1.  By DR Enemuo V C

2.  A hernia is the protrusion of a viscus or part of a viscus through a defect in its containing wall

3.  Covering  Sac  neck

4.  Groin-inguinal and femoral  Anterior-umbilical,epigastric and spigellian  Posterior-superior and inferior lumbar  Pelvic-obturator,sciatic and perineal

5.  Reducibility  Incarceration  Irreducibility  Obstruction  Strangulation  Gangrene

6.  richter” s hernia  Sliding hernia  Maydl s hernia  Sliding hernia  Littre s hernia

7.  Worldwide most commonly performed operation in surgery  Over 20million groin hernias are repaired annually  In USA over 1m cases are performed each year -750,000 Ing.H;166,000 Umb.h;97,000 Inc.h; 25,000 Fem.h; 76,000 Misc.h  The death rate from strangulated hernia in UK is twice that of USA.  The figures for Nigeria are not readily available.

8.  75% of abdo. wall hernias occur in the groin.  In children,  2.5% present with groin herniaS  Commoner among prems & Low birth wt  M:F 9:1  70%-R,25%-L,5%-Bil  30% present in 1 st yr of life  15% first present with incarceration

9.  IN ADULTS,  RIH > LIH  M:F ratio USA 7:1, UK 12:1  Peak incidence 6 th decade in UK but 4 th decade in Africans.  Indirect:direct ratio 3:1  10% groin hernias are femoral  Fem.hernias commoner in older patients.  Females at higher risk than males 4:1

10.  ON FEMORAL HERNIAS  Female:Male ratio4:1  Commoner in mid. aged & elderly women  Commoner in parous > nulliparous women  Much less common than inguinal hernias Fem:Ing 1:18  BEWARE OF MAKING DIAGNOSIS OF FEMORAL HERNIA IN WOMEN

11.  Modern concepts of groin herniation stress the laminar musculoaponeurotic structure of the groin region.  Parasagittal section- inguinal region shows ant. & post. laminar structures with midline laminar structure sandwiched.  What are these structures?  Ant.– Ext oblique m., Post.–Transversalis fascia (TF) medially & Transversalis abdominis / aponeurosis laterally. Midline- Int. oblique m.  TF- investing layer deep surface TM & its aponeurotic tendon- forms post. wall ing. Canal.

13.  Disruption or stretching of one or more these laminar gives rise to groin hernia.  Inguino-femoral hernias result from breakdown of the TF.  Direct inguinal hernia is secondary to weakening of the TF-in the Hesselbach’s triangle.  Dir. Ing. Her. are usually acquired & common among smokers.  Chronic smokers exhibit circulating proteoses of pulmonary origin > increased serum elastolytic activity > changes in the TF lamina – so called ‘metastatic emphysema’ > herniation.  Indirect inguinal hernia is due to dilatation /stretching of the TF at the deep ring. Also failure of closure of proc. Vag.allows abdo. contents further stretch the deep ring. Ind. Ing.hernia is,therefore, due to a congenital defect.  Femoral is caused by atrophy or dilatation of the fem.ring

18.  Non-structural causes include  Conditions which raise intra-abdo.pressure – chronic cough, straining on micturition or defaecation  Conditions that stretch abdominal musculature because of increase in content-ascites sec.to malignancy,liver/heart failure  Trauma, not a common cause, is a known cause eg motor bike handle groin injuries.

24.  Presence, in the line of the groin, of a lump which varies in size, expands on straining or coughing  Always exam. patient standing & recumbent  Expansile cough impulse may not always be visible but would be palpable  On exam.,inguinal hernia originates above & medial to the inguinal ligament.  Femoral hernia originates below and lat. to the ligament.

27.  It is possible to differentiate b/w direct and indirect hernias  Accuracy is approx 60-70%  Differential diagnosis of groin swellings include:- a. Inguinal hernia b. Femoral hernia c. Enlarged lymph nodes d. Saphena varix e. Subcutaneous lipoma f. Psoas abscess

28.  Repair could be open or laparascopic  Open repair could be conventional anterior non-prosthetic or conventional prosthetic.  Conventional ant. non- prosthetic repair include:- a.Bassini repair b.Maloney darn c.Shouldice repair d.McVay Cooper’s lig. repair e.Herniotomy

29.  Under LA, regional or general anaesthesia.  The steps are as follows:- 1.Initial incision on skin- oblique/horizontal 2. Mobilization of cord structures 3.Division of cremaster muscle 4.High ligation/excision of sac 5.Repair of post inguinal wall 6.Closure All the various repairs are similar except on step 5, where there are variations.

30.  Conventional ant. prosthetic repair, as described by Irving Lichtenstein, has similar steps as in the non-prosthetic repair except on step 5.  Lichtenstein tension-free hernioplasty involves placement of at least 16x8cm prosthetic mesh at post. wall of the canal.  Mesh should be tailored to individual’s size  The mesh is usually held in place with non- absorbable sutures.

32. OTHER PROSTHETIC TECHNIQUES 1.Plug and patch repair as described by Gilbert 2.Preperitoneal prosthetic repair 3.Combined ant. and post prosthetic repairs

33.  LOCAL COMPLICATIONS INCLUDE:-  Obstruction/ incarceration  Strangulation  Scrotal sepsis  GENERAL COMPLICATIONS INCLUDE:-  Intestinal obstruction  Cardiac failure  Deep vein thrombosis  Pulmonary embolism  Renal failure

34.  Inadequate resuscitation  SPECIFIC COMPLICATIONS:-  Wound haematoma/sepsis  Scrotal haematoma  Damage to vas  Ischaemic orchitis & testicular atrophy  Neurological complaints viz persistent wound pain, nerve entrapment syndromes  Recurrence

35.  Congenital type  Acquired type are more common in females

36.  Affects 3-5% of population  2-3 times more common in men  Between xiphoid and and umbilicus  Multiple in 20% of cases  80% are in the midline

37.  Incisional  Obturator  Lumbar  Interparietal  Sciatic  Perineal  parastomal

38.  Thank you