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Brainiac Breakdown
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00:00yeah in the previous class we had discussed about
00:03uh vermiform appendix so coming to the last topic in abdomen that is hernia okay hernia
00:12and abdominal wall this will be our last content in GIT so starting with hernia mainly we'll be
00:19discussing about inguinal hernia and then femoral hernia and then some other epigastric hernia and
00:25other rare hernias okay so before we start with inguinal hernia today we need to know about the
00:31anatomy of inguinal canal basically so for that i have just prepared an overview so just like we
00:39all know it is a passage for the contents from abdomen to external genitalia somewhere okay so
00:46just the contents from the abdomen will pass through this hole into the external genitalia
00:52in males and females that canal is called as inguinal canal so it is an oblique passage in
00:57the lower abdominal wall and it is about four to six centimeter in length it we can say the extent
01:04of inguinal canal is from the opening of deep inguinal ring to opening of superficial inguinal
01:09ring so there are two rings and this deep inguinal ring is a defect in facial transversalis
01:21okay so and it is oval in shape whereas this superficial inguinal ring it is a defect in
01:29external oblique muscle and it is triangular in nature okay so this is the inguinal canal through
01:36which the contents from the abdomen pass into the pelvis and it contains it is of about four to six
01:43centimeter in length okay after this we need to know about the walls like what is the anterior wall
01:48of the canal what is the posterior wall of the canal what is the roof of the canal and what is the floor
01:52of the canal so just like we all know there are mainly three layers of abdominal muscles first one
01:58being external oblique and then internal oblique and then transverse abdominis last one being fascia
02:06transversalis so external oblique internal oblique transverses abdominis and then fascia transversalis so
02:13these are the layers of abdominal muscle wall okay in that so anterior wall will be formed mostly by
02:20external oblique muscle along with that it can be supported laterally by internal oblique muscle
02:25okay so that is the anterior wall what is the posterior wall posterior wall is formed by
02:31basically conjoint tendon conjoint tendon is nothing but the combination of internal oblique
02:38and transversus abdominis both of these form a tendon called as conjoint tendon along with that
02:45transversalis fascia so all the four layers are covered here anteriorly external oblique posteriorly
02:51the other three muscles and then roof will be the arching fibers of internal oblique and transversus
02:56abdominis okay and the floor is formed by the inguinal ligament itself so this forms the walls of the
03:02inguinal canal so with this basic anatomical knowledge we will start with hernia okay yeah so what exactly
03:14mean is the definition of hernia hernia is nothing but protrusion of viscous or part of the viscous
03:21through the wall of its containing cavity suppose if this is an abdomen if this is a layer of and we
03:27are seeing uh from sideways this is a transverse action if there is a defect here and if this viscous
03:33or part of the viscous will protrude through this defect then that is called as hernia okay so what
03:40is the main cause weakness of the abdominal muscles or increased intra-abdominal pressure these two will
03:47cause the herniation of abdominal contents so mainly two main causes one being weakness in the abdominal wall
03:54or the other one being increased abdominal pressure so with these two we will start discussing the risk
04:00factors and what might be the etiological factors and all okay so there are various types of hernias
04:06like indirect hernia direct hernia will come to this okay there are various classifications which say
04:12which is indirect hernia which is direct hernia first we will discuss the risk factors and then we
04:16will see the uh classification okay so what exactly or who exactly will have hernia what causes development
04:27of hernia for that there are various risk factors will start going one by one so it starts right from
04:33the embryology if this processes vaginalis or canal of neck are patent then it will cause hernia
04:43so most probably we all know that processes vaginalis and uh canal of neck these are embryological structures
04:53okay so uh these should undergo obliteration soon after development or soon after fetus is well grown
05:04this should undergo obliteration they should not be present in a grown individual if they are present then
05:11that will pull the contents downwards and that will lead to hernia okay so basically canal of neck
05:17is present in females and processes vaginalis can be present in males okay so because of this if this
05:24if there is a patent processes vaginalis if there is a patent canal of neck then it they these individuals
05:31have an increased risk for developing uh hernia okay other than that connective tissue disorders
05:36basically this will lead to weak abdominal wall and that will lead to hernia and then prune belly
05:43syndrome again same uh increased intra-abdominal pressure can be there ectopia vesica this is a
05:48condition where there will be failure of abdominal wall and pelvic floor muscles fusion so because of this
05:54reason uh whatever the contents are there they will be exposed directly to the environment and hence
05:59that is called as hernia other than that lower abdominal incision this can lead to a type of hernia called as
06:04incisional hernia other than that again defective collagen synthesis smoking and steroid intake all
06:09this will lead to weakness in the abdominal muscle wall that will lead to hernia so basically whatever the
06:17risk factors are there you can divide them into ones leading to weak abdominal muscle wall and the other
06:24one leading to increased intra-abdominal pressure so whatever the causes we discussed now these lead to
06:30weakness in the abdominal muscle wall okay the other factors which we discussed now they lead to
06:35increase in the intra-abdominal pressure so what are those factors they are chronic cough so because
06:41of chronic cough there will be increased intra-abdominal pressure and that can lead to protrusion of the
06:46organs similarly COPD and bronchitis again will lead to increased intra-abdominal pressure then chronic
06:52constipation will lead to increased intra-abdominal pressure obstructive uropathy like bph and stricter
06:58stricter urethra this will again lead to increased intra-abdominal pressure heavy weight lifting
07:02ascites pseudomyxomoperitone pregnancy chronic ambulatory uh peritoneal dialysis all these are
07:09the causes which will lead to increase in the intra-abdominal pressure so there should be at least
07:14either one of the cause one though weak abdominal muscle wall
07:18or more intra-abdominal pressure irritable lung causes that will lead to hernia so for this how
07:27many factors you can write you can or you can recall you have to okay so next uh most common type of
07:34hernia in both male and females is indirect inguinal hernia okay so we will discuss what is direct hernia
07:41what is indirect hernia okay so just remember most common type is indirect inguinal hernia and the
07:47femoral hernia is more common in females when compared to males okay and deep ring it is a
07:53defect in fascia transversalis whereas superficial ring it is a defect in external oblicoponeuruses this
07:58we know from anatomy okay now we will come to the classification of hernia so indirect hernia andreeno
08:07what does indirect hernia mean so suppose this is a deep inguinal ring and this is a superficial
08:12inguinal ring this is the inguinal canal okay so if the content
08:20is passing from throughout the inguinal canal okay so the content or the protrusion is through
08:31deep inguinal ring and then it comes out through superficial inguinal ring so this hernia is called
08:35as indirect inguinal hernia that is it is passing throughout the inguinal canal if it is direct
08:43there will be weak abdominal muscle wall and because of that reason it will be directly pushing the
08:50defect in the abdominal wall and it will be coming out so that is direct hernia suppose
08:55this is this is abdomen this is rectus abdominis muscle length uncordana the muscle six-pack muscle
09:04length uncord okay and here there is a triangle called as hazel bag triangle which is usually
09:12most coincide for direct inguinal hernia okay regionally there will be defect in the abdominal
09:16muscle because of that reason from here direct so inguinal canal will be somewhere here
09:22okay it is not touching inguinal canal so this is directly coming from this defect this is direct
09:31inguinal hernia or it will not be coming from the indirect inguinal hernia indirect i mean deep
09:37inguinal ring involve a matter it will be coming directly from here okay so that type of hernia is
09:43called as direct hernia okay so based on this knowledge we will start uh reading about the classification of
09:51hernias so first one being nai has classification or new york hernia university society okay nai has
09:59new york so in this there are four types first type being indirect hernia which is normal internal
10:07inguinal ring either or normal deep ring either and the content is passing from deep inguinal ring to
10:13superficial inguinal ring okay if that enlarge if that deep inguinal ring is enlarged then that will
10:19come under type 2 okay type 3a is direct hernia type 3b is indirect hernia uh through uh indirect
10:29hernia enlarge enough to encroach upon posterior inguinal wall or indirect sliding or scrotal hernia or
10:36pantalone hernia you can say okay so type 3c is femoral hernia and type 4 is recurrent hernia which is which
10:45can be a direct hernia or indirect hernia femoral or combined recurrent it is type 4 okay type 3 is
10:50femoral hernia type 3 type 4 you know confusion inla in type 3b it is indirect inguinal hernia which will
10:58encroach upon posterior inguinal wall okay posterior inguinal wall we have seen posterior wall is found by
11:05all three other layers it is transversus abdominus and conjoint tendon so adhrum
11:09melgade this will encroach and that is called as type 3b okay so this was about nyhass classification
11:21other one being gilbert classification according to this type 1 is indirect and small type 2 indirect
11:27and medium type 3 is indirect and large so defect buggy algebra basically deep inguinal ring if it is
11:32small okay if the deep inguinal ring is defect is medium then it is type 2 if defect is large then it
11:40is type 3 and type 4 is again directing vinyl hernia which involves entire floor type 5 is direct and it
11:46is diverticular type 6 combined that is pantaloon or saddle back or dual hernia or rhomberg's hernia
11:54combine another it will be having both direct and indirect okay and type 7 is femoral hernia this is
12:06again gilbert's classification so now we will come to proper types of hernia indirect inguinal hernia
12:14so in this what happens just like i have explained before the sac or the protrusion or the viscous
12:20will enter via the deep inguinal ring and transfers throughout the inguinal canal and goes out via
12:25the superficial inguinal ring so throughout the defect it is traveling then it is called as indirect
12:30inguinal hernia indirect inguinal hernia the sac is protruding directly from the posterior abdominal
12:35wall that is triangle of hasselbach and then enters the inguinal canal okay now so yeah here this is the
12:44hasselbach's triangle just lateral to the rectus abdominis muscle so illinda contained direct
12:52agbundu it will be protruding over the superficial inguinal canal hence this is called as direct
12:58inguinal hernia okay so for this reason we need to know about the boundaries of the triangle of hasselbach
13:07okay so triangle of hasselbach the lateral boundary and either laterally
13:11lateral boundary is this artery which is called as inferior epigastric artery okay so medially it
13:17is formed by the lateral border of this rectus abdominis muscle
13:22and then inferiorly is this ligament that is inguinal ligament so how can we say if the
13:30hernia we are seeing is direct or indirect and the main landmark is this inferior epigastric artery
13:37okay now so we have seen inferior epigastric artery is forming the lateral border of
13:44triangle of hasselbach so if the hernia is from here and the unkodona okay then we will say if the
13:51hernia is medial to inferior epigastric artery it is direct hernia that is medial if the hernia is
13:58lateral to inferior epigastric artery then it is called as indirect inguinal hernia because deep
14:03pinguinal ring is lateral to inferior epigastric artery vessels so hernia
14:12lateral to inferior epigastric artery vessels
14:15is indirect okay and hernia medial to inferior epigastric artery vessels is direct so you don't
14:27point to it is most important okay
14:33after this yeah relation of sac with spermatic cord so literally you know sac is posterior to spermatic
14:40cord in directing vinyl hernia and sac is anterolateral to spermatic cord in case of indirect
14:44inguinal hernia again this will all help in differentiating whether the hernia is direct or
14:51indirect okay you know sac yak bantu yeah indirect inguinal hernia directly it is coming out from the
15:00posterior abdominal wall so sac will be posterior to the spermatic cord whereas in indirect inguinal hernia
15:07it is passing through the canal where spermatic cord is also passing so because of that reason it
15:13will be anterolateral sac is anterolateral sac is anterolateral to the spermatic cord okay
15:19next relation of the neck of sac so in this
15:23in inguinal hernia above and medial to pubic tubercle
15:28that is this is used under neck of sac relation any qsmartivander to differentiate between
15:33inguinal hernia and femoral hernia so in inguinal hernia okay it will be
15:42this is inguinal hernia so fubic tubercle
15:47so it is above and medial to fubic tubercle okay in case of femoral hernia it is below and lateral to
15:53fubic tubercle so this what i have shaded in yellow is femoral hernia and what i am shading now in green this
16:00is inguinal hernia so and relation fubic tubercle being this so if it is medial to fubic tubercle
16:08it is inguinal hernia if it is lateral to fubic tubercle it is femoral hernia okay now coming to
16:15types of indirect inguinal hernia okay there is no doubt in indirect inguinal hernia and direct inguinal hernia
16:24so basically now we should know about two to three things to differentiate if the hernia is direct or indirect
16:34basically when we are seeing a patient as a whole when he comes to opd it will be like
16:42just in the one though if the appa get data
16:45so we can't say if it is direct or indirect or femoral so basically a swelling in the inguinal
16:55region will be the presentation
17:03so to we ourselves have to differentiate if it is direct inguinal hernia or if it is indirect inguinal
17:10hernia or if it is femoral hernia in for in order to differentiate this we have discussed all these
17:19three points first point being relation with
17:26inferior epigastric vessels so but inferior epigastric vessels will not be visible
17:31per se so we can't say this i thought only after proper dissection or only after
17:36only while the patient is undergoing surgery we can differentiate it while visualizing the
17:41inferior epigastric vessels so anatomically how we can differentiate and the by relation with spermatic
17:46cord
17:53and hernia sac so you were to know compare mod if the sac is posterior to this spermatic
18:00cord
18:06spermatic cord will be passing through the inguinal canal and sac will be here
18:11so that that is sac is posterior to spermatic cord then that is direct inguinal hernia okay
18:24because sac is here in the hindgad and cord inguinal canal is here in the antral lateral
18:30is here in the hindgad and sac then that is indirect inguinal hernia so sac which is one relation
18:35after that another relation being
18:40neck of sac with fubic tubercle
18:43if the fubic tubercle if the sac is lateral to fubic tubercle then that is femoral hernia
18:56if the sac is medial to fubic tubercle then that is inguinal hernia
19:00okay so if this points go thither we can differentiate the swelling in the inguinal
19:06region whether it is indirect or direct so after knowing this we will have to know about types of
19:12indirect inguinal hernia indirect inguinal hernia the last types is based on that we
19:17can say first one being bubino seal that is hernia content is limited to inguinal canal
19:23okay so if again you know you do deep inguinal ring this is superficial inguinal ring protrusion
19:29agide but it has not protruded until scrotum it has just stopped at the level of inguinal canal
19:35so four centimeter length idhra four centimeters ashti herniation agide that is called as bubino seal
19:41okay funicular and the processes vaginalis is closed above epididymis so epididymis
19:47so this is called as funicular type of indirect inguinal hernia uh hence this content will be
20:03felt separately from the testes so you can palpate it as two different swellings okay complete
20:13indirect inguinal hernia up to scrotum it would have uh descended so that is called as complete
20:18inguinal hernia so here we can we can't feel the hernia separately it will be feeling like testes only
20:27so these are the three types of indirect inguinal hernia okay so what will be the clinical feature
20:32patient hengbarthar namatrikana and just like i said he will come with a swelling in the inguinal
20:36scrotal region which will become more prominent and coughing and straining because this will raise the
20:41interrupt downward pressure and that will make the hernia more prominent and usually this will
20:46reduce spontaneously on lying position so standing idhaga it will be more prominent and on lying down
20:52it will usually spawn reduce spontaneously okay and there will be progressive increase in size of the
20:58swelling over the period of time ivaga suppose a patient has come with inguinal scrotal swelling we
21:03ask him to stand and cough okay after that we will make him sleep so on sleeping again there will be
21:10spontaneous resolution of the swelling again we will ask him to stand and we will not ask him to cough
21:14or anything so gradually there will be increase in the size of the swelling as the content of the
21:21hernia protrudes so that these are the three features swelling will be there in the inguinal
21:26scrotal region and it will become more prominent and coughing or straining and it will reduce
21:31spontaneously on lying down okay so these are the clinical features in this again there are various
21:37types of hernias which can be seen okay and we are seeing the definitions
21:46okay so first one being irreducible hernia so if i held the hernia will be usually
21:56reducing spontaneously on lying down if that hernia does not reduce spontaneously on lying down
22:02because there is some additions between the sac and the content in that case it is called as irreducible
22:08hernia okay what is incarcerated hernia contents cannot be reduced due to the presence of a fecal
22:14matter in the content so ivaga this is hernia it has protruded out and wadagada in the fecal matter
22:23so because of this reason it can't be reduced back and that is called as incarcerated hernia
22:29incarcerated with fecus feces fecal matter okay other type of hernia is obstructed hernia in which
22:37because of intestinal obstruction and there will be preserved blood supply blood supply
22:43then ishemia necrosis enagila but wadagada because there is an obstruction this this much canal is not
22:49sufficient for the content to go back and for that reason it has got obstructed and this can lead to
22:55ishemia and necrosis so obstructed hernia is dangerous it is it can lead to complication like
23:02strangulated hernia in this intestinal obstruction and the blood supply is also lost and because of this
23:09loss of blood supply there will be ishemia and then finally necrosis okay so enteros
23:16content is small intestine the first part is difficult to reduce and last part is easy to reduce
23:22so that is why they are saying first part in this ishemia is like this okay so in this small intestine
23:33has content initially there is difficulty because here ishemia and it will be difficult to pass through
23:40this reduce but once this initial part goes in the rest all part will move in around so that is why
23:51they are saying first part is difficult to reduce but the last part is easy to reduce whereas it is
23:56ulta in case of omento seal omento seal alenagathe first part is easy to reduce but the last part is
24:01difficult to reduce okay because the content is duffy omentum so duffy omentum idhra yengi rathe it is
24:09basically like uh uh so it will be like initially it will be easy but after while going in it will
24:20swirl around however it wants so because of this reason initially it is easy to reduce
24:26but last part it will become difficult
24:28is yak important andre in case of hernia we ourselves will have to examine the patient and
24:37reduce the hernia know what exactly is the content so while reducing we will have to look if the first
24:43part is easy to reduce or difficult to reduce if the first part is easy to reduce it is omento seal
24:49okay if the first part is difficult to reduce then the content is small intestine based on the content
24:54also treatment will differ so for that reason we will have to know these points okay so what is
25:00litter's hernia if the content is macus diverticulum then the hernia is named named as litter's hernia
25:07if the content of the hernia is appendix then it is named as amyans hernia okay so these are
25:13various named hernias which we can see first one being irreducible incarcerated obstructed
25:19strangulated enterosal and momentosal litter's hernia damayans hernia okay so after knowing the
25:24clinical features and various types of hernia we are knowing about diagnosis how to diagnose the case
25:29of hernia so similar to appendicitis diagnosis is mainly by clinical examination okay and the exception
25:37for this is only spegelian hernia or internal hernia which can't be visualized externally and in order
25:43to diagnose it we need a special scanning like ultrasound or CT hence it can cannot be
25:49diagnosed clinically rest all types of hernias can be diagnosed clinically okay so what is the
25:55treatment once we know that this patient is having hernia how do we treat him so one being the treatment
26:01of the sac okay that is herniotomy opening of the sac that is called as automy hernia herniotomy
26:08opening the sac and for that reason it is called as treatment of sac so herniotomy ln
26:13martyvi first inguinal skin crease incision then division of subcutaneous fat figure after that
26:18two layers in the scrotum that is campus fascia and scarpa fascia after that incision along the
26:24directional fibers and external oblique upon your system after this isolate the sac from the spermatic
26:31cord because cord cord should be separated from the sac and then once the sac open the sac at the fundus
26:40region then invert the region then invert the contents back apply purse string suture over the sac exercise
26:44the redundant sac so these are the steps of herniotomy okay first obviously it's male
26:50again is skinny that has been subcutaneous fat so that has been fascia so that has been muscle
26:56so that external oblique external oblique muscle we will have to identify the herniated content and then
27:03herniated content only sac na cord na separate madha we will open the sac sac open madhi we will
27:11whatever the content has protruded outwards we will push it back okay invert the contents back and we will
27:17push it back and yen content yen sac would be that will be like a plastic cover so adhikkya one purse string
27:23suture on the round suture hakko beko okay so after that purse string suture exercise the redundant sac okay so
27:32that is the sac and that sac is removed okay so this is the procedure of herniotomy once uh after this
27:41class you just watch a video of herniotomy in youtube you will be clear with it okay so often this was
27:48treatment of hernia that is sac okay one is herniotomy other one be herniorafi
27:54israel i know upto herniotomy it is same okay once the sac is excised then you will have to go for
28:01inguinal floor reconstruction with the sutures like all the connective tissue using that connective tissue
28:09we will reconstruct the floor that is inguinal ligament we will add this uh connective tissue
28:17so that it becomes strong and there won't be recurrence of the hernia okay and this is called
28:24as herniorafi if we use a mesh for strengthening the inguinal floor then that procedure is called as
28:31hernioplasty okay that is the difference if we don't use mesh it is herniorafi if we use mesh that is
28:38hernioplasty okay after this treatment of sac ito you are the inguinal floor reconstruction that can be
28:47by three different types that is primary tissue repair and these techniques have specific names
28:53so first one being bassinies repair and shoulders repair okay other one being anterior tension free
28:59repair and this is most commonly used and gold standard that is anterior tension free repair lichenstein
29:05repair repair repair other one third step being laparoscopic or pre-peritoneal repair that can
29:11be tap or tap it is total extra peritoneal and trans abdominal pre-peritoneal okay we will discuss
29:18about all these steps now so primary tension free repair hydralian martyvi basically we are
29:26trying to strengthen the inguinal floor
29:28okay so inguinal florally and then just inguinal ligament today
29:39but that is a basic principle here so based on their that specific scientist we have given the names
29:52as bassinies repair hydralian martyvi we will use internal oblique transverse abdominus and fascia
29:57transversalis so external oblique and the inguinal ligament is nothing but continuation of external
30:03oblique muscle remaining all three muscles of the abdomen is used to strengthen this and that is called
30:09as bassinies primary tension free repair and this these are the sutures to inferior edge or shelving of
30:16shelving edge of the inguinal ligament okay this is known as triple layer repair so moore layer use
30:21maadithi bhi hence the name triple layer repair this increases the tension in tissues and increases
30:26the recurrence rate okay so first two is in tri maadithi rashti andhra allhe abdominal allhe inna
30:33moore muscle layer idha adhane is much strengthen maadana and tri maadithi rho but result
30:37hyena hai tu that increase the tension in the tissues because they are pulling these three muscles and tying
30:43it to the inguinal ligament because of that reason there is increased tension and recurrence koda jasthi
30:49so then they then the other scientist what they did like a scientist called shoulders he said okay
30:55we will do one thing we will do double breasting of the fascia transversalis okay and that is called as
31:00four layer so iwaga one do transversal abdominus so adha adh mele internal oblique adhra jyotek fascia
31:06transversal transversalis in maadithi rho ered layer ithara fold maaditha gondro adhana double
31:10breasting of the fascia transversalis karitare so iwaga instead of three layers there are four layers
31:16for supporting the inguinal floor okay and this because of this double breasting there was relatively
31:22low tension in the tissues and this led to low recurrence rate so because of that reason
31:26shoulders is compared better okay after this again there was a modification to this shoulders in
31:32which there was double breasting of internal oblique transversal abdominus and fascia transversalis so
31:37yalla adhunu double breasting maadithi rho awaga naithu there was six layered repair and this
31:42is called as modified shoulders repair okay so basically this is these are all the techniques
31:49where inguinal floor reconstruction is done okay this was about primary tissue repair
31:54next anterior tension free repair this is gold standard for uh inguinal repair inguinal hernia repair
32:02and it is called as lichen stains repair ithara lay naithu they will fix the mesh that is hernioplasty
32:08idu it is a type of hernioplasty and whatever we discussed previously primary tension free they were
32:15herniorafi because we were using the abdominal muscles only okay this is a type of hernioplasty
32:24hernioplasty will fix the mesh to the anterior rectus sheath just above the fubic tubercle and then
32:31after fixing the mesh to the inferior aspect to inguinal ligament okay and then create an artificial
32:38deep ring by overlapping the cut edge of the mesh and then superior aspect of the mesh is then fixed to
32:43conjoint tendon basically defect the other mesh to cover so fubic tubercle
32:49detistant success is theторical and code
33:06so joining these two is the inguinal ligament inguinal ligament tally next to there will be two openings so
33:10okay so after this you again they will keep a mesh over the just above the fubic tubercle so
33:16just above the fubic tubercle they are keeping a mesh like this
33:25so after this they will fix this mesh to inferior uh you know the inferior aspect to
33:30inguinal ligament and then create a artificial deep ring by overlapping the cut edges of the
33:35mesh so whatever the mesh i have drawn this is smaller one dot mesh so okay so basically we
33:45have covered both superficial inguinal ring and deep inguinal ring with a mesh then we will have to
33:50create a deep inguinal ring so that the contents can pass so artificially we will
33:55cut some part of the mesh and we create a deep inguinal ring
34:07so now whatever the thing i have drawn in black that is deep inguinal ring and superficial inguinal
34:14ring is below the mesh okay so then superficial aspect of the mesh whatever is there that is
34:19fixed with the conjoint tendon so it is in all the conjoint tendon stitch so one cut a inferior
34:24aspect of inguinal ligament stitch so only this deep inguinal ring is created and the contents are
34:33allowed to pass okay superficial inguinal ring because of that defect there was inguinal hernia
34:38happening and we have closed that defect this was about lichenstein's repair okay so next other
34:47approach being laparoscopic approach so laparoscopic approach all the total extra peritoneal and the
34:53peritoneum gola ke enter aakta illa aachakada indane we are trying to repair other one being transabdominal
34:59but pre-peritoneal okay so first one being total extra peritoneal ithra laenvartta ra
35:08advantage is there is decreased risk of bowel injury because we are not entering into the abdominal cavity
35:14but we are outside the peritoneum and we are trying to repair the defect okay but disadvantage
35:19in another and there is a small working space and surgery is difficult hence experienced surgeon is
35:23preferred okay tap only total abdominal pre-peritoneal transabdominal pre-peritoneal we
35:31can say so either a leno laparoscopy proper laparoscopy tarane we will enter the abdominal cavity and from
35:36behind we will try to close the defect and this is preferred by beginners because there will be huge
35:40working space disadvantages there is increased risk of bowel injury and adhesion formation okay in
35:46government setup usually we will prefer lichen strain and the ram hospital is government hospital
35:49salala on meshak butto hernioplasti madadan pre-permata jasi hence it is called as gold standard
35:55private set up ali they will go for laparoscopy because surgical scar come here and
36:00expert surgeons here they can perform all this and facilities will be available usually early repair
36:06and no scar is visible in case of laparoscopy adhike laparoscopy doctor so basically if i have to explain
36:12tap and tap okay so suppose a patient is lying down like this okay so just start telling the layers of
36:24the abdomen now external oblique muscle internal oblique after that transverse abdominis
36:33after that is a fascia called as transversalis fascia or fascia transversalis okay so these are the four
36:41layers after this four layers there is peritoneum
36:44and this is obviously bowel okay so this is vertebra okay so we are imagining a patient is lying down and we are seeing from above okay so tip tap
37:08the difference and difference and totally extra peritoneal so we are not reaching inside this peritoneum we
37:16are creating a laparoscopy port in such a way that we will reach this plane
37:20so if i will shade shade we will reach this plane which is extra peritoneal just outside the peritoneum
37:35and we will see okay if i have to see fascia transversalis deep inguinal ring so if i have to see deep inguinal ring
37:40so we will reach this plane and we will put a mesh here okay so that this defect is covered so hence hernia
37:54adhu defect close maadudhange so n maadudhvi iwaga basically if i have to say more clearly
38:00the bovel would have been herniated like this so imagine this is a bovel and it has herniated like
38:15this so this is the hernia so now what we will do we will create a laparoscopic port we will reach this
38:21plane and we will reach till here uh we will reach hernia we will pull this whatever the herniated
38:27content is there we will put it backwards okay so it will come back so hernia is reduced now
38:37so once this hernia is reduced we will put a mesh here
38:43so eva hernia reduce hai to
38:48now we will place a mesh over the deep inguinal ring so we have not entered the
38:54the bovel we are outside the peritoneum adhi ke totally extra peritoneal lan karithar
39:03but ade we discussed alwa there is a small working space
39:10hence expert surgeons are needed okay in case of tap but tap
39:16again same layers of abdomen so external oblique internal oblique transverse abdominus
39:25fascia transversalis peritoneum
39:31okay again this bowel might have protruded like this this is deep inguinal ring this is superficial inguinal ring
39:41hernia okay okay so now what they will do they will directly enter here into the peritoneal cavity
39:48peritoneum no pierce maadi abdominic interact thare so total at the trans abdomen
39:56okay illik bandhaya matthare they will laparoscopically they will pull this content backwards so avaga hernia reduce
40:02agathe now hernia is reduced bowel is remaining here okay now through this inside only they will put a mesh
40:17so that again this hernia won't happen because of this reason we are calling this as transabdominal
40:23preperitoneal
40:31okay so transabdominal approach through the abdomen we are correcting the hernia okay but here totally
40:39extra peritoneal outside the peritoneum we are we are treating the hernia okay this is about laparoscopic
40:45approach or laparoscopic correction tip tip and tap in case of tap again large working space is the
40:52the hernia because of this reason easy and preferred by beginners okay
41:05yeah so while doing this laparoscopic repair we should be having concern regarding two specific
41:13triangles that is nothing but the region of our body where there can be damage that can lead to death
41:21first one being triangle of doom so just like the name suggests it is a dangerous triangle
41:28where the boundaries include suppose see this is deep inguinal ring okay so after deep inguinal ring
41:34there are there is a triangle here medially there is vast difference
41:41okay laterally there is gonadal vessels and base is by the fold of the peritoneum apex is deep ring
41:47contentane in the iliac vessels that is iliac artery and iliac vein so while doing laparoscopic surgery if
41:58we enter or if we damage the vessels in this triangle then there will be uncontrollable bleeding the patient
42:07will undergo shock and he'll die hence the name triangle of doom because if we by any chance do a sharp
42:14dissection here and lead to injury of the iliac vessels then there will be profuse bleeding and the
42:20patient won't survive hence the name triangle of doom okay the nerves between iliophobic tract
42:27gonadal vessels and fold of peritoneum like femoral nerve femoral branch of genitofemoral nerve
42:32anterior cutaneous nerve and lateral cutaneous these are also the contents of triangle of doom
42:37okay and the next triangle being triangle of pain so the triangle of pain what are the boundaries
42:44and the laterally it is by the fold of peritoneum so here are two triangles here and the akka pakka
42:48so one through medial boundary bandu yeah vast difference lateral boundary band gonadal vessel so again fold of
43:02peritoneum is the base so one through the base in under the lateral boundary you can draw imagining that
43:12so suppose
43:18this is the base
43:23like this so this is triangle of doom this is triangle of pain okay so either with base of this
43:30is lateral wall so base of triangle of doom is a lateral wall of triangle of pain that is found by
43:35the fold of peritoneum medially again these are gonadal vessels and superiorly it has a iliophubial tract
43:42okay so e regionally act triangle of pain andrea if we use electrocautery in this area then that will
43:49lead to significant amount of pain because it is full of nerves okay like lateral border of reflected
43:57peritoneum medially lateral femoral cutaneous nerve anterior femoral cutaneous nerve femoral branch of
44:03genitofemoral nerve deep circumflex celiac vessels okay and then femoral nerve so all nerves are there in
44:08this region and if we use electrocautery these nerves will get stimulated and it will lead to
44:13significant amount of pain hence it is named as triangle of pain okay so these two triangles
44:18should be kept in mind so yeah triangle of pain the content femoral nerve femoral branch of genitofemoral
44:24nerve anterior cutaneous nerve of thigh lateral cutaneous nerve of thigh most commonly injured while
44:29surgery performing surgeries lateral cutaneous nerve of thigh this will lead to a condition called as
44:34meralgia parasitica that we will discuss later on okay other condition or other thing we need to keep
44:40in mind is crown of death or coronamortis while performing inguinal surgeries so crown of death
44:49in some individuals there can be an abnormal branch okay so usual again again the inferior epigastric artery is
44:57a branch is a branch from the external iliac artery so abdominal abdominal aorta bandhu again it will divide
45:03into external iliac and internal iliac correct okay external iliac is this so this external iliac artery will
45:16give a branch that will give a branch that will give a branch called as inferior epigastric artery okay
45:27obturator artery is from the internal iliac artery so that is internal iliac artery so that is internal
45:33iliac artery in one branch that is obturator artery this one okay usually there is no communication between
45:42this inferior epigastric artery and obturator artery and obturator artery so you have to
45:46be ready to be ready to the branches so either major communication here allah but in some individuals there
45:51will be an aberrant obturator artery which is arising from this inferior epigastric artery this will connect
45:57obturator artery and there is a formation of a loop again so imagine this is abdominal aorta
46:04aorta it is forming two branches internal iliac and external iliac so this is external iliac artery this is
46:14internal iliac artery
46:19external iliac internal iliac and tancurana okay so
46:34external iliac okay so yeah external iliac and internal iliac
46:52iliac artery so yeah external iliac artery so yeah external iliac and internal iliac artery
47:21these won't be joining one another in normal individuals if there is an aberrant artery which
47:28is joining these two arteries in that case there is a vascular loop
47:34it has divided into external iliac and internal iliac for a purpose and again
47:38if it is connecting there is a vascular loop so either internal iliac or external iliac is damaged
47:44there will be continuous blood loss and because of that reason there will be more bleeding and death
47:49hence hence the name coronamortis or crown of death okay
47:57yeah
48:02so this is external iliac and then again internal iliac so external iliac the branch
48:08when the inferior epigastric artery internal iliac the branch when the obturator artery
48:12so again if these two join there is a loop so because of that reason
48:24there will be increased bleeding if any of these vessel is injured and this connection is called as
48:30aberrant obturator artery
48:37okay so hence the name coronamortis or crown of death okay after this we need to know about two spaces
48:46called as space of rhizzius and space of bogros so space of rhizzius and it is a retrofubic space okay
48:54so suppose we are seeing uh transverse section so this is a fubic bone and then there will be
49:10this will be urinary bladder
49:13if we are drawing a female and then after that
49:17rectum and anal canal so whatever the space is there between the fubic bone and
49:23urinary bladder this is called as space of rhizzius
49:31okay space of bogros and it is a retro inguinal space okay it is between extra peritoneal space
49:37located deep to the inguinal ligament it is situated laterally and cranial to the space of rhizzius
49:44so this space we are seeing so this space we are seeing in transverse section correct
49:47correct
49:48if we see anteriorly it will be like
49:55this is a urinary bladder above this there will be uterus and behind will be the rectum okay so
50:01fubic bone
50:04okay so fubic bone
50:05that is space space that is space of bogros
50:10this space is space of rhizzius
50:12that is laterally and cranially space space of bogros okay
50:18so these two spaces we need to remember okay after this what are the complications of groin hernia repair
50:26hernia repair
50:27so surgery in the nn complications are both one though again hernia is
50:34recurrent disease if there is no proper preventive measures taken after that so suppose if you
50:43operated on a patient who is a chronic smoker so operate we have corrected a hernia and we have sent him home
50:50again he starts smoking because of that reason again there will be weak abdominal muscle wall again
50:55he'll develop hernia so recurrence after that there can be a hematoma formation and then seroma
51:01formation can happen ischemic orchitis that is blood supply to testes might undergo ischemia and
51:08because of that reason there will be loss of function of testes we can say then if there is this ischemic
51:15orchitis then that can lead to testicular atrophy if the testicular artery is injured during surgery
51:21other than that osteitis fubus due to damage to periosteum of the fubic tubercle so while uh just
51:27like i said primary tissue repair margarita we will take we will try to uh suture the mesh to fubic
51:32tubercle and then rest of the parts to conjoint tendon during that time if we damage the periosteum of
51:38the fubic tubercle then that will lead to inflammation of that fubic tubercle called osteitis fubis
51:44other than that because of close relation with uh pelvic structures like bladder there can be bladder
51:49injury infection our chances just because we have entire we have opened through abdomen through
51:55and through because of that reason there will be increased chances of infection wound infection
52:00and then mesh related complications like contraction of the mesh erosion due to mesh and infection
52:05usually even number hospital most common of birth mesh infections
52:12maybe because of uh unhygienic practices which is being followed in the hospitals can be one of
52:18the reason otherwise uh other one being uh yeah the same old like wound infection
52:26so some reasons are there okay so these are the complications which can follow the uh gross
52:33groin hernia repair
52:39yeah last one more hernia is remaining we will finish it off
52:42okay so after all this strangulated hernia strangulated hernia it is obstructed hernia
52:51plus impaired blood supply
52:56so usually hernia is a elective type of surgery but in case of strangulated hernia there is impaired
53:04blood supply because of which there is loss of blood supply to the particular part of intestine which has
53:09undergo necrosis and hence it becomes an emergency surgery
53:15that is strangulated hernia is characterized by intestinal obstruction so intestinal obstruction
53:19and it can undergo perforation again so intestinal obstruction active and it is an emergency surgery
53:25and impaired vascular supply of the bowel aggregate because of that reason we'll do emergency okay so
53:30most common constricting agent is the neck of the sack okay
53:34clinical features here in case of uh strangulated hernia and the hernia won't be reducible and because
53:42of intestinal obstruction there will be signs and symptoms of intestinal obstruction like colic
53:46pain here and bilious vomiting non passage of feces inflators will be there that is absolute
53:55obstipation we can say other than that there will be history of sudden pain over hernia followed by
54:00generalized pain okay examination martaga this area will be tense and tender swelling will be tense
54:06and tender extremely tender this coloration agak shurva agath because ishemi agathirth necrosis
54:11other blackish or bluish reddish ithara okay color change agathirth overlying the hernia there
54:16will be no cough impulse cough impulse on the reno on coughing the swelling should increase
54:21small holes but it is an airline it has struck in one place so it started uh changing color
54:32and pain shurva that is called as strangulated hernia diagnosis again based on clinical examination only
54:38if there is colic pain and signs of intestinal obstruction and if there is all these features
54:42like tense tender swelling or discoloration of the skin and no cough impulse then we can say it is a type of
54:48strangulated hernia. Treatment in Marthiv since it is an emergency first
54:52intestinal obstruction in treatment like put IV fluids and resuscitate him well
54:58keep him NPO put nasogastric that is ryle's tube
55:03don't give anything through mouth and then IV fluids so IV antibiotics we have
55:06to prevent infection and then we will take him to surgery
55:09surgery in Marthiv we will put an incision on the most prominent part of
55:14the hernia and we will start dissecting once we reach the sac we will open the
55:18sac fundus and then whatever the fluids is there that is aspirated
55:22then we will examine the bowel this is the most important step in case of
55:25strangulated hernia open the bowel open one not the way if the bowel
55:30is viable and now if we started the surgery as early as possible and if the
55:34bowel is not yet undergone complete necrosis then the bowel is viable
55:39so we will put the bowel back we can retain the bowel
55:42okay and then closer surgery if the bowel is gangrenous already gangrene
55:47then we will have to excise that part of the bowel also
55:51after that if omentum is also non-viable then we will remove the omentum also if
55:55otherwise we will then secure the ligature and excise the non-viable part of the
55:59bow and omentum then close the surgery okay
56:03so here strangulated hernia the lead on the step for extra
56:06examining the bowel if bowel is viable we will reduce the bowel
56:09and just excise the sac if the bowel is already gangrenous we will have to
56:13excise the bowel also and then we will look for omentum if omentum is also non-viable then
56:19excise that non-viable part of the omentum also
56:23okay other than that use of synthetic mesh is contraindicated in case of strangulated hernia
56:28because increased risk of infection already gangrene
56:30there is no other treatment we will have to remove the mesh and then treat him with appropriate
56:45antibiotics so again it will become like a one more surgery so we will avoid putting mesh in case of if
56:50there is an increased risk of infection and then if mesh is needed then we will have to put absorbable
56:55mesh or bioprosthetic because infection rate is less in this case so non-biodegradable or synthetic mesh
57:01hakala is contraindicated okay so this brings us to the end of class of hernia one okay so in our
57:11case of accident
57:17the
57:17system
57:19the
57:20system
57:20the
57:25the
57:30the
57:33the
57:38the