Hernia

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"hernia"[MeSH Terms] AND "repair"[MeSH Terms]

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Here is a concise but thorough clinical summary of hernia:

Hernia - Quick Clinical Summary

Definition

A hernia is the protrusion of a viscus (or part of it) through an abnormal opening in the walls of its containing cavity, most commonly the abdominal wall.

Classification

By Origin

Type	Features
Congenital	Result from a developmental defect (e.g., patent processus vaginalis causing indirect inguinal hernia)
Acquired	Develop from progressive wall weakness, raised intra-abdominal pressure, or post-surgical defects

By Location (Common Types)

Hernia	Key Features
Indirect Inguinal	Most common of all hernias; exits through the internal inguinal ring lateral to inferior epigastric vessels; congenital (patent processus vaginalis); more common on the right; can descend into the scrotum
Direct Inguinal	Pushes through Hesselbach's triangle medial to inferior epigastric vessels; acquired (wall weakness); rarely strangulates
Femoral	Below the inguinal ligament, medial to femoral vessels; more common in women; up to 40% present as emergencies with strangulation
Umbilical	Through umbilical ring; common in infants (mostly resolve by age 2) and in adults (obesity, pregnancy, ascites)
Incisional	Through a previous surgical scar; lowest risk of strangulation (~2%)
Hiatal	Stomach herniates through the diaphragmatic esophageal hiatus
Internal	Paraduodenal (congenital) or post-surgical (Roux-en-Y, colectomy); found incidentally or at laparotomy

Hesselbach's triangle boundaries: laterally - inferior epigastric vessels; medially - lateral border of rectus sheath; inferiorly - inguinal (Poupart's) ligament. - Maingot's Abdominal Operations

Anatomical States

State	Description
Reducible	Contents return spontaneously or manually to the abdominal cavity
Irreducible / Incarcerated	Contents cannot be reduced; not necessarily ischemic
Obstructed	Bowel within hernia causes small bowel obstruction (SBO)
Strangulated	Ischemia from compression at the neck of the hernia - a surgical emergency

The risk of strangulation is inversely related to the size of the defect - smaller necks are more dangerous:

Femoral hernias: ~40% strangulated at first presentation
Umbilical hernias: up to 60% strangulated when requiring emergency surgery
Incisional hernias: only ~2% strangulated
Sleisenger & Fordtran's GI and Liver Disease

Clinical Features

Reducible hernia: Soft intermittent swelling, appears on coughing/straining, reduces on lying down; impulse on cough
Irreducible/strangulated hernia: Tender, firm, non-reducible lump; signs of bowel obstruction (nausea, vomiting, distension); overlying skin erythema and systemic sepsis in late strangulation
Percussion: resonant (enterocele - bowel) vs. dull (epiplocele - omentum)
Auscultation: peristaltic sounds audible in enterocele

Inguinal Canal Anatomy (Key for Repair)

Boundary	Structure
Anterior	External oblique aponeurosis
Posterior	Transversalis fascia (+ transversus abdominis)
Superior	Arching fibers of internal oblique
Inferior	Inguinal ligament + lacunar ligament

The internal (deep) ring is where the spermatic cord/round ligament enter the abdomen through the transversalis fascia. The external (superficial) ring is an opening in the external oblique aponeurosis, inferior and medial to the internal ring. - Maingot's Abdominal Operations

Management

Repair Options for Inguinal Hernia

Technique	Notes
Lichtenstein (open flat mesh)	Gold standard for open repair since 1980s; tension-free; 8x15 cm polypropylene mesh behind spermatic cord; lowest recurrence but chronic pain in up to 20%
Shouldice / Bassini (suture)	Layered suture repair of posterior wall; no mesh; useful where mesh is contraindicated
TEP (Total Extraperitoneal)	Laparoscopic; stays outside the peritoneum; preferred laparoscopic approach
TAPP (Transabdominal Preperitoneal)	Laparoscopic; enters peritoneal cavity then places mesh preperitoneally
Stoppa (open preperitoneal)	For complex recurrent bilateral hernias; largely superseded by TEP
Robotic-assisted	Emerging; better ergonomics for complex repairs

Mesh plugs are not recommended by the 2018 European Hernia Society guidelines due to risk of meshoma and migration. - Bailey & Love's Surgery, 28th Ed.

Laparoscopic vs. open Lichtenstein: recurrence data is inconclusive; surgeon experience is the most important factor. - Current Surgical Therapy, 14th Ed.

When to Operate Urgently

Signs of strangulation (pain, erythema, systemic sepsis) = contraindication to manual reduction - urgent surgery
Successful manual reduction of incarcerated hernia = temporary measure only; expeditious elective repair follows

Special Points

Pantaloon hernia: Combined direct + indirect inguinal hernia, straddling the inferior epigastric vessels
Hernia in women: Inguinal hernias still most common overall, but femoral hernias proportionally more frequent than in men
Previous inguinal repair is a risk factor for subsequent femoral hernia development
Obturator/sciatic hernias: Rare, often present first as bowel obstruction

Explain hernia according to SRB book of surgery for my college internals exams LAQ

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I now have comprehensive material. Note that the SRB textbook is not available in the library - the closest equivalent Indian surgery exam book available is S. Das Manual on Clinical Surgery, which covers exactly the same topics and format. Let me compile the complete LAQ answer now.

Note: The SRB (Sriram Bhat M.) textbook is not available in this library. The answer below is compiled from S. Das - A Manual on Clinical Surgery (13th Ed.), which is the other gold-standard Indian undergraduate surgery exam book covering hernia in the same depth and format as SRB. The content, classifications, and clinical descriptions mirror what SRB covers. All key exam points are included.

HERNIA - Long Answer Question (LAQ)

S. Das - A Manual on Clinical Surgery, 13th Ed.

DEFINITION

A hernia is the protrusion of a viscus or part of a viscus through an abnormal opening in the wall of the cavity which normally contains it.

Every hernia has three components:

The sac - an outpouching of peritoneum
The coverings - derived from the layers of the abdominal wall through which it passes
The contents - omentum, intestine, bladder, etc.

ETIOLOGY / PREDISPOSING FACTORS

Raised intra-abdominal pressure (the "forcing factor"):

Chronic cough, constipation, straining at micturition (BPH)
Heavy lifting, ascites, pregnancy

Weakness of the abdominal wall (the "allowing factor"):

Congenital defects (patent processus vaginalis)
Muscle atrophy (old age, malnutrition, obesity)
Previous surgery (incisional hernia)

CLASSIFICATION

A. ANATOMICAL TYPES

1. According to extent:

Type	Description
Bubonocele	Hernia does not emerge through the superficial inguinal ring
Incomplete hernia	Emerges through the superficial ring but does not reach the bottom of the scrotum
Complete hernia	Reaches the bottom of the scrotum

2. According to site of exit:

Type	Description
Oblique (Indirect)	Comes through the deep inguinal ring, i.e., lateral to the inferior epigastric artery
Direct	Comes through Hesselbach's triangle - bounded medially by lateral border of rectus abdominis, laterally by inferior epigastric artery, below by inguinal ligament; neck lies medial to inferior epigastric artery

3. According to contents:

Type	Contents	Signs
Enterocele	Intestine (enteron)	Elastic, resonant on percussion, reduces with gurgle, peristalsis audible
Epiplocele / Omentocele	Omentum (epiploon)	Doughy and granular, dull on percussion, reduces without gurgle
Cystocele	Urinary bladder	Swelling enlarges before micturition, reduces after; pressure induces desire to void; only in direct or sliding hernia

B. CLINICAL TYPES (Five Types - HIGH YIELD)

1. Reducible Hernia

Normal, uncomplicated hernia
Contents can be returned to the abdominal cavity manually or spontaneously
The sac itself remains in position

2. Irreducible Hernia

Contents cannot be returned to the abdomen
No compromise of blood supply
Causes of irreducibility:
- Adhesion of contents to each other
- Adhesion of contents to the sac
- Adhesion of one part of the sac to the other
- Sliding hernia
- Very large scrotal hernia (scrotal abdomen)
Clinically: not tense, not tender, no skin redness (differentiates from strangulation)

3. Obstructed / Incarcerated Hernia (Irreducibility + Intestinal Obstruction)

Hernia associated with intestinal obstruction due to occlusion of the bowel lumen
No interference with blood supply (key differentiating point from strangulation)
Dangerous to diagnose obstructed hernia when strangulation may actually be present - this wastes valuable time

4. Strangulated Hernia (Irreducibility + Obstruction + Arrest of blood supply - SURGICAL EMERGENCY)

Contents are constricted to the point of interference with their blood supply
Intestinal obstruction may NOT be present in: omentocele, Richter's hernia, Littre's hernia
Clinical diagnosis: Hernia is irreducible, without impulse on coughing, extremely tense and tender, followed by features of acute intestinal obstruction

5. Inflamed Hernia (rare)

Content (appendix, salpinx, Meckel's diverticulum) becomes inflamed
Overlying skin red and oedematous, swelling painful and tender
Key difference from strangulation: hernia is NOT tense and NOT associated with intestinal obstruction

RARE / SPECIAL VARIETIES

Variety	Description
Sliding Hernia (Hernia-en-glissade)	Extraperitoneal bowel (caecum on right, pelvic colon on left, or bladder) forms part of the wall of the sac itself; surgical danger - accidental injury to the bowel during sac dissection
Richter's Hernia	Only a portion of the circumference of the bowel is strangulated; bowel lumen not occluded until >50% of circumference involved; dangerous because intestinal obstruction is absent initially, mimics gastroenteritis; commonly femoral hernia
Littre's Hernia	Contains Meckel's diverticulum
Maydl's Hernia (Hernia-en-W / Retrograde Strangulation)	Two loops in the sac; the connecting loop lies WITHIN the abdomen and strangulates first; sac loops look like 'W'; strangulation in the abdomen may be missed - suspect when tenderness is found above the inguinal ligament with intestinal obstruction

INGUINAL HERNIA - DETAILED (Most Common Type)

Indirect (Oblique) Inguinal Hernia

Comprises >80% of inguinal hernias
Almost all hernias in children and women are of this type
Occurs earlier than direct hernia
Congenital type: Whole processus vaginalis remains patent; reaches the scrotum quickly; seen in adults despite the name
Acquired type: Does not protrude into a pre-formed sac; progresses gradually
Reduces obliquely in the opposite direction
Does not reduce spontaneously; requires a cough to come back out
Occluding the deep inguinal ring prevents the hernia from emerging on coughing

Direct Inguinal Hernia

More common above age 40
Frequently incomplete (may descend into scrotum only after years untreated)
Comes out as soon as the patient stands; disappears immediately on lying down
Spherical in shape
Invagination test: finger goes directly backwards (not upwards, backwards and laterally as in indirect)
On occluding the deep ring and asking the patient to cough: hernia bulges medial to the occluding finger
Rarely strangulates - neck of the sac is wide

Clinical Examination of Inguinal Hernia - Key Tests

Test	Indirect Hernia	Direct Hernia
Invagination test direction	Upwards, backwards, laterally	Directly backwards
Deep ring occlusion test	Hernia stopped	Hernia bulges medial to finger
Shape	Usually elliptical / pyriform	Spherical
Age	Any age	>40 years
Strangulation risk	Higher	Low (wide neck)

FEMORAL HERNIA

Protrusion through the femoral canal
Femoral canal boundaries:
- Superoanteriorly: Inguinal ligament
- Inferoposteriorly: Pubic ramus and pectineus
- Medially: Lacunar (Gimbernat's) ligament
- Laterally: Femoral vein
Emerges through the saphenous opening - 1.5 inches below and lateral to the pubic tubercle
Assumes the shape of a retort (narrow neck, expands below, then turns upward above the inguinal ligament)
More common in women (2:1), but inguinal hernia is still the commonest hernia in women
Right side affected twice as often as the left; 20% bilateral
Very rare below age 20; incidence peaks after age 50
Up to 40% present with strangulation at first presentation (narrow, rigid femoral canal)

Differentials of Femoral Hernia (Important for Exams)

Saphena varix - impulse on coughing is actually a fluid thrill; Schwartz's test positive; varicosities present
Enlarged lymph nodes - no impulse, look for a focus of infection in the drainage area
Psoas abscess - pulsatile, lateral to femoral artery; cross-fluctuation with iliac fossa; X-ray shows spinal disease
Enlarged psoas bursa - cystic, diminishes on hip flexion; associated with osteoarthritis of hip
Femoral aneurysm - expansile pulsation (pathognomonic)
Lipoma
Hydrocele of a femoral hernial sac - extremely rare; neck plugged by omentum/adhesions

UMBILICAL HERNIA - Four Varieties

Type	Features
Exomphalos	Abdominal contents protrude into umbilical cord at birth; covered by diaphanous (transparent) membrane
Congenital Umbilical Hernia	Through umbilical scar; common in first months of life; common in Negroes; wide neck - rarely strangulates; ~90% resolve spontaneously by age 5
Para-umbilical Hernia	Adults; through peri-umbilical area (not the exact umbilicus); more in obese women; high risk of strangulation (narrow neck)
Acquired Umbilical Hernia	In adults with raised intra-abdominal pressure (ascites, obesity, pregnancy)

MANAGEMENT OF HERNIA

Conservative

Truss - external support device; used in unfit patients; not curative
Indications: elderly unfit patients, patient's refusal for surgery

Surgical

Surgery is the definitive treatment. Three operative steps:

Herniotomy - excision of the sac (sufficient in children)
Herniorrhaphy - repair of the posterior wall with sutures
Hernioplasty - reinforcement with mesh or tissue flap

Operations for Inguinal Hernia:

Operation	Type	Description
Herniotomy	Suture	Children only; sac ligated and excised
Bassini's repair	Suture	Conjoined tendon sutured to inguinal ligament
Shouldice repair	Suture	Multilayer repair; low recurrence without mesh
Lichtenstein repair	Mesh	Tension-free; flat polypropylene mesh; gold standard open repair
TEP (Total Extraperitoneal)	Laparoscopic	Stays outside peritoneum; preferred laparoscopic approach
TAPP (Transabdominal Preperitoneal)	Laparoscopic	Enters peritoneum then places preperitoneal mesh
Stoppa repair	Open preperitoneal	For bilateral or recurrent hernias

Strangulated Hernia - Emergency Management

IV fluids, NG decompression, correction of electrolytes
Urgent surgery - taxis (manual reduction) is contraindicated in strangulated hernia
At surgery: sac opened, bowel viability assessed
If bowel viable - reduce and repair
If bowel gangrenous - resection and anastomosis before repair

COMPLICATIONS OF HERNIA

Irreducibility
Intestinal obstruction
Strangulation - most serious
Inflammation of contents
Injury to surrounding structures (bladder in sliding hernia)
Recurrence after repair

HIGH-YIELD EXAM POINTS SUMMARY

Most common hernia overall: Indirect inguinal hernia
Most common hernia in women: Indirect inguinal hernia (not femoral)
Highest strangulation risk: Femoral hernia (~40%)
Rarely strangulates: Direct inguinal hernia (wide neck)
Retrograde strangulation: Maydl's hernia
Only part of bowel circumference: Richter's hernia
Contains Meckel's diverticulum: Littre's hernia
Bowel forms wall of sac: Sliding hernia
Strangulation without intestinal obstruction: Richter's, Littre's, Omentocele
Deep ring occlusion test: positive (stops hernia) = Indirect; negative (hernia still comes out medially) = Direct
Taxis is contraindicated in: Strangulated hernia

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