HERNIA
Definition
Hernia is the protrusion of a viscus or part of a viscus through an abnormal opening in the wall of the cavity that normally contains it, covered by peritoneum (except some types).
Components of Hernia
1. Hernial Orifice – Defect/opening
2. Hernial Sac – Neck, Body, Fundus
3. Contents
- Omentum (most common)
- Small intestine
- Colon, appendix, bladder, ovary (rare)
Classification of Hernia
I. According to Etiology
1. Congenital
- Indirect inguinal hernia
- Umbilical hernia (children)
2. Acquired
- Direct inguinal
- Femoral
- Incisional
II. According to Anatomical Site
A. Groin Hernias
1. Inguinal Hernia (most common – ~75%)
- Indirect
- Direct
2. Femoral Hernia
- More common in females
- High risk of strangulation
B. Ventral Hernias
- Umbilical
- Paraumbilical
- Epigastric
- Incisional
C. Others
- Hiatus hernia
- Obturator hernia
- Lumbar hernia
- Spigelian hernia
Inguinal Hernia
- Indirect Inguinal Hernia
- Congenital (patent processus vaginalis)
- Passes lateral to inferior epigastric vessels
- Enters deep inguinal ring
- Can reach scrotum
2. Direct Inguinal Hernia
- Acquired (weak posterior wall)
- Passes medial to inferior epigastric vessels
- Through Hesselbach’s triangle
- Rarely enters scrotum
- Hesselbach’s Triangle
- Medial: Lateral border of rectus abdominis
- Lateral: Inferior epigastric vessels
- Inferior: Inguinal ligament
Types According to Reducibility
1. Reducible Hernia
2. Irreducible (Incarcerated)
3. Obstructed Hernia – Lumen blocked, blood supply intact
4. Strangulated Hernia – Blood supply compromised → gangrene
5. Richter’s Hernia – Only part of bowel wall involved
6. Maydl’s Hernia – “W-shaped” loop → high mortality
7. Sliding Hernia – Sac wall formed by viscus (colon, bladder)
Clinical Features
Symptoms
- Groin/abdominal swelling
- Increases on coughing/straining
- Dull aching pain
- Dragging sensation
Signs
- Expansile cough impulse
- Reducibility
- Location above/below pubic tubercle
- Scrotal extension
Complications
- Intestinal obstruction
- Strangulation
- Gangrene
- Perforation
- Peritonitis
Diagnosis
- Clinical diagnosis is gold standard
- Inspection
- Palpation
- Cough impulse test
- Ring occlusion test
Investigations (when needed)
- USG abdomen/groin
- CT scan (obese / recurrent / occult hernia
Management of Hernia
General Principle
> All hernias should be repaired surgically unless contraindicated
Surgical Options
1. Open Repair – Herniotomy (children)
- Herniorrhaphy
- Hernioplasty (mesh repair)
- Common techniques – Bassini, Shouldice, Lichtenstein tension-free repair (gold standard)
2. Laparoscopic Repair
- TEP (Totally Extraperitoneal)
- TAPP (Transabdominal Preperitoneal)
Advantages
- Less pain
- Early recovery
- Bilateral hernia in same sitting
Emergency Hernia Surgery
Indications:
- Strangulated hernia
- Obstructed hernia
- Principles:
- Assess bowel viability
- Resection if gangrenous
- Mesh usually avoided in contaminated field
Special Hernias
Femoral Hernia
- Below & lateral to pubic tubercle
- Narrow neck → strangulation common
Richter’s Hernia
- No intestinal obstruction
- High risk of gangrene
Sliding Hernia
- Never open sac blindly
Ayurveda Correlation – Hernia ≈ Antravriddhi / Vata Vyadhi
Vata prakopa
Dhamani shaithilya
Management:
- Vata-shamana
- Bandhana
- Panchakarma (selected cases)
- Surgery (Shalya Tantra)
Key Exam Pearls
- Most common hernia: Inguinal
- Most common strangulated hernia: Femoral
- Gold standard repair: Lichtenstein
- Hernia in children → Herniotomy only