosebumps Later – D & D"'))
story.append(b("Ilioinguinal nerve • Genital branch of genitofemoral nerve • Gonadal (testicular) vessels • Lymphatics • Deferens (vas) • Dartos/cremasteric fibres"))
story.append(p("<i>(In female: round ligament replaces vas deferens)</i>"))
story.append(sp(4))

story.append(h2("Hesselbach's Triangle  (Short Note Favourite)"))
story.append(mnemonic_box('Mnemonic: "RIL" – Rectus, Inferior epigastric, Ligament inguinal'))
hess_data = [
    ["Medial",   "Lateral border of Rectus abdominis"],
    ["Lateral",  "Inferior epigastric artery"],
    ["Inferior", "Inguinal ligament"],
]
story.append(sp(2))
story.append(make_table(["Boundary", "Structure"], hess_data, [40*mm, W-40*mm]))
story.append(p("<i>Direct hernia passes through Hesselbach's triangle (medial to inferior epigastric artery)</i>"))
story.append(sp(6))

story.append(h2("Indirect vs Direct Inguinal Hernia  (Classic Comparison Question)"))
comp_data = [
    ["Frequency",       "80–85% of inguinal hernias",              "15–20% of inguinal hernias"],
    ["Age",             "Any age (even infants)",                   "Middle-aged & elderly"],
    ["Sex",             "Male > Female",                            "Almost exclusively male"],
    ["Cause",           "Congenital (patent processus vaginalis)",  "Acquired weakness of posterior wall"],
    ["Neck of sac",     "Lateral to inferior epigastric artery",   "Medial to inferior epigastric artery"],
    ["Path",            "Deep ring → canal → superficial ring → scrotum",  "Directly through Hesselbach's triangle"],
    ["Completeness",    "Often complete (reaches scrotum)",         "Rarely complete"],
    ["Strangulation",   "More common",                              "Less common"],
    ["Deep ring control","Hernia CONTROLLED by pressure on ring",   "NOT controlled"],
    ["Zieman's test",   "Index finger impulse = indirect",          "Middle finger impulse = direct"],
]
story.append(sp(3))
story.append(make_table(["Feature", "Indirect (Oblique)", "Direct (Medial)"],
                        comp_data, [42*mm, (W-42*mm)/2, (W-42*mm)/2]))
story.append(sp(4))
story.append(mnemonic_box('Neck position: "DILM" – Direct = Inferior epigastric Lies Medially (neck medial to artery)'))
story.append(sp(4))

story.append(h2("Types by Extent (S Das)"))
story.append(b("1. <b>Bubonocele</b> – hernia within inguinal canal, does not exit superficial ring"))
story.append(b("2. <b>Incomplete hernia</b> – exits superficial ring but does not reach scrotum"))
story.append(b("3. <b>Complete hernia</b> – reaches the bottom of the scrotum"))
story.append(sp(6))

story.append(h2("Management of Inguinal Hernia"))
story.append(b("• <b>Conservative:</b> Truss – only for elderly/unfit with direct hernia; NOT recommended routinely"))
story.append(b("• <b>Surgery:</b> Elective repair recommended for all symptomatic hernias"))
story.append(b("• <b>Watchful waiting</b> acceptable for asymptomatic direct hernia in elderly"))
story.append(sp(8))

# ── SECTION 4 ───────────────────────────────────────────────────────────────
story.append(section_header("4.  FEMORAL HERNIA", TEAL))
story.append(sp(4))
story.append(h2("Femoral Canal (Short Note)"))
story.append(mnemonic_box('Femoral sheath contents: "NAVY" – Nerve (outside sheath), Artery, Vein, Y = empty canal (with fat/lymphatics)'))
story.append(sp(3))
story.append(b("• Length of femoral canal: ~1.3 cm"))
story.append(b("• Normally contains: fat + lymphatics + lymph node of Cloquet (Rosenmuller)"))
fem_bounds = [
    ["Anterior",  "Inguinal ligament"],
    ["Posterior", "Pectineal ligament (Cooper's ligament) & pectineus muscle"],
    ["Medial",    "Lacunar (Gimbernat's) ligament – <b>SHARP EDGE → causes strangulation</b>"],
    ["Lateral",   "Femoral vein"],
]
story.append(sp(3))
story.append(make_table(["Boundary", "Structure"], fem_bounds, [35*mm, W-35*mm]))
story.append(sp(4))

story.append(h2("Key Facts"))
story.append(b("• More common in <b>women</b> (but inguinal is still commonest hernia in women overall)"))
story.append(b("• Right side > Left (2:1) | Bilateral in 20%"))
story.append(b("• Most common age: >50 years"))
story.append(warn_box("High risk of strangulation – rigid femoral ring with sharp lacunar ligament medially"))
story.append(sp(4))

story.append(h2("Femoral vs Inguinal – Distinguishing Features"))
fvsi = [
    ["Position", "Lateral & BELOW inguinal ligament", "Medial & ABOVE inguinal ligament"],
    ["Relation to pubic tubercle", "Lateral to pubic tubercle", "Medial to pubic tubercle"],
    ["Invagination test", "Inguinal canal EMPTY", "Impulse felt in inguinal canal"],
    ["Deep ring control", "Cannot be controlled", "Indirect: can be controlled"],
]
story.append(sp(3))
story.append(make_table(["Feature", "Femoral", "Inguinal"], fvsi, [50*mm, (W-50*mm)/2, (W-50*mm)/2]))
story.append(sp(4))
story.append(mnemonic_box('Mnemonic: "FBI" = Femoral Below Inguinal (lateral to pubic tubercle)'))
story.append(sp(4))

story.append(h2("Surgical Approaches"))
fem_app = [
    ["Lockwood's (Low)", "Below inguinal ligament", "Most common for ELECTIVE repair"],
    ["Lotheissen's",     "Through inguinal canal (transpubic)", "Allows inguinal canal access"],
    ["McEvedy's (High)", "Through lower rectus sheath / preperitoneal", "BEST for STRANGULATED femoral hernia"],
    ["TEP / TAPP",       "Laparoscopic preperitoneal", "Bilateral or recurrent hernias"],
]
story.append(sp(3))
story.append(make_table(["Approach", "Route", "Indication"], fem_app, [42*mm, 60*mm, W-102*mm]))
story.append(sp(4))
story.append(mnemonic_box('Mnemonic: "LLM" – Low Lockwood → Lotheissen → McEvedy (High for strangulated)'))
story.append(sp(8))

# ── SECTION 5 ───────────────────────────────────────────────────────────────
story.append(section_header("5.  SPECIAL VARIETIES OF HERNIA", AMBER))
story.append(sp(4))
story.append(mnemonic_box('Mnemonic: "SLIMPR" – Sliding, Littre\'s, Richter\'s (+ Irreducible), Maydl\'s, Pantaloon, Spigelian'))
story.append(sp(5))

specials = [
    ("Sliding Hernia (En Glissade)",
     "Part of the sac WALL is formed by a viscus (caecum on right, sigmoid on left, urinary bladder).",
     "Never blindly ligate the sac – the viscus forms part of the sac wall and will be injured!"),
    ("Littre's Hernia",
     "Hernia sac contains a Meckel's diverticulum. Can strangulate diverticulum alone without bowel obstruction.",
     "Meckel's diverticulum may strangulate without intestinal obstruction features."),
    ("Richter's Hernia",
     "Only a KNUCKLE (antimesenteric border) of bowel wall is trapped. No full lumen obstruction. Can strangulate SILENTLY.",
     "Most common at femoral canal. No obstruction features yet bowel goes gangrenous – very dangerous!"),
    ("Maydl's Hernia (W-hernia)",
     "Two loops in sac + connecting loop INSIDE abdomen forming a 'W'. The middle (intra-abdominal) loop strangulates.",
     "Opening sac shows 2 visible loops but the MIDDLE loop inside abdomen is gangrenous – always inspect both limbs!"),
    ("Pantaloon Hernia",
     "Combined direct + indirect hernia straddling the inferior epigastric artery – like 2 legs of trousers.",
     "Divide inferior epigastric artery to treat both sacs as one."),
    ("Spigelian Hernia",
     "Through Spigelian fascia (lateral rectus edge at arcuate line). INTERPARIETAL – lies between muscle layers, often missed clinically.",
     "CT scan is investigation of choice. Cannot palpate easily – high index of suspicion needed."),
]

for name, desc, caution in specials:
    story.append(KeepTogether([
        h3("▶ " + name),
        p(desc),
        warn_box(caution),
        sp(4),
    ]))

story.append(sp(4))

# ── SECTION 6 ───────────────────────────────────────────────────────────────
story.append(section_header("6.  UMBILICAL HERNIA"))
story.append(sp(4))
story.append(mnemonic_box('Mnemonic: "ECAP" – Exomphalos, Congenital, Acquired, Para-umbilical'))
story.append(sp(4))

umb_data = [
    ["Exomphalos\n(Omphalocele)",
     "Congenital. Abdominal contents in umbilical cord covered by translucent diaphanous membrane. Distinguish from Gastroschisis (no sac, lateral to umbilicus, bowel directly exposed, better prognosis)."],
    ["Congenital\nUmbilical Hernia",
     "Through umbilical scar in infants. Wide neck → rarely strangulates. 90% resolve spontaneously by 5 years. Observe till 5 years before surgery."],
    ["Acquired\nUmbilical Hernia",
     "Adults; through umbilical scar due to raised IAP (pregnancy, ascites, ovarian cyst, fibroid). Treat underlying cause first."],
    ["Para-umbilical\nHernia",
     "Most common acquired umbilical hernia. Just above umbilicus, between the two recti. Obese middle-aged women. Omentum often adherent → irreducible. Repair: Mayo's operation."],
]
story.append(make_table(["Type", "Key Features"], umb_data, [45*mm, W-45*mm]))
story.append(sp(4))
story.append(h3("Mayo's Operation (Para-umbilical repair):"))
story.append(b("• Transverse elliptical incision excising redundant skin"))
story.append(b("• Sac opened, contents reduced, neck transfixed"))
story.append(b("• Fascia imbricated in VEST-OVER-PANTS technique (upper flap overlaps lower)"))
story.append(b("• Mesh preferred for large defects"))
story.append(sp(8))

# ── SECTION 7 ───────────────────────────────────────────────────────────────
story.append(section_header("7.  INCISIONAL HERNIA"))
story.append(sp(4))
story.append(p("Hernia through a defect in the musculofascial layers at the site of a previous surgical scar. Incidence: <b>10–50% of laparotomies, 1–5% of laparoscopic port sites</b>."))
story.append(sp(4))
story.append(h2("Causes"))
story.append(mnemonic_box('Mnemonic: "MOAN WIPS"'))
moan = [
    ("M", "Malnutrition / Midline incision (higher risk than transverse)"),
    ("O", "Obesity"),
    ("A", "Anaemia / Corticosteroids / Age (elderly)"),
    ("N", "Non-absorbable suture not used / poor suture technique"),
    ("W", "Wound infection / Wound haematoma"),
    ("I", "Intraabdominal pressure raised (post-op cough, ileus, constipation)"),
    ("P", "Patient factors – immunosuppression, collagen disorders, cancer"),
    ("S", "Steroid therapy / Systemic illness (jaundice, uraemia, diabetes)"),
]
story.append(sp(3))
story.append(make_table(["Letter", "Cause"], moan, [20*mm, W-20*mm]))
story.append(sp(4))

story.append(h2("Clinical Features"))
story.append(b("• Swelling through previous scar, increases on straining/standing"))
story.append(b("• Expansile cough impulse"))
story.append(b("• Often multiple defects found at surgery even if single bulge clinically"))
story.append(b("• Heralded by serosanguineous discharge ~6th postoperative day (fascial layer failure)"))
story.append(sp(4))

story.append(h2("Management"))
inc_mgmt = [
    ["Conservative",      "Supportive belt – only for unfit/elderly patients"],
    ["Primary repair",    "Direct suture closure – only for small (<2 cm) defects"],
    ["Onlay mesh",        "Mesh placed over fascial repair – higher infection risk"],
    ["Sublay/Retrorectus","Mesh in retrorectus space (between rectus & posterior sheath) – preferred; lowest recurrence"],
    ["IPOM laparoscopic", "Intraperitoneal onlay mesh – moderate-sized hernias; less wound morbidity"],
    ["Component separation","Releasing external oblique laterally to advance rectus; for large/complex defects"],
]
story.append(sp(3))
story.append(make_table(["Method", "Details"], inc_mgmt, [50*mm, W-50*mm]))
story.append(sp(8))

# ── SECTION 8 ───────────────────────────────────────────────────────────────
story.append(section_header("8.  STRANGULATED HERNIA – EMERGENCY MANAGEMENT", RED))
story.append(sp(4))
story.append(h2("Pathophysiology"))
story.append(b("1. Tight neck → compresses venous return → venous congestion"))
story.append(b("2. Oedema → arterial occlusion → ischaemia → GANGRENE within ~6 hours"))
story.append(b("3. Sac fluid becomes blood-stained / turbid → 'Champagne sign' = irreversible ischaemia"))
story.append(sp(4))

story.append(h2("Clinical Features"))
story.append(b("• Previously reducible hernia becomes suddenly IRREDUCIBLE + PAINFUL"))
story.append(b("• Tense, tender, red swelling – NO cough impulse"))
story.append(b("• Features of intestinal obstruction: vomiting, distension, absolute constipation"))
story.append(b("• Systemic: fever, tachycardia, toxaemia, shock"))
story.append(warn_box("Richter's hernia – strangulates WITHOUT features of obstruction. Easily missed!"))
story.append(sp(4))

story.append(h2("Emergency Management"))
story.append(h3("Step 1 – Resuscitation:"))
story.append(b("• IV access + crystalloid fluid resuscitation"))
story.append(b("• Nasogastric tube (NGT) + urinary catheter"))
story.append(b("• Bloods: FBC, U&E, LFT, coagulation, group & save"))
story.append(b("• IV broad-spectrum antibiotics (e.g. co-amoxiclav + metronidazole)"))
story.append(h3("Step 2 – Emergency Surgery:"))
story.append(b("• Open sac carefully – do NOT reduce before assessing viability"))
story.append(b("• Assess bowel viability"))
story.append(mnemonic_box('Viability mnemonic: "CPC" – Color (pink vs black/dark) | Peristalsis | Circulation (mesenteric pulse)'))
story.append(b("• If VIABLE → reduce, repair hernia"))
story.append(b("• If NON-VIABLE → resect + primary anastomosis"))
story.append(b("• Approximately 20% require bowel resection"))
story.append(b("• Mesh acceptable even with mild contamination if covered with antibiotics"))
story.append(sp(8))

# ── SECTION 9 ───────────────────────────────────────────────────────────────
story.append(section_header("9.  HERNIA REPAIR OPERATIONS"))
story.append(sp(4))
story.append(mnemonic_box('Mnemonic: "3 H\'s" – Herniotomy, Herniorrhaphy, Hernioplasty'))
story.append(sp(4))
three_h = [
    ["Herniotomy",     "Dissect sac → open → reduce contents → transfix neck → excise sac. NO posterior wall repair.",
     "Children (superficial + deep rings are superimposed, no canal repair needed), young adults with indirect hernia"],
    ["Herniorrhaphy",  "Herniotomy + repair of posterior wall with SUTURES (tissue-based, tension repair).",
     "Adults; older techniques (Bassini, Shouldice)"],
    ["Hernioplasty",   "Herniotomy + reinforcement with MESH (tension-free). Current gold standard.",
     "All adults; Lichtenstein open mesh repair"],
]
story.append(make_table(["Operation", "What is done", "When used"], three_h,
                        [38*mm, (W-38*mm)*0.55, (W-38*mm)*0.45]))
story.append(sp(6))

story.append(h2("Open Tissue Repairs"))
open_r = [
    ["Bassini's",    "Conjoint tendon sutured to inguinal ligament"],
    ["Shouldice",    "4-layer continuous stainless steel wire repair of transversalis fascia. GOLD STANDARD tissue repair. <1% recurrence"],
    ["McVay (Cooper's)", "Conjoint tendon to Cooper's (pectineal) ligament. Good for femoral hernia too"],
    ["Darn repair",  "Prolene lattice darn, tension-free"],
]
story.append(make_table(["Repair", "Key Feature"], open_r, [50*mm, W-50*mm]))
story.append(sp(4))

story.append(h2("Mesh Repair"))
story.append(b("• <b>Lichtenstein Tension-free Mesh Repair</b> – current GOLD STANDARD for open inguinal hernia repair"))
story.append(b("• Polypropylene mesh; placed over posterior wall; sutured to conjoint tendon, inguinal ligament"))
story.append(b("• Recurrence rate <5% at 5 years"))
story.append(sp(4))

story.append(h2("Laparoscopic Repairs"))
lap_r = [
    ["TEP\n(Totally Extraperitoneal)",
     "Extraperitoneal dissection only. Peritoneal cavity NOT entered. Fewer bowel adhesions, faster recovery.",
     "Preferred for bilateral hernia, recurrent hernia"],
    ["TAPP\n(Trans-Abdominal Pre-Peritoneal)",
     "Enter peritoneal cavity → dissect preperitoneal space → place mesh → close peritoneum.",
     "When TEP is difficult; allows inspection of abdominal contents"],
]
story.append(sp(3))
story.append(make_table(["Approach", "Technique", "Preference"], lap_r, [35*mm, (W-35*mm)*0.58, (W-35*mm)*0.42]))
story.append(sp(4))
story.append(mnemonic_box('Mnemonic: "TEP stays outside, TAPP goes in" (peritoneal cavity)'))
story.append(sp(8))

# ── SECTION 10 ──────────────────────────────────────────────────────────────
story.append(section_header("10.  QUICK ONE-LINERS FOR MCQs & VIVA", GREEN))
story.append(sp(4))

one_liners = [
    ("Most common hernia overall",                    "Inguinal hernia"),
    ("Most common hernia in WOMEN",                   "Inguinal hernia (NOT femoral!)"),
    ("Femoral hernia – commoner in",                  "Women (but inguinal still #1 in women)"),
    ("Highest strangulation risk",                    "Femoral hernia (rigid ring + sharp lacunar ligament)"),
    ("Silent strangulation (no obstruction features)", "Richter's hernia"),
    ("W-hernia",                                      "Maydl's hernia"),
    ("Hernia of Meckel's diverticulum",               "Littre's hernia"),
    ("Sac wall formed by viscus",                     "Sliding hernia"),
    ("Hernia straddling inferior epigastric artery",  "Pantaloon hernia"),
    ("Interparietal hernia at lateral rectus edge",   "Spigelian hernia"),
    ("Investigation of choice for Spigelian",         "CT scan"),
    ("Gold standard OPEN repair",                     "Lichtenstein tension-free mesh repair"),
    ("Gold standard TISSUE repair (no mesh)",         "Shouldice repair"),
    ("Best approach for strangulated femoral hernia", "McEvedy's (high) approach"),
    ("Para-umbilical hernia repair",                  "Mayo's operation (vest-over-pants)"),
    ("Champagne sign",                                "Strangulated hernia – turbid sac fluid = non-viable bowel"),
    ("Congenital umbilical hernia – 90% resolve by",  "5 years of age"),
    ("Incisional hernia after laparotomy",            "10–50% incidence"),
    ("Chronic pain after inguinal hernia repair",     "Up to 20% of patients (>3 months = chronic)"),
    ("Laparoscopic repair preferred for bilateral",   "TEP (Totally Extraperitoneal) repair"),
    ("Herniorrhaphy in children – sac only, no repair", "Because deep and superficial rings are superimposed"),
]
story.append(make_table(["Question", "Answer"], one_liners, [W*0.52, W*0.48]))
story.append(sp(8))

# ── SECTION 11 ──────────────────────────────────────────────────────────────
story.append(section_header("11.  MNEMONICS MASTER SHEET", AMBER))
story.append(sp(4))
mn_data = [
    ["Parts of hernia",                  '"SNC Covered"',       "Sac, Neck, Contents, Coverings"],
    ["Clinical states",                  '"ROIS"',              "Reducible, Obstructed, Irreducible, Strangulated"],
    ["Inguinal canal walls",             '"2A2P"',              "2 Anterior structures, 2 Posterior structures"],
    ["Inguinal canal contents",          '"I Get Goosebumps Later – D&D"', "Ilioinguinal, Genital GF, Gonadal, Lymphatics, Deferens, Dartos"],
    ["Hesselbach's triangle",            '"RIL"',               "Rectus, Inferior epigastric, Ligament inguinal"],
    ["Direct hernia neck",               '"DILM"',              "Direct = Inferior epigastric Lies Medially"],
    ["Femoral position vs inguinal",     '"FBI"',               "Femoral Below Inguinal (below inguinal lig, lateral to pubic tubercle)"],
    ["Femoral canal approaches",         '"LLM"',               "Lockwood (elective), Lotheissen, McEvedy (strangulated)"],
    ["Femoral sheath contents",          '"NAVY"',              "Nerve (outside), Artery, Vein, Y (empty canal)"],
    ["Special hernias",                  '"SLIMPR"',            "Sliding, Littre's, Richter's, Maydl's, Pantaloon, Spigelian"],
    ["Umbilical hernia types",           '"ECAP"',              "Exomphalos, Congenital, Acquired, Para-umbilical"],
    ["Incisional hernia causes",         '"MOAN WIPS"',         "Malnutrition, Obesity, Anaemia, Non-absorbable, Wound infxn, IAP, Patient factors, Steroids"],
    ["Bowel viability check",            '"CPC"',               "Colour, Peristalsis, Circulation (mesenteric pulse)"],
    ["3 hernia operations",              '"3 H\'s"',            "Herniotomy, Herniorrhaphy, Hernioplasty"],
    ["Lap repairs",                      '"TEP stays outside, TAPP goes in"', "TEP = extraperitoneal; TAPP = enters peritoneum"],
]
story.append(make_table(["Topic", "Mnemonic", "Expansion"], mn_data,
                        [50*mm, 50*mm, W-100*mm]))
story.append(sp(8))

# ── SECTION 12 ──────────────────────────────────────────────────────────────
story.append(section_header("12.  EXAM TRAPS – DO NOT MAKE THESE MISTAKES", RED))
story.append(sp(5))
traps = [
    "Most common hernia in WOMEN = INGUINAL (NOT femoral) – classic examiner trick",
    "Richter's hernia → strangulation WITHOUT obstruction features – diagnosis is easily missed",
    "Maydl's hernia → the MIDDLE loop inside abdomen is gangrenous – always pull out both limbs",
    "Sliding hernia → NEVER blindly ligate the sac (bowel/bladder wall forms sac)",
    "Femoral strangulation → use McEVEDY approach (NOT Lockwood) – allows bowel inspection",
    "Herniotomy in CHILDREN – superficial and deep rings are superimposed, so NO canal repair needed",
    "Spigelian hernia is interparietal – clinically missed easily; use CT scan to diagnose",
    "Congenital umbilical hernia – watch till 5 years; DO NOT rush to operate",
    "Para-umbilical hernia (NOT umbilical) is the COMMONEST acquired umbilical hernia in adults",
    "Direct hernia – posterior wall weakness, NOT from patent processus vaginalis",
]
for trap in traps:
    story.append(warn_box(trap))
    story.append(sp(2))

story.append(sp(8))

# ── FOOTER NOTE ─────────────────────────────────────────────────────────────
footer = Table([
    [Paragraph("Sources: Bailey & Love's Short Practice of Surgery 28th Ed | S Das Manual of Clinical Surgery 13th Ed | Schwartz's Principles of Surgery 11th Ed", SUBTITLE_STYLE)],
    [Paragraph("Prepared for RGUHS Final Year MBBS Surgery Examination | Orris Medical", SUBTITLE_STYLE)],
], colWidths=[W])
footer.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), NAVY),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 12),
    ("RIGHTPADDING",  (0,0), (-1,-1), 12),
]))
story.append(footer)

# ── BUILD ────────────────────────────────────────────────────────────────────
doc.build(story)
print("PDF generated:", OUTPUT)