SRBs Bedside Clinics in Surgery.pdf

 SRB’s Bedside Clinics in SURGERY  SRB’s Bedside Clinics in SURGERY Sriram Bhat M MS (General Surgery) Associate Professor in Surgery Kasturba Medical College, Mangalore Karnataka, India...

 SRB’s Bedside Clinics in SURGERY  SRB’s Bedside Clinics in SURGERY Sriram Bhat M MS (General Surgery) Associate Professor in Surgery Kasturba Medical College, Mangalore Karnataka, India e-mail: [email protected] Foreword Thangam Verghese Joshua ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi Ahmedabad Bengaluru Chennai Hyderabad Kochi Kolkata Lucknow Mumbai Nagpur St Louis (USA) Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357 Registered Office B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672 Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: [email protected], Website: www.jaypeebrothers.com Branches 2/B, Akruti Society, Jodhpur Gam Road Satellite Ahmedabad 380 015, Phones: +91-79-26926233, Rel: +91-79-32988717 Fax: +91-79-26927094, e-mail: [email protected] 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East Bengaluru 560 001, Phones: +91-80-22285971, +91-80-22382956, 91-80-22372664 Rel: +91-80-32714073, Fax: +91-80-22281761, e-mail: [email protected] 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road Chennai 600 008 Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089 Fax: +91-44-28193231, e-mail: [email protected] 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498, Rel: +91-40-32940929 Fax:+91-40-24758499, e-mail: [email protected] No. 41/3098, B and B1, Kuruvi Building, St. Vincent Road Kochi 682 018, Kerala, Phones: +91-484-4036109, +91-484-2395739, +91-484-2395740 e-mail: [email protected] 1-A Indian Mirror Street, Wellington Square Kolkata 700 013, Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415 Rel: +91-33-32901926, Fax: +91-33-22656075, e-mail: [email protected] Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar Lucknow 226 016, Phones: +91-522-3040553, +91-522-3040554, e-mail: [email protected] 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896 Fax: +91-22-24160828, e-mail: [email protected] “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road Nagpur 440 009 (MS), Phone: Rel: +91-712-3245220, Fax: +91-712-2704275, e-mail: [email protected] USA Office 1745, Pheasant Run Drive, Maryland Heights (Missouri), MO 63043, USA, Ph: 001-636-6279734 e-mail: [email protected], [email protected] SRB’s Bedside Clinics in Surgery © 2009, Jaypee Brothers Medical Publishers All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition : 2009 ISBN 978-81-8448-581-3 Typeset at JPBMP typesetting unit Printed at This book is dedicated to all my students  Foreword Sriram Bhat M, author of SRB’s Bedside Clinics in Surgery is known for his innovative works, writing books related to his profession, collecting all clinical and operative photographs. He has already authored SRB’s Manual of Surgery; SRB’s Surgery for Nursing Students, SRB’s Surgery for Dental Students and Jaypee Gold Standard Mini Atlas Series: Surgical Diseases. This new innovation of his, SRB’s Bedside Clinics in Surgery is of different type with illustrations, clinical methods, X-rays, discussion on surgical pathology and basic surgical procedures. It is more of clinical and practical book by which undergraduate and surgical postgraduate students will be benefited. It will also be useful in the process of learning to any practitioner who still has the zeal to learn. I am proud of the fact that a student of mine has reached such heights of excellence and I feel privileged to be given the honor of penning the foreword for this special book. I wish him success in all his endeavors which I am sure will be an inspiration for every young aspiring surgeon. Thangam Verghese Joshua MS MCh Head, Department of Surgery Kasturba Medical College Mangalore 575 001 Karnataka, India  Preface It is observed that students, especially undergraduates, often find difficult to prepare themselves for clinical examination after theory papers. They need to know basic clinical methods with relevant discussion of the specific cases; X-ray discussion; surgical specimens; instruments; basic operative procedures and principles. Keeping this in mind, this book SRB’s Bedside Clinics in Surgery has been brought out to go through quickly prior to clinical examinations. This is also useful to surgical residents and postgraduates, especially for instruments and surgical pathology, which are of great importance to them. Many a times, students need to refer to SRB’s Manual of Surgery, 3rd edition (whenever required) and other specific books for detailed theory aspects of many topics. I hope this book will earn its value in its own way in student circle. I thank everybody including publishers who are backbone of this title. Any criticisms are well accepted. Sriram Bhat M  Acknowledgements I am happy to bring out this new book of clinical and practical importance SRB’s Bedside Clinics in Surgery, first edition. This is due to constant help and support of many. I thank our Chancellor Dr Ramdas M Pai, Pro-Chancellor Dr HS Ballal, Vice-Chancellor of MAHE Prof Rajashekaran Warrier, our beloved Dean Prof CV Raghuveer, our Vice-Deans Prof Anand Kini and Prof Venkatraya Prabhu for their academic support. I thank Prof Thangam Varghese, Head of Department of Surgery, KMC, Mangalore, for her constant encouragement in academic work and progress. I always remember my senior teachers, Prof CR Ballal and Prof Suresh Kamath for their constant help. Surgical unit heads in our college Prof K Prakash Rao, Dr BM Nayak, Dr Jayaram Shenoy, Dr Jayaprakash Rao, Dr Harish Rao, Dr Ramachandra Pai, Dr Alfred Augustine and Dr Shivananda Prabhu are always supportive for my work and are worth to be remembered always. I am grateful to all my teachers and colleagues in Surgery Department who directly or indirectly helped me to bring out this edition. I appreciate District Medical Officer and Resident Medical Officer of Government Wenlock Hospital, Mangalore for their kind help. I thank very much to the faculty, Department of Surgery and Paediatric Surgery, JJMMC, Davangere for providing the needed photographs. I sincerely thank Prof Navin Chandra Shetty, Head of Radiology Department, KMC, Mangalore and also other faculty of the department for their help in providing and guiding me in X-rays, CT scans and imaging methods. I acknowledge Prof Kishore Chandra Prasad, Head of Department of ENT for his help, guidance and encouragement in bringing out this book. I thank Dr Shivaprasad Rai, Dr Ahfaque Mohammed, Dr Kalpana Sridhar, Dr Yogish Kumar, Dr Ramesh, Dr K Akbar, Dr Keshava Prasad, Dr Kishore Reddy, Dr Achaleshwar Dayal, Dr Raghav Pandey, Dr Rupen, Dr Ashwini Mallya, Dr Praveen, Dr Ashok Hegde, Dr Rajesh Ballal, Dr Devidas Shetty, Dr Venkatesh Sanjeeva, Dr Sunil, Dr Shanbogh, Dr Harish Nayak, Dr Subraya Kamath, Dr Venkatesh Shanbogh, for their help in various aspects. I sincerely appreciate Dr Raghavendra Bhat and Dr Ravichandra, consultants in Radiology Department, Yenepoya Medical College, Mangalore for their contribution and affectionate help. I will never forget my close associates Dr Ganapathy MD, Mangala Hospital, Kadri, Mangalore and Dr Ashok Pandit, MCh (Urologist) for their affectionate help and encouragement in all my endeavours. They always stood with me in my difficulties. I thank my friend Dr Jagadish MDS for his contributions to X-ray. My wife Dr Meera Karanth helped me day and night in editing this new book and without her help this could not have been possible. My beloved daughter Ananya helped me in drawing new diagrams artistically. I enjoy her love and affection towards me. I remember my students Dr Ravi CR, Dr Ashwini Polnaya; Dr Ishwara Keerthi and Dr Sudesh for their special contributions. I thank all my students especially postgraduates of Surgery Department who were helping regularly in bringing out this book. Words are not sufficient to remember all my patients who are the main material for the book. I pray for their good health always. I appreciate Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director- Publishing) and all staff of the Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, for doing appreciable work in their respective field of printing and publishing. Sriram Bhat M  Contents 1. Surgical Long Cases................................................................................................................ 1 Introduction and Writing Case Sheets of Surgical Cases (Basic Pattern of Case Sheet Writing)............................................................................................................. 2 Hernia..................................................................................................................................... 7 Vascular Diseases............................................................................................................... 40 Varicose Veins..................................................................................................................... 73 Breast.................................................................................................................................... 91 Thyroid............................................................................................................................... 132 Differential Diagnosis of Mass Abdomen.................................................................. 181 2. Surgical Short Cases........................................................................................................... 209 3. Surgical Pathology.............................................................................................................. 289 4. X-rays....................................................................................................................................... 357 5. Newer Imaging Modalities............................................................................................... 429 6. Instruments............................................................................................................................ 447 7. Surgical Principles and Procedures................................................................................ 501 Preoperative Preparations.............................................................................................. 502 Surgical Procedures.......................................................................................................... 511 8. Miscellaneous....................................................................................................................... 545 Definitions of Common Terminologies in Surgery.................................................. 546 Most Commons in Surgery............................................................................................ 561 Index.............................................................................................................................................. 577 2 SRB's Bedside Clinics in Surgery INTRODUCTION AND WRITING CASE SHEETS OF SURGICAL CASES (BASIC PATTERN OF CASE SHEET WRITING) A case sheet comprises a detailed history of a particular Then come to the next complaint, if it is patient admitted to the hospital, has to be written swelling, mode of onset, whether there is recent carefully and neatly without any spelling mistakes. increase in size, pain, its relation to activities, Two important aspects of a case sheet are— etc. Then the next complaint, if it is fever, mention Detailed history. in detail the type, time of onset, whether Physical examination. associated with chills, sweating. Once the chief complaints are elaborated, only relevant questions in respect to symptoms HISTORY pertaining to other systems should be asked and Particulars of the patient— mentioned. 1. Name. GIT: history of haematemesis, melaena, heart 2. Age. burn, flatulence, weight loss, appetite, details 3. Sex. of bowel habits, (frequency, nature, bleeding), 4. Religion. jaundice. 5. Occupation. Respiratory system: H/O chest pain, cough, 6. Address. haemoptysis, breathlessness. 7. Date of admission. Cardiovascular system: H/O chest pain, 8. Hospital number. palpitation, breathlessness on exertion Urinary system: Details of urinary habits Chief Complaint (frequency, dysuria, urgency, hesitancy), Should be mentioned in brief, and if multiple, haematuria, burning micturition in chronological order of appearance Neurological: H/O of head ache, vomiting, e.g. difficult speech, walk, weakness in limbs, etc. Pain in the right knee joint—15 days. Swelling in the right knee joint—7 days. Past History Fever since 2 days. Do not simply mention ‘nothing significant’. All minor complaints should not be listed; only History of any other major illness, pulmonary 2-3 appropriate complaints must be noted. Koch’s been treated, epilepsy (treated or on History of Present Illness treatment), hypertension, jaundice, diabetes, psychiatric illness, autoimmune disorder. Write in detail about the complaints, along with History of surgery in the past, nature of illness, mentioning other minor ailments also. type of surgery, emergency/elective, type of Begin with an opening statement such as the anaesthesia used, mode of recovery, any ‘patient was apparently normal’ (not perfectly complication, any blood transfusion given. or absolutely normal) before this episode of illness, e.g. Personal History If the chief complaint is pain, then write in detail about the site, nature, duration, mode of Following aspects must be looked into— onset, radiation, shifting of pain, aggravating Dietary habits. and relieving factors, its relation to food/sleep/ Addiction (alcohol; drugs/cigarettes/ physical activities, whether associated with tobacco, betel nut chewing). vomiting. Sleep (disturbed or normal).  Surgical Long Cases 3 Bowel habits, micturition (if not mentioned Systemic Examination in the h/o presenting complaints). All other systems which has not been included Socioeconomic status, marital status. in local examination has to be examined and Menstrual history in females (nature of the written. cycle, duration of flow, obstetric h/o, LMP, postmenopausal bleeding in old women). Abdomen Family History Inspection: Ask for history of any illness in the parents, Shape of abdomen (normal/obese scaphoid/ siblings, spouse and children. distended). Position of umbilicus (central/deviated/ Treatment History pushed up or down). History of treatment received for the present Movements of abdomen. illness. Skin over the abdomen ( scar/pigmentation/ History of receiving treatment for any other venous engorgement). illness. Hernial sites (look for expansile impulse on cough). History of Allergy to Drugs and Food External genitalia. Palpation: PHYSICAL EXAMINATION Done for— Done under three main categories— Swelling, if palpated, its relation to abdominal quadrants has to be mentioned, mobility, General Examination tenderness, consistency is noted. Level of consciousness, degree of cooperation, Tenderness both deep and superficial is build, facies, nutrition decubitus, anaemia, elicited; any rebound tenderness with jaundice, cyanosis, clubbing, oedema neck guarding and rigidity is noted. veins, lymph nodes. Liver, spleen, kidneys are palpated for Pulse— enlargement, their consistency, tenderness, Mention the rate, regularity, volume of blood flow, nodularity if any is noted. vessel wall, and palpate all the peripheral pulses Percussion: (radial, brachial, temporal, dorsalis pedis). General note all over the abdomen. Blood pressure— Shifting dullness. Respiratory rate— Free fluid thrill. Upper border of liver dullness. Temperature— Pigmentation— Auscultation: Bowel sounds, nature intensity, abnormality Local Examination is noted. Site of disease has to be thoroughly examined Any added sounds-bruit. in detail under 4 heading ( inspection, palpation, percussion, auscultation), e.g., Perrectal Examination Examination of inguinal region in hernia. Examination of breast in breast disease. Pervaginal Examination (in women) 4 SRB's Bedside Clinics in Surgery Respiratory System b. Urine routine. c. Stool for routine (ova/cyst/parasite). Inspection: Shape, movement of chest, respiratory d. Chest X-ray. rate is noted. e. ECG. Palpation: Position of trachea, tenderness over Special investigation—based on clinical findings ribs and costochondral junction, vocal fremitus. and provisional diagnosis. Percussion DIFFERENTIAL DIAGNOSIS Auscultation: Breath sounds, any crepitus/ rhonchi, vocal resonance. Can be mentioned in order of significance. Cardiovascular System IMPORTANT POINTS OF Inspection: Shape of precordium, apex beat, any GENERAL PHYSICAL pulsation. EXAMINATION Palpation: Apex beat, parastenal heave, thrill. Anaemia Auscultation: 1st and 2nd heart sound in all the It is qualitative or quantitative reduction in RBC areas. or HB% in relation to standard age or sex. Murmur It is assessed by presence of pallor at the lower palpebral conjunctiva, tip and dorsum of Examination of Nervous System tongue, nail beds skin over palms and soles. Higher functions: Consciousness, speech, alertness, cooperation noted. Gait examined. Cranial nerves examined. Motor system: Tone, power of upper and lower limb muscles must be mentioned. Sensory system: Pain, touch, temperature over arms, chest, back and lower limbs; vibrations and reflexes are checked. Cerebellar sign ± noted. Examination of Cranium and Spine PROVISIONAL DIAGNOSIS Fig. 1.1: Anaemia A complete diagnosis has to be given. e.g—Carcinoma right breast with mobile axillary Jaundice lymph nodes—T2NIM0. Yellowish discolouration of sclera, skin and mucous membrane due to excess bilirubin in INVESTIGATION SUGGESTED blood. Base line investigations— Normal serum bilirubin—0.2mg% to 0.8mg% a. HB%, TC, DC, ESR, blood for sugar, blood Jaundice is looked for in day light over sclera urea, creatinine. by asking the patient to look down and retracting  Surgical Long Cases 5 the upper eye lid, over soft palate and under Pitting on pressure becomes evident only surface of tongue, skin over palms and soles. when the circumference of limb increases by 10%. Cyanosis In non-ambulant patient, it is checked by Bluish discolouration of skin and mucus pressing over the sacrum. membrane due to increased amount of reduced Hb in circulation (> 5 gm%). Types Peripheral: Periphery (tip of nose, tips of finger and toes, palms, soles, ear lobule) is blue due to sluggish circulation or vasoconstriction leading to more oxygen desaturation at capillary bed. Central: Excessive oxygen desaturation of central arterial blood (in severe VSD, tetrology of Fallot), looked for in the undersurface of tongue, and inner aspect of lips. Here periphery is also blue. Clubbing It is increase in anteroposterior and transverse curvature of nail leading to bulbous enlargement of the terminal phalanges. The angle between nail and nail bed is obliterated. Degrees of Clubbing Fig. 1.2: Oedema should be looked 1st: Increased fluctuation of nail bed (looked for for in both feet at the base of the nail with two index fingers). Lymph Nodes 2nd: Fluctuation associated with increased anteroposterior and transverse curvatures. Cervical Lymph Nodes 3rd: Above changes associated with increased Level 1: Submental group in submental triangle; pulp tissue in terminal phalanges producing submandibular group in submandibular triangle— parrot beak or drum stick appearance. Palpated with pulp of fingers after flexing the neck to the same side. 4th: In addition to above changes there is Level 2: Upper jugular group, situated along the hypertrophic osteoarthropathy (subperiosteal thickening of wrist and ankle bones). upper third of the internal jugular from carotid bifurcation to base of skull. Oedema Level 3: Middle jugular group, situated along the Due to excessive of fluid collection in extra- middle third of internal jugular. vascular compartment. Level 4: Lower jugular group, situated along the In ambulant patient, medial surface of tibia, lower third of internal jugular. 2.5 cm above the ankle is pressed for 5-10 Level 2, 3, 4 are palpated along the jugular seconds. with the pulp of finger. 6 SRB's Bedside Clinics in Surgery Level 5: Posterior triangle group palpated in Radial artery is ideally and conveniently used posterior triangle, and also includes supraclavi- to palpate for pulse against the lower end cular group which is palpated in supraclavicular of radius above the wrist joint. fossa by asking the patient to shrug the shoulder. Normal pulse rate: 60-100/minute; < 60/mt— bradycardia; > 100/mt—tachycardia. Level 6: Anterior compartment, includes peri- laryngeal, pericricoid, peritracheal nodes from Not only rate-noting the rhythm is also hyoid bone above to suprasternal notch below important. Rhythm is appearance of successive and to medial border of sternomastoid laterally. pulse wave with time, regular if successive pulse The number of nodes, consistency, mobility/ beat appears at definite interval, irregular if it fixity to underlying structures, tenderness,has is not appearing at regular interval. to be noted. Respiration Axillary Group of Nodes Normal respiration is abdominothoracic, normal Pectoral group: Situated behind the anterior fold rate 18-20/min. of axilla, palpated with pulp of fingers of right hand for left side, with examiners fingers Temperature insinuated behind the pectoralis major, and with Normal body temperature: 98-99 degree Farenheit. patient’s arm made to rest over the examiners Pyrexia: >99° Farenheit forearm. Hyperpyrexia: >106° Farenheit. Brachial group: Lies on the lateral wall of axilla Pyrexia of unknown origin (PUO): It is fever along the cephalic vein, left hand is used for of >101° Farenheit persisting for more than left side, with palm directed laterally towards 2 weeks with cause remaining obscure in spite the upper end of humerus. of intensive investigation. Subscapular group: Lies along the posterior fold of axilla, palpated standing behind the patient, Blood Pressure keeping the arm in semi-flexed position. Recorded is done in lying down supine position Central group: This group is palpated in the apex and sitting position, with sphygmomanometer of the axilla, left side with examiners right hand. cuff tied firmly around the left arm, one inch above the elbow joint. The cuff is inflated till Apical group: This group is palpated higher than the radial pulse disappears. The diaphragm of the above nodes. stethoscope is placed over the brachial artery. The pressure reading at which there is a clear Inguinal Group tapping sound on deflating the cuff is the systolic Both horizontal and vertical group must be blood pressure and the reading which corres- examined. ponds to complete disappearance of sound is the diastolic pressure. Pulse It is lateral expansion of arterial wall by a Pigmentations column of blood forced by the contraction Looked in face, oral cavity, tongue, palmar of heart into the peripheral circulation. creases and general body skin.  Surgical Long Cases 7 HERNIA Hernia is an important clinical topic for Any changes in the size and extent of the undergraduate as well as postgraduate students swelling on standing/walking/straining/ in surgery. It is a long case for undergraduate lying down. student and a short case for postgraduate Whether swelling is reducible on lying students in surgery. It is the one of the commonest down/partially reducible or irreducible on surgical entity that surgeons come across and lying down or needs any manoeuvre to so detail knowledge of the subject is mandatory reduce it. History of gurgling sound in the to both undergraduates and postgraduates. scrotum signifies enterocele. Writing a case sheet for hernia is important If swelling is irreducible, then whether it as a long case. is painful or any abdominal distension vomiting should be asked. METHOD OF WRITING A CASE Pain Site of pain—whether it is in the groin or SHEET FOR INGUINAL HERNIA in the scrotum. Patient’s name. Duration of pain. Age. Severity of the pain, type of pain—dull aching Sex. or severe pricking type. Occupation. Aggravating or relieving factors. Aggravated by straining/walking/weight lifting; relieved Elderly people are more prone for hernia. Men by lying down. with strain full occupation like manual labourer, sportsmen, weight lifters, etc. are more prone for History Relevant to Precipitating Factors hernia. Chronic cough, tuberculosis, bronchial asthma or other respiratory diseases. Chief Complaints Constipation, altered bowel habits, tenesmus, Swelling in the groin, right or left or both bloody stool—in relation to anorectal stric- sided for....durations; or swelling in right/ ture/carcinoma. left/both inguinoscrotal region for....dura- Dysuria/urgency/hesitancy/altered tions. stream/night frequency/retention of urine/ Pain over the swelling for....durations. burning urine/haematuria—in relation to benign prostatic hyperplasia/urethral History stricture. History of Present Illness Past History Swelling Past history of hernia surgery—same side/ Duration of the swelling. opposite side. Type of surgery whether mesh Mode of onset of the swelling—spontaneous used or repair done. or on straining. History of appendicectomy earlier and if so Site of the first appearance of the swelling detail about the surgery (can cause right direct in the groin or in the scrotum. hernia). Progress and extent of the swelling, whether Past history suggestive of irreducibility/ it limits only to the groin or extends to the obstruction and treatment for that conser- scrotum. vative/surgical. 8 SRB's Bedside Clinics in Surgery Personal History direct inguinal hernias are in inguinal region. Smoking- duration, number per day, whether Complete indirect inguinal hernia (rarely beedi or cigarette. Pan chewing/alcohol complete direct inguinal hernia) is inguino- intake. scrotal extending down into the bottom of Appetite and altered weight. the scrotum. Swelling extends from the proximal part of the inguinal canal towards Treatment History the scrotum below. Any previous treatment given. Both transverse and vertical dimensions of the size should be mentioned. General examination Shape of the swelling is pyriform in indirect Examine for general built and nutritional status, inguinal hernia and globular in direct pallor, clubbing, cyanosis, jaundice, lympha- inguinal hernia. denopathy, oedema feet, pulse and blood Expansile impulse on coughing over the pressure. swelling is diagnostic. It is better seen than felt. Local Examination Surface smooth/uneven. Inguinoscrotal region should be examined in Margin—well-defined/ill-defined. standing position as swelling commonly reduces Visible peristalsis over the swelling should and disappears in lying down position. be noted if present. It means it could be enterocele. Scar/dilated veins/discolouration/redness over the swelling. On inspection, whether testis is seen sepa- rately from the swelling or covered by the swelling all over. Fig. 1.3: All hernias should be inspected initially on standing. Inspection Inspection in standing position— A B Mention the side of the swelling. Figs 1.4A and B: Expansile impulse on coughing is better Extent of the swelling is important. Incomp- seen than felt. It should be inspected with patient standing lete indirect inguinal hernia and usually and examiner sitting beside the patient.  Surgical Long Cases 9 reduction of contents of the scrotum by gentle manipulation by flexion and rotation of hip join. Zieman’s test is done to find out over which finger cough impulse is felt and so which type of hernia it could be whether femoral/ direct inguinal or indirect inguinal. Deep ring occlusion test: When deep ring is occluded, if impulse on coughing is absent then it is indirect inguinal hernia; if impulse on coughing is still present then it is direct inguinal hernia. Finger invagination test: Size of the superficial ring is noted and site of the impulse felt is observed whether it is in the tip of the finger or on the pulp. Fig. 1.5: Inguinal hernia is reduced in lying down position Palpation of testis, epididymis and spermatic with elevation of scrotum and flexion and rotation of the cord should be done without fail. Relation hip—taxis. of swelling to testis also should be noted. Bulbar urethra is palpated by lifting the Palpation scrotum and feeling in the midline. (To look Temperature and tenderness over the swelling for thickening and button like depression- Whether get above the swelling is possible or a feature of stricture urethra). not- purely scrotal swelling one can get above Opposite inguinal region, opposite testis, the swelling but in inguinoscrotal swelling epididymis and spermatic cord should be one can not get above the swelling. examined. Presence or absence of impulse Position and extent of the swelling. on coughing on opposite side should be Size in vertical and transverse directions. mentioned. Margin well defined or ill-defined. Surface smooth/lobular/tense. Consistency is soft and elastic in enterocele; doughy in omentocele. Location of the swelling—swelling is above and medial to pubic tubercle in inguinal hernia and below and lateral to pubic tubercle in femoral hernia. Reducibility of the swelling is checked by different methods. Whether it is reducible spontaneously while lying down and gets reduced completely or partially. In enterocele, it is difficult to reduce the first part but last part gets reduced easily. In Fig. 1.6: Bulbar urethra should be palpated by raising omentocele it is difficult to reduce the last the scrotum in midline posteriorly. Any stricture urethra is felt as thickening/button like depression. Gonococcal part but first part gets reduced easily. urethritis and trauma are the commonest causes of stricture Whether swelling needs any manipulation urethra. Bulbar urethra is the commonest site of stricture to get reduced like taxis. Taxis is gradual urethra. 10 SRB's Bedside Clinics in Surgery Percussion Without reducing contents of the swelling, percussion is done over the surface. If it is resonant, it is enterocele. If it is dull on percussion, then it is omentocele. Auscultation Bowel sounds may be heard over the swelling if it is enterocele. Fig. 1.8: Clinically per-rectal examination is a must in Perabdomen examination hernia to look for prostate enlargement, and rectal stricture Abdomen muscle tone should be checked by which are precipitating factors. head raising test, leg raising test and Valsalva manoeuvre. It should be inspected for Malgaigne bulging and should be palpated to check whether the tone is adequate (firm) or inadequate (supple). Any scar over the abdomen (appendicectomy scar may cause right-sided direct inguinal hernia); ascites or mass per abdomen should be mentioned. Fig. 1.9: Respiratory system should be examined to find out the precipitating causes for hernia like bronchitis, tuberculosis or asthma. A B Other Systems Cardiovascular system, nervous system including Figs 1.7A and B: Head raising and valsalva manoeuvre tests are needed to check the tone of abdominal muscle spine and cranium for any neurological problems in hernia. are examined for management of hernia. Digital Examination of the Rectum Diagnosis Digital examination of the rectum (P/R) must Diagnosis should be written complete with be done in all hernia cases to look for prostate mentioning of side, type,whether complicated or enlargement in elderly and rectal/anorectal not. strictures. For example, left sided indirect incomplete uncomplicated inguinal hernia-enterocele. Examination of Respiratory System Examination of respiratory system for altered Investigations breath sounds (rhonchi, bronchial breathing), All case sheets for long case should mention effusion, etc. to find out any precipitating the investigations required for that particular causes. case.  Surgical Long Cases 11 Relevant investigations required for inguinal Expansile impulse on coughing is also felt by hernia are chest X-ray, haematocrit, blood placing the thumb in front, middle and index sugar, serum creatinine, ultrasound abdomen fingers behind the root of the scrotum and asking depending on the age/suspected cause of the the patient to cough. hernia. Note: Presentation of the case should be in order When in a hernia impulse on coughing as mentioned above. One cannot alter the order will not be there? of presentation like presenting percussion first Strangulated hernia will not show impulse on and later palpation or likewise in a haphazard coughing. manner. Students should strictly follow the proper order What is the meaning of the ‘get above the of presentation in clinical methods. swelling’? Root of the scrotum is palpated between the Discussion thumb in front, index and middle fingers behind. In examination, discussion is usually in question In purely scrotal swelling like vaginal hydrocele, and answers method. A provisional discussion fingers and thumb meet each other well without often done after a presentation is given here. any additional structure other than cord in between (one can get above the swelling). In case Why clinically it is inguinal hernia? of inguinoscrotal swelling thumb and fingers Patient presented with swelling in the left groin, do not meet each other properly because of the gradually increased in size which often descends descent of hernial contents down (one cannot get into the scrotum and gets reduced on lying down. above the swelling). It occurs in funicular and It increases on straining, coughing or walking. complete type of inguinal hernia not in Expansile impulse on coughing is present and bubonocele. reduces on lying down or by taxis. Why it is indirect inguinal hernia? It is pyriform in shape. It descends obliquely in the groin. On occluding the internal ring in ring occlusion test, swelling does not appear later on coughing. On ring invagination test, impulse is felt at the tip of the invaginating finger. Zieman’s test confirms the impulse over the index finger. If it is direct inguinal hernia, then what A are the differentiating features? Direct inguinal hernia is globular in shape. After occluding the deep ring, swelling still appears on coughing on the medial side of the inguinal region. Impulse is felt on the pulp of the finger in invagination test and over the middle finger in Zieman’s test. How expansile impulse on coughing is clinically demonstrated? B Expansile impulse on coughing is seen on Figs 1.10A and B: In inguinoscrotal swelling inspection when patient is asked to cough. one cannot get above the swelling. 12 SRB's Bedside Clinics in Surgery ring occlusion test/invagination test/Zieman’s test if hernia is irreducible. How is finger invagination test done? Patient is asked to lie down. Contents are reduced completely. Using the little finger, scrotal skin is invaginated from below upwards near upper part of the testis. Finger is reached towards the superficial inguinal ring/external ring. Normally external ring does not admit the tip of the little finger. Finger is rotated inwards so that nail is towards the cord side. Patient is asked to cough. Fig. 1.11: Ring occlusion test is done to find out whether If the impulse is felt on the tip of the finger, then hernia is direct or indirect. If after occluding the ring swelling it is indirect inguinal hernia. If impulse is felt appears on the medial side, it is direct hernia. If swelling on the pulp then it is direct inguinal hernia. does not appear on occlusion and coughing it is indirect In case of complete inguinal hernia or funicular hernia. hernia external ring is patulous which can be very well-assessed by invagination test. Index What is ring occlusion test? finger can also be used for the test. It is the most important test in inguinal hernia. Invagination test should be done very gently, Deep/internal ring is located 1.25 cm above the otherwise it will be very painful. It cannot be mid-inguinal point. Mid-inguinal point is mid- done in children. point between the anterior superior iliac spine and pubic symphysis. (Note: Mid point of the inguinal ligament is center point between anterior superior iliac spine and pubic tubercle). Patient is asked to lie down to reduce the hernial contents. Thumb is placed over the mid-inguinal point. Patient is asked to cough. If there is expansile impulse on coughing on the medial side of the A thumb, in spite after deep ring occlusion, it is then direct inguinal hernia. If there is no impulse on coughing then patient is asked to stand with thumb occluding the deep ring. Patient is once again asked to cough; impulse on the medial side of the occluded thumb is looked for to rule out the direct inguinal hernia. If there is no impulse even on standing, it is indirect inguinal hernia. The occluded thumb is removed and patient is asked to cough to show the swelling and impulse due to indirect inguinal hernia. What is the prerequisite to do ring- occlusion test? B Hernia should be reduced completely prior to Figs 1.12A and B: Ring or little finger is do deep ring occlusion test. One cannot do deep used to do invagination test.  Surgical Long Cases 13 How is Zieman’s test done? What are the boundaries of the inguinal canal? Reduce the hernial contents. Index ring is placed Boundaries over the deep ring. Middle finger is placed over In front: External oblique aponeurosis and the superficial ring and ring finger over the conjoint muscle laterally. femoral ring. Patient is asked to cough. Behind: Inferior epigastric artery, fascia trans- If impulse touches— versalis and conjoint tendon medially. Index finger it is indirect inguinal hernia Middle finger it is direct inguinal hernia Above: Conjoint muscle (Arched fibres of internal Ring finger it is femoral hernia. oblique). Below: Inguinal ligament. A Fig. 1.14: Anatomy of the inguinal canal. IL—Inguinal Ligament. SIR—Superficial Inguinal Ring. DIR—Deep Inguinal Ring. CT—Conjoint Tendon. ASIS—Anterior Superior Iliac Spine. IEA—Inferior Epigastric Artery. What is inguinal defence mechanism? B It is the natural mechanism to maintain the Figs 1.13A and B: Zieman’s test—done on both sides. strength of the inguinal canal. Three fingers are used to do Zieman’s test. It is by Obliquity of the inguinal canal. How inguinal hernia is differentiated from Arched conjoined tendon. femoral hernia? Shutter mechanism of internal oblique. Inguinal hernia is above and medial to the pubic Ball valve mechanism of the cremaster. tubercle. Femoral hernia is below and lateral to Slit valve mechanism of the intercrural the pubic tubercle. fibres of the superficial inguinal ring. 14 SRB's Bedside Clinics in Surgery What are the differences between indirect inguinal and direct inguinal hernias? Indirect inguinal hernia Direct inguinal hernia Can occur from childhood to adult. Common in elderly. Occurs in a pre-existing sac. Always acquired. Protrusion through the deep ring. Herniation through posterior wall of the Herniation occurs later. inguinal canal. Pyriform/oval in shape. Globular/round in shape. Descends obliqulely and downwards. Descends directly forwards as a bulge. Can become complete by descending. Descends down into the scrotum is rare. down into the scrotum. Neck of the sac is narrow and lateral to Neck of the sac is wide and medial to inferior inferior epigastric artery. to epigastric artery. Sac is anterolateral to the cord. Sac is posterior to the cord. Ring occlusion test does not show any Test shows impulse even after occluding the deep ring. impulse after occluding the deep ring. Invagination test shows impulse on Impulse is felt over the pulp of the little finger. the tip of the little finger. Zieman’s test shows impulse Test shows impulse on the middle finger. on the index finger. Commonly unilateral but can be bilateral. Commonly bilateral. Obstruction/strangulation are common. Rare but can occur. Sac should be opened during surgery. Sac is not necessarily opened unless— obstruction is present. Fig. 1.15: Diagrammatic representations of direct and indirect sacs. How clinically is enterocele and omentocele differentiated? In enterocele In omentocele (epiploecele) First part is difficult to reduce but First part is easier to reduce but last part is last part is easier There will be gurgling difficult. Has a doughy feeling. sound on reduction. Resonant on percussion. Dull on percussion. Peristalsis is seen. No peristalsis seen. Bowel sounds may be heard. Bowel sounds not heard.  Surgical Long Cases 15 Fig. 1.16: Bilateral direct hernia. Note the medial location of the hernia. Direct hernia occurs through Hesselbach’s triangle. Fig. 1.18: Direct sac on table during surgery. Fig. 1.17: Large bilateral direct hernias. Note, on right Fig. 1.19: Irreducible hernia with bowel as well as omentum side it has descended into the scrotum to become complete. as contents. Note the change in colour of the bowel. Usually direct hernia will not descend into the scrotum but long standing direct hernia can descend down and become complete. A B Figs 1.20A and B: Hernial sac with small bowel (enterocele) as content. 16 SRB's Bedside Clinics in Surgery What is Hesselbach’s triangle? It is bounded by inferior epigastric artery laterally, lateral border of rectus muscle medially and inguinal ligament below. Direct hernia protrudes out through this triangle. Fig. 1.22: Anatomy of Hesselbach’s triangle. LUL—Lateral Umbilical Ligament. CT—Conjoint Tendon. ASIS—Anterior Superior Iliac Spine. IEA—Inferior Epigastric Artery. A hernia or femoral hernia or Maydl’s hernia. Taxis should be done very gently. How is tone of abdominal muscle checked and why? Abdominal muscle tone is checked by head rising (without supporting the elbows) or leg rising tests. It is initially inspected for any bulges in the abdominal wall which signifies Malgaigne bulgings. Later abdomen should also be palpated for muscle tone. Firmness signifies adequate tone whereas suppleness signifies poor muscle tone. Poor muscle tone indicates that patient needs B hernioplasty using mesh. Abdominal muscle tone is also checked by Valsalva manoeuvre. Figs 1.21A and B: Direct hernia aries through Use five fingers of the hand to complete all tests Hesselbach’s triangle for hernia’ Thumb for deep ring occlusion test. What is taxis? Index, middle and ring fingers for Zieman's Taxis is a method used to reduce the complete test. inguinal hernia. Hip and knee are flexed and Little finger for superficial ring invagination thigh is adducted. One hand held near the fundus test. of the sac in the bottom of the scrotum, other hand adjacent to external ring, contents are gently Rules of hernia examination reduced towards the proximal side. Often patient Never forget to check expansile impulse on himself does this technique in a better way. coughing and reducibility. It is contraindicated in obstructed/strangulated Never forget to examine opposite side.  Surgical Long Cases 17 Never forget to do perrectal examination. What are the types of indirect inguinal hernia? Never forget to examine bulbar urethra. It can be incomplete wherein sac does not reach Never forget to check abdominal muscle tone. to the bottom of the scrotum. It can be complete wherein sac descends completely up to the bottom What are the differential diagnoses for of the scrotum. Incomplete type can be bubonocele groin swelling? where hernia limits to inguinal region without Indirect/direct inguinal hernia. passing through the superficial inguinal ring Hydrocele—vaginal/encysted. or can be funicular where sac reaches up to the Femoral hernia. level of the upper part of the testis into the scrotum Lipoma of the cord. across the external ring. Inguinal lymphadenopathy. Groin abscess. A B Fig. 1.23: Parts of hernia—neck, body and fundus. C Figs 1.24A to C: Types of indirect inguinal hernia. What is groin hernia? (A) Bubonocele (B) funicular (C) Complete It is hernia occurring through a myopectineal orifice. It can be indirect inguinal hernia/direct inguinal hernia or femoral hernia. What is Fruchaud’s myopectineal orifice? It is an osseomyoaponeurotic tunnel. It is bounded— – medially by lateral border of rectus sheath. – above by the arched fibres of internal oblique and transverse abdominis muscle. – laterally by the iliopsoas muscle. – below by the pectin pubis and fascia covering it. It is through this tunnel all groin hernias Fig. 1.25: Complete inguinal hernia is one where occur. hernia descends completely into the scrotum. 18 SRB's Bedside Clinics in Surgery What are the newer classifications of groin hernias? Gilbert classification(1987) Type I: Hernia has got snug internal ring through which a peritoneal sac passes out as indirect sac. Type II: Hernia has a moderately enlarged internal ring which admits one finger but lesser than two finger breadth. Once reduced it protrude during coughing or straining. Type III: Hernia has got large internal ring with defect more than two fingerbreadth. Hernia descends into the scrotum or with sliding hernia. A Once reduced it immediately protrudes out without any straining. Type IV: It is direct hernia with large full blow out of the posterior wall of the inguinal canal. The internal ring is intact. Type V: It is a direct hernia protruding out through punched out hole/defect in the transversalis fascia. The internal ring is intact. Type VI: Pantaloon/double hernia. Type VII: Femoral hernia. B Type VI and VII are Robbin’s modifications. Nyhus classification Type I: Indirect hernia with normal deep ring. Type II: Indirect hernia with dilated (patulous) deep ring. Type III: Posterior wall defect. a. Direct hernia, sliding hernia. b. Pantaloon hernia. c. Femoral hernia. Type IV: Recurrent hernia. Bendavid classification Type I: Anterolateral defect (indirect). Type II: Antero medial (direct). C Type III: Posteromedial (Femoral). Figs 1.26A to C: Diagram and photos of indirect inguinal hernial sac. IL—Inguinal Ligament. SIR—Superficial Inguinal Type IV: Posteriorprevascular hernia. Ring. DIR—Deep Inguinal Ring. ASIS—Anterior Superior Type V: Anteroposterior defect (Inguino-femoral Iliac Spine. IEA—Inferior Epigastric artery hernia).  Surgical Long Cases 19 What are the precipitating causes for How local anaesthesia is given for inguinal hernia? inguinal hernia surgery? Smoking. Around 50-60 ml of xylocaine 0.5% is used. Plain Obesity. xylocaine 0.5% or xylocaine 0.5% with adrenaline Respiratory causes like bronchial asthma, can be used. Plain xylocaine dose is 2 mg/kg tuberculosis, bronchitis. body weight. Xylocaine with adrenaline is Ascites. 7 mg/kg body weight. Previous surgery like appendicectomy which Two methods are used— causes direct inguinal hernia. a. Nerve block method (point block) Chronic constipation due to anorectal 10 ml of xylocaine is infiltrated 2 cm above strictures. Rectal stricture may be due to and medial to anterior superior iliac spine chronic proctitis (amoebic), tuberculosis of to block the iliohypogastric nerve. anorectum, previous anorectal surgery, rectal Midinguinal point is infiltrated with carcinoma or stricture due lymphogranuloma 10 ml xylocaine. venereum. Pubic tubercle place is infiltrated with Urinary problems like benign prostatic 10 ml xylocaine. hyperplasia (BPH), urethral stricture. 10 ml of xylocaine is infiltrated just below Straining. the inguinal ligament lateral to femoral Multiple pregnancies. artery to block the genital branch of genitofemoral artery. How patient with hernia is evaluated for Line of skin incision is infiltrated with treatment? 10 ml of xylocaine. Routine investigations like haemoglobin, total Later neck of the hernial sac is infiltrated count, blood urea, serum creatinine. with 10 ml of xylocaine. Blood sugar b. Field block method (Shouldice method) Specific investigations like chest X-ray, Skin of around 4 cm wide area is infiltrated U/S abdomen to confirm BPH. into the subcutaneous plane as first layer from anterior superior iliac spine to pubic What is the treatment? symphysis. Skin, subcutaneous and two Initially precipitating causes should be layers of superficial fascia (Camper and treated. Asthma, tuberculosis and bronchiec- Scarpa’s) are incised. tasis are treated by proper drugs, broncho- Area deep to external oblique aponeurosis dilators, respiratory physiotherapy. is infiltrated with 10 ml of xylocaine. Later definitive surgical treatment is under- External oblique aponeurosis is incised. taken. Exposed inguinal canal and hernial sac Commonly used procedure at present is is infiltrated with 10 ml of xylocaine to hernioplasty using prolene mesh. Modified continue with the dissection. Bassini’s repair is done in young individual with indirect hernia. Shouldice repair is also What is modified Bassini’s repair? used in some centers. It is strengthening of the posterior wall of the inguinal canal by approximation of the conjoint What is the anaesthesia used for inguinal tendon to inguinal ligament using monofilament hernia repair? nonabsorbable suture material. Absorbable General/spinal/epidural or local anaesthesia suture material like catgut should not be used can be used to do inguinal hernia repair. as 50% of the tensile strength will be lost in 20 SRB's Bedside Clinics in Surgery 7 days. It takes 6 months to achieve more than 80% of tensile strength in repaired hernial wound; and so non-absorbable suture material has to be used here to maintain the same adequate tensile strength in these period. Multifilament suture material like silk may precipitate infection because of the crevices in the suture material and tensile strength is not as good as monofilament suture material. Commonly used suture material is either polypropelene (prolene (blue in colour)) or polyethylene (ethylon (black in colour)). Continuous sutures compromise the blood supply and interfere with proper healing; and strength will not be as adequate as interrupted sutures. So always interrupted sutures are used. Earlier, commonest surgery done for groin inguinal hernia is modified Bassini’s repair. But now hernioplasty is the commonly done procedure for both direct and indirect sac. In direct hernia, sac is usually not opened but Fig. 1.27: Cord holding forceps is used to in indirect hernia, sac is always opened. hold cords in inguinal hernia surgery. What is herniotomy? Herniotomy is done for indirect sac, where the sac is dissected, neck of the sac is ligated and redundant sac is excised. What are the steps in inguinal hernia surgery? What are the different modifications? 1. Herniotomy Procedure After cleaning and draping, skin is incised 1.25 cm above and parallel to the medial two/ third of inguinal ligament. Two layers of superficial fascia (outer Camper’s fascia and inner Scarpa’s fascia) are incised. External oblique aponeurosis is incised. Upper leaf is reflected above and lower leaf is reflected downwards to visualise and expose the inguinal ligament. Ilioinguinal nerve is safeguarded. Fig. 1.28: Twisting the sac after exposing and dissecting Cremasteric muscle is opened. Cord structures the indirect sac. Sac should be twisted after opening so are dissected. Sac which is anterior and lateral as to avoid any content from coming back into the sac to cord is identified and is pearly white in colour. during transfixation of the sac.  Surgical Long Cases 21 2. Modified Bassini’s herniorrhaphy Conjoint tendon and inguinal ligament are approximated using interrupted nonabsorbable monofilament sutures [polypropylene (prolene, blue in color)]; medial most stitch is taken from the periosteum of pubic tubercle (called as key or Bassini’s stitch); external oblique is closed and other layers are closed. 1-0 polypropylene suture material is used for repair. Lytle’s repair Often internal ring is narrowed by placing Fig. 1.29: Bassini’s repair interrupted sutures over the medial side of the ring to the transversalis fascia using either thread or silk (To narrow the ring and push the cord Dissection is usually started from the fundus laterally). and extended towards the neck which is identified by extraperitoneal fat. The neck is Shouldice repair narrow and is lateral to the inferior epigastric Eventhough transversalis fascia is thin, it is a artery. Sac is opened at the fundus. Finger is tough layer and so double breasting of this fascia passed to release any adhesions. Sac is twisted using continuous sutures (with nonabsorbable so has to prevent the contents from coming back. material) strengthens the posterior wall of the It is transfixed using absorbable suture material inguinal wall. (vicryl or chromic catgut 2-0) and is excised It is a multilayered repair. It was originated distally. at Shouldice clinic in Toronto where it was usually A B C D E F Figs 1.30A to F: On table pictures of inguinal hernia surgery from cleaning, incision, exposure of external oblique, opening of external oblique and identification of the cord before dissecting the sac. 22 SRB's Bedside Clinics in Surgery A B C D E F G H I J Figs 1.31A to J: Steps in herniorrhaphy (modified Bassini’s repair) identification of sac, dissection of sac, opening of the sac, herniotomy, exposure of conjoint tendon and inguinal ligament, placing interrupted, approximating sutures between conjoint tendon and inguinal ligament and putting the knots of repair.  Surgical Long Cases 23 Fig. 1.33: Tanner's slide operation—relaxing incision placed over the lower medial aspect of the rectus sheath to reduce the tension after modified Bassini’s repair. Darning (Abrahamson nylon darning) Continuous intervening network of non- Fig. 1.32: Lytle’s repair absorbable sutures are placed between conjoint tendon and inguinal ligament to give good done under local anaesthesia. After doing support to posterior wall inguinal wall. herniotomy as in any other inguinal hernia, transversalis fascia is incised along the line of the wound from deep ring to pubic tubercle. Lower flap of fascia is sutured to posterior part of the upper flap. Upper flap is sutured to the inguinal ligament. It causes double-breasting of the transversalis fascia. Then conjoint tendon and inguinal ligament is further approximated by two layers of continuous sutures. External oblique aponeurosis is sutured in two layers (double-breasting) in front of the cord. Hence the original Shouldice repair is 6 layered procedure. First two layers of transversalis fascia, next two layers of conjoint tendon and last two Fig. 1.34: Darning of the posterior wall of inguinal canal layers of external oblique aponeurosis. Suture using nonabsorbable suture material either polypropylene/ material used here is fine steel wire 34 gauge polyethylene. (in original Shouldice repair) or polypropylene or polyethylene. Recurrence rate is 1%. Kuntz‘operation In old people after taking consent, orchidectomy Berliner modified shouldice repair: Involves double- is done along with removal of full cord, testis breasting of the transversalis fascia like in and total closure of posterior inguinal wall by Shouldice repair and single layer closure of the repair so as to reduce the recurrence. external oblique aponeurosis without any additional two-layered repair of conjoint Removal of cord at inguinal region tendon to inguinal ligament. Cord is removed from the inguinal canal by ligating both at external and internal ring. But Tanner’s slide operation testis is retained (for psychological reason) and To reduce the tension in the repair area, relaxing closure of inguinal canal by repair is done. incision is placed over the lower rectus sheath so that conjoint tendon is allowed to slide Andrew’s operation downward. Overlapping the external oblique aponeurosis. 24 SRB's Bedside Clinics in Surgery A B Figs 1.35A and B: Hernia truss. Note the position where sac is supported. It is not commonly used now as it may precipitate strangulation. Macvay operation (Cooper’s ligament repair) Suturing the conjoined tendon to Cooper’s ligament. Conservative treatment 1. Taxis: Patient lying in supine position, with flexion of hip and knee, and internal rotation of hip, contents are pushed with one hand directing with other hand 2. TRUSS: Rat-tailed sprung truss is used. Measurement is taken from the tip of greater trochanter to third piece of sacrum. Complications are discomfort, ulceration, strangulation, inflammation It may be used in old people who are not fit for anaesthesia and surgery Fig. 1.36: Bilateral inguinal hernia-operated. Postoperative Conservative treatment should be avoided wound infection has occurred on left side. in hernia as much as possible What are the complications of the inguinal What is hernioplasty? hernia surgery? It is strengthening of the posterior wall of the inguinal canal using synthetic material like Complications of inguinal hernia surgery prolene mesh, or Dacron. Earlier natural materials Haemorrhage, haematoma, haematocele. like tensor fascia lata, temporal fascia were being Infection 1-5% used. Now prolene mesh is commonly used. Postherniorrhaphy hydrocele, lymphocele It is placed in front of the conjoint tendon between Hyperaesthesia over the medial side of conjoint tendon and inguinal ligament. It is inguinal canal due to injury to ilioinguinal sutured using nonabsorbable suture material nerve below to the inguinal ligament and above to the Injury to iliohypogastric nerve, vas deferens, conjoined tendon. Prolene suture material is white urinary bladder, intestine in colour. Recurrence Size of the mesh should be 1.5 cm wider than Testicular atrophy, rarely oedema of the the defect. Adequate haemostasis and prevention penis of infection is important. Mesh should overlap Osteitis pubis over pubic tubercle adequately.  Surgical Long Cases 25 Inlay mesh repair by placing mesh deep to conjoint tendon. Lichtenstein tension free mesh repair (1993) with encircling the cord with mesh which is often done under local anaesthesia. Nyhus pre-peritoneal mesh repair. It is done through suprainguinal horizontal incision. Mesh is placed in the preperitoneal space deep to the cord, conjoined tendon, and transversalis fascia. Below, it is folded deep to the iliopectineal ligament of Cooper and sutured to it using two or three interrupted non-absorbable sutures. It is sutured to transverse abdominis above and transversalis Fig. 1.37: Mesh repair. Prolene mesh is reinforced fascia from deep. between conjoint tendon and inguinal ligament. Rives preperitoneal mesh repair is pre- peritoneal mesh repair through transinguinal What are the different types of hernioplasty? approach. Here mesh is folded and sutured Hernioplasty is becoming the prime treatment for below to iliopectineal ligament, above to the inguinal hernia. transverse abdominis in deeper plane. Often transversalis fascia opened earlier is sutured Different types are back using nonabsorbable suture material Onlay mesh repair by placing mesh in front. in front of the placed mesh. A B C D E F Figs 1.38A to F: Hernial sac should be dissected up to the neck of the sac. It is then twisted and transfixed using catgut or vicryl and redundant sac is excised. 26 SRB's Bedside Clinics in Surgery A B C D E F G Figs 1.39A to G: Placement of prolene mesh in inguinal hernia repair. i.e Inlay-Lichtenstein mesh repair. Stoppa’s giant prosthesis reinforcement of visceral sac (GPRVS). It is done in large hernias, hernias in elderly, bilateral hernias, recurrent and re-recurrent hernias, hernia with very lax abdomen. Horizontal length (size) of the mesh is 2 cm less than distance between two anterior superior iliac spines and vertical length (size) is distance between the umbilicus and pubic symphysis. Large mesh is placed between peritoneum and lateral, inferior, anterior abdominal wall which stretches in the lower abdomen and Fig. 1.40: Mesh after hernioplasty got infected with pelvis. It is done through lower midline or wound Dehiscence. It needs removal of mesh.  Surgical Long Cases 27 Pfannensteil incision. Usually such large only in case of nonavailability of TURP or very mesh is placed without any anchorage. large BPH. Gilbert mesh repair: after herniotomy, internal ring is plugged by cone-shaped piece of prolene mesh. Later onlay/inlay mesh repair of posterior wall of the inguinal canal is done. Transabdominal preperitoneal laparoscopic mesh repair (TAPP repair): becoming popular. Totally extraperitoneal laparoscopic mesh repair (TEP): becoming popular. Case A 65 years old male patient presents with bilateral direct inguinal hernia with features of prostatism with night frequency, burning micturition, and incomplete urination. Fig. 1.41: Left-sided complete inguinal hernia in a patient with Benign Prostatic Hyperplasia (BPH) who is on Foley’s catheter. He needs trans urethral résection of prostate How will you manage the case? (TURP) with hernioplasty. Patient is having bilateral inguinal hernia with benign prostatic hyperplasia (BPH). Digital Recurrent Hernia examination of the rectum (P/R) should be done. What are the causes of recurrent hernia? Patient is evaluated with ultrasound exami- Infection—most common—50%. nation, serum acid phosphatase and PSA Haematoma in the wound. (Prostate specific antigen). Residual urine should Early straining. be assessed. Normal value is 30 ml. More than Retained indirect sac, after repair of a direct 50 ml is abnormal. More than 200 ml signifies sac (Pantaloon hernia). severe obstructive uropathy which needs surgical Smoking, constipation, obstructive uropathy, intervention. old age, nutritional deficiencies. Altered tension in repair site. Altered collagen What surgery is done to this patient? synthesis. TURP (Transurethral Resection of Prostate) with hernioplasty either Lichtenstein or preperitoneal mesh repair should be done. Both surgeries are done at single sitting usually under spinal anaesthesia. If TURP facility is not available what other options are there? Open prostatectomy, either transvesical or retropubic can be done, which also can be com- bined with hernioplasty. But many advocate hernioplasty 12 weeks after open prostatectomy. Incidence of open prostatectomy has drastically Fig. 1.42: Recurrent hernia on table. Note the come down because of advent of TURP. It is done defect on the medial aspect. 28 SRB's Bedside Clinics in Surgery What are the recent approaches for inguinal/groin hernias? Transabdominal preperitoneal mesh repair (TAPP) using laparoscope. This is used in large indirect hernia or irreducible inguinal hernia. 10 mm umbilical port is used for laparoscope. 5 mm ports on pararectal point at the or above the level of the umbilicus one on each side so that to achieve adequate triangulation. Contents of the hernia are reduced. Hernial sac is dissected in preperitoneal plane after making horizontal incision at the upper part of Fig. 1.43: Sac in a case of recurrent hernia. the sac opening. Vas, gonadal vessels, pubic bone, inferior epigastric vessels are identified. Once sac is dissected and excised, a prolene/ Recurrence rate vipro/ultrapro mesh of 15 × 10 cm sized is placed Bassini’s repair—10% in preperitoneal space. It is fixed to pubic bone Shouldice repair—1% using tacks. Peritoneum is closed with Hernioplasty—1 to 3% continuous prolene sutures. Other methods—1 to 5% Totally extra peritoneal repair (TEP repair) using What are the types of recurrent hernias? laparoscope—This technique is gaining more True or false recurrence—based on type of popularity than TAPP. Through subumbilical recurrence—whether inguinal recurrence after incision (10 mm) extraperitoneal space is reached. inguinal hernia repair (true)/femoral hernia or After CO2 insufflation, another 5 mm port is obturator or other rare types after inguinal hernia inserted 4 cm below the first port in the midline. repair (false). But presently hernia is classified Third 5 mm port is inserted in the same line grossly as groin hernias and so all recurrences 4 cm below or in the right iliac fossa. Dissection are true recurrences. is carried out downwards carefully, then medially up to the pubic tubercle, iliopectineal ligament, laterally to iliac vessels, inferior epigastric How is patient with recurrent hernia vessels. Once adequate space is dissected 15 × investigated? 15 cm mesh is placed and spread. Care should Patient is investigated by chest X-ray, pulmonary be taken not to have any folding in the mesh. function tests, U/S abdomen for BPH, uroflow- Mesh may be sutured to iliopectineal ligament. metry, etc. Displacement of mesh is not common. Other side also can be done together. How such patient is treated? Treatment is always by surgery—always by Anatomical Considerations hernioplasty. Ideally preperitoneal mesh repair Preperitoneal space is a potential space in front is done either Rives or Nyhus or giant prosthetic of the peritoneum and behind the transversalis reinforcement of visceral sac (Stoppa’s GPRVS). fascia and anterior rectus muscle. Below in front Technically dissection is difficult because of the of the urinary bladder it is called as space of distorted anatomy of the inguinal canal and Retzius (medially), laterally it is called as space scarring. Orchidectomy may be added in old of Bogros. Median umbilical fold is formed people only after taking formal consent. by urachus in the midline. Medial umbilical  Surgical Long Cases 29 ligament is formed by obliterated umbilical arteries. Lateral umbilical fold by inferior epigastric vessels. Three fossae are lying in relation to these folds—supravesical and medial fossae are medial to lateral umbilical fold which are sites of direct hernia whereas lateral fossa is lateral to lateral umbilical ligament is site of indirect hernia. In 1956, Fruchaud described his myopectineal orifice bounded medially by the lateral border of rectus abdominis, laterally by iliopsoas, superiorly by conjoined tendon and inferiorly by pectin pubis. This area is the site of groin hernia which should be covered by mesh of adequate size to strengthen the defect and to prevent the recurrence. Iliopubic tract is analogue of the inguinal ligament extends from Cooper’s ligament to anterior superior iliac spine which divides endoscopic view of preperitoneal space Fig. 1.44: Ports used for TEP (red colour) and into superior compartment (contains inferior for TAPP (yellow colour). Fig. 1.45: Diagrammatic representations of TEP and TAPP. 30 SRB's Bedside Clinics in Surgery epigastric artery, Hesselbach’s triangle, cord replacing its pubic branch travels across Cooper’s structures and site of indirect inguinal hernia) ligament, which during fixation of mesh can and inferior compartment (contains femoral canal, cause torrential haemorrhage—circle of death. iliac vessels, iliopsoas muscle, genitofemoral Triangle of pain is formed by gonadal vessels nerve, lateral femoral cutaneous nerve). External medially, iliopubic tract laterally and peritoneal iliac vessels lie in a triangle formed by gonadal