	In children - measles, whooping cough
	In adults - smoking, chr. bronchitis, emphysema
	hard physical labor, IA malignancy
	Stricture urethra, chr. constipation

2) Increased Intra Abdominal Pressure due to excess content stretching muscles

	Ascites
	Pregnancy

3) Theories for hernia formation - (pathogenesis)

Complaints

	dull dragging pain referred to the testis - increases on work
	If obstructed may have constipation, vomiting, pain
	If strangulated may have severe pain, shock, collapse.

Clinical Findings

	piriform swelling - in the inguinal canal
	bubonocele does not come into scrotum
	Cough impulse + Reducibility +
	Neck of the hernia is supero-medial to pubic tubercle

Special tests -

	Deep ring occlusion - hernia does not appear
	Invagination - impulse at tip of finger
	post canal wall intact.

Types :

1. 1] Reducible

2. 2]Irreducible ( complication of (1))

3. 3]Obstructed -------"---------

4. 4]Strangulated ------"----------

5. 5]Inflamed ( the viscus in the hernia is inflamed - e.g. appendicitis, salpingitis)

Differential Diagnosis:

Males

1. Femoral hernia

2. Direct inguinal

3. Vaginal hydrocele

4. encysted hydrocele of cord

5. Undescended testis

6. Spermatocele

7. Varicocele

8. Diffuse lipoma of cord.

Females

1. Femoral hernia

2. Hydrocele of canal of Nuck

Treatment

[1] Principles of treatment :

1. Restore the disrupted anatomy

2. Repair using fascia / aponeurosis NOT muscle

3. NO tension

4. Suture material used should hold until natural support is formed over it. ( i.e. monofilament nylon or polyethylene)

[2] Management

*** 4 'R's of hernia management - described by DEVLIN

1. Resuscitation - in case of strangulated hernia with gangrene with shock or with intestinal obstruction.

2. Reduction of hernia - includes taxis, & reduction under anesthesia.

3. Repair - of the defect - may be herniorrhaphy or hernioplasty.

Strangulated hernia -

	treat as emergency
	treat shock if any. Start IV antibiotics
	Incision over the most prominent part of swelling - sac carefully identified & dissected out. Sac opened.
	Aspirate all fluid ( highly infectious)
	Resect any unviable intestine or omentum
	EO aponeurosis & external ring divided. Sac opened throughout the length upto deep ring & a little inside.
	Viable contents reduced. Definite repair carried out - any prosthetic repair is contra-indicated.

- Non - Operative approach - in elderly, unfit / unwilling for surgery.

- Use of truss is advised - must be applied with hernia reduced. Must prevent reappearance of the hernia on straining.

- Surgery - treatment modality of choice.

1 - Herniotomy - may be sufficient in young, muscular individuals and in children.

2 - Herniorrhaphy - in adults with good muscular tone.

3 - Hernioplasty - in elderly with poor muscular tone.

C/I in strangulated hernia - may get infected leading to wound sinus.

Herniorrhaphy -

o Dr. Desarda's repair: Giving physiologically dynamic and strong posterior wall should be the principle of any type of inguinal hernia repair to give 100% success rate. Undetached strip of the external oblique aponeurosis is sutured between the muscle arch and the inguinal ligament to give a strong posterior wall which is kept physiologically dynamic by the additional muscle strength provided by the external oblique muscle to the weakened muscle arch.

	Lytle's repair (syn : Marcie's repair)- narrowing of the deep ring by suturing medial wall - Tight enough so that cord & little finger just fit in.
	Bassini's repair - Suturing of conjoint tendon to the incurved part of inguinal ligament - medial most stitch through the pubic periosteum - sutures taken with non-absorbable sutures - originally done by Bassini using black silk - now monofilament nylon used. - Chances of femoral hernia increased.
	Shouldice repair - Double breasting of transversalis fascia - stainless steel wire used for darning.
	Ogilvie's repair - plication of transversalis fascia
	McVay's repair / Cooper's repair - Conjoint tendon sutured to the Cooper's ligament - also prevents Femoral hernia formation - closes off the Fruchaud's orifice.
	Condon's repair - Conjoint tendon sutured to the ilio-pubic tract.
	Halsted's repair - repaired at 3 levels (6 layer repair) - Bassini's + Shouldice + double breasting of external oblique - cord becomes subcutaneous
	NYHUS / Cheatle - Henry repair - pre-peritoneal repair - may be combined with prostatectomy. Used for large double hernias (direct + indirect), bilateral hernias, & Recurrent hernias.
	Inguinoclysis - only in elderly men with recurrent / very large hernias - obliteration of the inguinal canal with bilateral orchidectomy.
	Pantaloon hernia - Treated by 1^st converting the hernia into one giant indirect hernia & then treating it as indirect hernia

Complications :

1] Of the hernia -

	Irreducibility
	Obstruction
	Strangulation
	Toxic shock
	Peritonitis

2] Of the surgery -

	Sepsis ( most common ) - may lead to formation of incisional hernia.
	Hematoma
	2ndary hydrocele - damage to lymphatics
	Testicular ischemia & atrophy
	Division of the vas deferens - especially in children
	Sinus formation - use of non-absorbable sutures
	Nerve entrapment - ilioinguinal N.
	Lymphocele - common after operations for femoral hernia
	Recurrence of hernia.

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