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Good Morning

Good Morning. Prof C M K Reddy. A TRIBUTE TO A GREAT TEACHER AND SOCIAL WORKER - Prof RNR. Prof R Nanjunda Rao CME Program for Undergraduates. INGUINAL HERNIA. ACKNOWLEDGEMENTS. Prof R Nanjunda Rao & A S I – Chennai City Branch Prof D Nagarajan, President

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Good Morning

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  1. Good Morning Prof C M K Reddy

  2. A TRIBUTE TO A GREAT TEACHERAND SOCIAL WORKER - Prof RNR

  3. Prof R Nanjunda RaoCME Program forUndergraduates INGUINAL HERNIA

  4. ACKNOWLEDGEMENTS Prof R Nanjunda Rao & A S I – Chennai City Branch Prof D Nagarajan, President Dr G Chandrasekar, Secretary Dr Ravindran Kumeran, Treasurer

  5. BY Prof C M K REDDY DSc (Hon) FRCS (Glas) FRCS (Ire) Emeritus Professor, TN Dr MGR Med University General & Vascular Surgeon Apollo Hospitals & Halsted Surgical Clinic C H E N N A I

  6. President TN Medical Practitioners’ Association (TAMPA) Indian Chapter, Royal College of Surgeons in Ireland Core Committee for Hosp. Waste Mgmt. of Chennai

  7. Formerly Medical Director, Sri Jayendra Saraswathi Inst of Med Sciences Honorary Professor of Surgery Stanley Medical College President, Tamil Nadu Medical Council

  8. Receiving Dr B C Roy National Award as EminentMedical Teacher from the President of India (2000)

  9. Honorary Doctorate (DSc) conferred by the TN Dr MGR Medical University (2007)

  10. INGUINAL HERNIA HERNIA IS DEFINED AS AN ABNORMAL PROTRUSION OF A VISCUS THROUGH NORMAL OR ABNORMAL OPENING LINED BY A SAC IF A VISCUS FORMS A PART OF THE SAC, IT IS CALLED A SLIDING HERNIA IF THERE IS NO SAC, IT IS A PROLAPSE

  11. SLIDING HERNIA(Hernie-en-glissade) PROPLASE RECTUM & UTERUS

  12. INGUINAL HERNIAPROLAPSE OF BOWEL (TRAUMA)

  13. INGUINAL HERNIA GROIN IS A COLLOQUIAL TERM TO INCLUDE THE FOLLOWING REGIONS : INGUINAL FEMORAL ROOT OF SCROTUM or LABIA MAJORA WHILE DESCRIBING A MASS, THE PARTICULAR AREA TO BE SPECIFIED

  14. INGUINAL HERNIA ANATOMY OF INGUINAL CANAL IT IS AN OBLIQUE CANAL, 6cm LONG, EXTENDS FROM DEEP TO SUPERFICIAL RING PARALLEL TO THE MEDIAL HALF OF THE INGUINAL (POUPART) LIGAMENT

  15. INGUINAL ANATOMY

  16. INGUINAL HERNIA EXTERNAL (SUPERFICIAL) RING A TRIANGULAR OPENING IN THE EXTERNAL OBLIQUE APONEUROSIS 2cm ABOVE & MEDIAL TO PUBIC TUBERCLE IT DOESN’T NORMALLY ADMIT TIP OF A FINGER. FORCIBLE ATTEMPT IS RESISTED DUE TO DISCOMFORT

  17. INGUINAL HERNIA INTERNAL (DEEP) INGUINAL RING IT IS A ‘U’ SHAPED DEFECT IN THE TRANSVERSALIS FASCIA, 2cm ABOVE THE MIDPOINT OF INGUINAL LIGT (MIDWAY BETWEEN ANT SUP ILIAC SPINE & PUBIC TUBERCLE)

  18. INGUINAL HERNIA BOUNDARIES OF ING CANAL FLOOR : INGUINAL LIGT POST WALL : TRANSVERSALIS FASCIA & MEDIALLY CONJOINT TENDON ROOF : ARCHING FIBRES OF CONJOINT TENDON ANT WALL : EXT OBLIQ APONEUROSIS & INT OBLIQ MUSCLE LATERALLY

  19. INGUINAL HERNIA HESSELBACH’S TRIANGLE WEAK AREA IN POSTERIOR WALL THROUGH WHICH DIR HERNIA PRESENTS BOUNDARIES LATERAL : INF EPIGASTRIC VESSELS RAISING LATERAL UMBILICAL LIGT (FOLD) MEDIAL : LATERAL BORDER OF RECTUS INFERIOR : MEDIAL THIRD OF ING LIGT FLOOR BISECTED BY MEDIAL UMB LIGT, FORMED BY OBLITERATED UMB ARTERY

  20. INGUINAL HERNIA EXTERNAL DISSECTION HESSELBACH’S TRIANGLE Laparoscopic view from inside

  21. INGUINAL HERNIA • AS WE GO FROM OUTSIDE • SKIN • TWO LAYERS OF SUPERFICIAL FASCIA SUPERFICIAL (FATTY) : CAMPER’S FASCIA DEEP (MEMBRANOUS) : SCARPA’S FASCIA A THIN AREOLAR LAYER IMMEDIATELY OVER THE EXT OBLIQ APONEUROSIS : FASCIA INNOMINATUM (OF GALLAUDET) EXT OBLIQ APONEUROSIS & EXT RING INGUINAL CANAL & SPERMATIC CORD

  22. INGUINAL HERNIALaparoscopic Anatomy INDIRECT INFERIOR EPIGAST VESSELS DIRECT FEMORAL

  23. INGUINAL HERNIAMyopectineal Orifice of Fruchaud Boundaries Medial : Rectus muscle Lateral : Iliopsoas Superior : Conjoint tendon Inferior : Pectin pubis

  24. INGUINAL HERNIA INGUINAL HERNIA MAY BE DIRECT – THRO’ THE H’ TRIANGLE INDIRECT – THRO’ THE INT RING SADDLE or PANTALOON (ROMBERG) WITH BOTH COMPONENTS SADDLED BY INF EPIGAST VESSELS • ALL OF THEM ULTIMATELY COME OUT THRO’ THE EXTERNAL RING

  25. INGUINAL HERNIA DIRECT TYPE ACQUIRED SAC LIES SEPARATE FROM AND POSTERIOMEDIAL TO THE CORD STRANGULATION IS RARE SINCE THE NECK OF THE SAC IS WIDE IT IS GLOBULAR AND DOESN’T READILY DESCEND INTO SCROTUM

  26. INGUINAL HERNIA INDIRECT TYPE CONSIDERED TO BE CONGENITAL DUE TO IMPERFECT OBLITERATION OF PROCESSUS VAGINALIS COMES OUT THRO’ BOTH RINGS RETORT SHAPED DESCENDS READILY INTO SCROTUM DUE TO THE ‘READY MADE’ SAC SAC LIES WITH IN AND ANTEROSUPERIOR TO THE CORD STRUCTURES

  27. Diff between Ind. & Dir. Ing Hernia

  28. INGUINAL HERNIA HOW DO WE SAY IF AN IRREDUCIBLE HERNIA IS DIRECT OR INDIRECT ? SHAPE WHETHER DESCENDED INTO SCROTUM THE FACT IT IS IRREDUCIBLE, IS IN FAVOR OF INDIRECT HERNIA BUT IT IS ONLY OF ACADEMIC INTEREST, SINCE EARLY SURGERY IS NECESSARY & IT COULD BE DECIDED AT THAT TIME

  29. INGUINAL HERNIA TOPOGRAPHIC TYPES BUBONOCELE (Boubon : Groin) FUNICULAR TYPE (UPTO THE TOP OF TESTIS) COMPLETE or CONGENITAL ENTIRE PROCESSUS IS PATENT TESTIS BECOMES A CONTENT OF THE HERNIAL SAC

  30. INGUINAL HERNIABubonocele Funicular Complete

  31. INGUINAL HERNIABILATERAL BUBONOCELES

  32. INGUINAL HERNIA GIBBON’S HERNIA LARGE INGUINAL HERNIA PRODUCING SECONDARY HYDROCELE, DUE TO COMPRESSION OF VENOUS AND LYMPHATIC CHANNELS

  33. INGUINAL HERNIA INTERPARIETAL or INTERSTITIAL TYPE DOWN’S or PRUNE BELLY SYND UNDESCENDED TESTIS SAC DISSECTS INTO THE LAYERS OF ABDOMINAL WALL PREPERITONEAL INTERPARIETAL or INTERMUSCULAR (COMMONEST) EXTRAPARIETAL or INGUINO-SUPERFICIAL

  34. LARGE RIGHT INGUINAL INTERSTITIAL HERNIA

  35. INGUINAL HERNIA RIGHT INGUINAL INTERSTITIAL HERNIA

  36. INGUINAL HERNIA CLASSIFICATION REDUCIBLE (UNCOMPLICATED) IRREDUCIBLE OBSTRUCTED STRANGULATED INFLAMED

  37. INGUINAL HERNIA COMPRESSIBLE Vs REDUCIBLE COMPRESSIBLE SWELLING REFILLS IMMEDIATELY (SPONTANEOUSLY) AS SOON AS THE PRESSURE IS RELEASED Eg : HEMANGIOMA, LYMPHANGIOMA, ANEURYSM, MENINGOCELE ETC REDUCIBLE SWELLING MAY REQUIRE SOME MANEUVERING TO BRING IT OUT AFTER REDUCTION

  38. INGUINAL HERNIA PREDISPOSING / PRECIPITATING FACTORS CHRONIC COUGH / COPD (SMOKING) CHRONIC CONSTIPTION OBSTRUCTIVE UROPATHY BPH or STRICTURE URETHRA STRENUOUS PHYSICAL ACTIVITY PREVIOUS SURGERY

  39. INGUINAL HERNIA HISTORY OF PREVIOUS SURGERY IN LINE WITH ILIOHYPOGASTRIC & ILIOINGUINAL (L-1) NERVES APPENDECTOMY THRO’ McBURNEY’S DRAINAGE OF PSOAS ABSCESS LUMBAR SYMPATHECTOMY URETERIC or RENAL SURGERY EXTENDED PFANNENSTEIL INCN

  40. INGUINAL HERNIA SYMPTOMS ASYMPTOMATIC, MAY BE DISCOVERED DURING ROUTINE EXAM A MASS APPEARING / DISAPPEARING VAGUE LOCAL DISCOMFORT IRREDUCIBLE or PAINFUL LUMP FEATURES OF INTEST OBSTRUCTION FEATURES OF SEPTICEMIA (LATE CASES OF STRANGULATION)

  41. INGUINAL HERNIA SIGNS SHOULD BE EXAMINED BOTH IN STANDING & SUPINE POSITIONS TWO CLASSICAL SIGNS OF UNCOMPLICATED HERNIA : EXPANSILE COUGH IMPULSE & REDUCIBILITY

  42. INGUINAL HERNIA WHY SHOULD IT BE EXAMINED IN ERECT POSITION ? IN SUPINE POSITION, NORMAL PROTECTIVE MECHANISMS COME TO PLAY BEFORE THE VISCERA ENTER THE DEEP RING

  43. INGUINAL HERNIA SIGNS ….. POSITION SCROTAL or INGUINOSCROTAL COUGH IMPULSE (EXPANSILE) CONSISTENCY (DOUGHY or ELASTIC) REDUCIBILITY OMENTOCELE : INITIALLY EASY ENTEROCELE : INITIALLY DIFFICULT & REDUCES WITH A GURGLE

  44. INGUINAL HERNIABUBONOCELE, LEFT

  45. INGUINAL HERNIALARGE LEFT INGUINAL HERNIA IN A CHILD

  46. INGUINAL HERNIA SIGNS …. INTERNAL RING OCCLUSION TEST 2cm ABOVE THE MIDPOINT OF ING LIGT DON’T SAY POSITIVE or NEGATIVE THIS TEST IS NOT POSSIBLE IF THE HERNIA IS IRREDUCIBLE

  47. INGUINAL HERNIA SIGNS …. EXTERNAL RING INVAGINATION TEST NORMLLY PAINFUL SIZE OF EXTERNAL RING (IMPORTANT) STRENGTH OF POSTERIOR WALL IMPULSE TOUCHING THE TIP or PULP OF THE FINGER (UNRELIABLE)

  48. INGUINAL HERNIAEXT RING INVAGINATION TESTNOTE : PATIENT EXPERIENCS DISCOMFORT

  49. INGUINAL HERNIA EXT RING INVAGINATION IS NOT POSSIBLE IN WOMEN ASSOCIATED WITH LARGE HYDROCELE or FILARIAL SCROTUM IRREDUCIBLE HERNIA

  50. INGUINAL HERNIA SIGNS …. THREE FINGER TEST (ZIEMAN’S) DIFFICULT TO ELICIT NEVER DONE BY SENIORS BETTER TO EXAMINE INDIVIDUAL AREAS FOR COUGH IMPULSE

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