...

INTRODUCTION
1

INTRODUCTION
Inguinal hernias are one of the most common problems
encountered by the surgeon, accounting for about 10-12% of all
operations.
An inguinal hernia can be defined as protrusion of a part or whole
abdominal viscous into the inguinal canal either through the deep ring or
through hasselbach's triangle.
It forms nearly 75% of all external abdominal wall hernias.
Different techniques and different materials used by different
surgeons conclude the same problem of lack of enough satisfaction due
to the same problem of recurrence.
Throughout the ages inguinal hernia has been treated in all sorts of
ways ranging from exorcism, to trusses to surgery.
The gold standard for any hernia surgery is lowest recurrence rate.
The ideal hernia surgery should restore form and function to normal and
return a temporarily incapacitated human being back to full health and
earning capacity.
In our hospital, various methods of repair are used, among which
modified Bassini's is used frequently. Other methods used are the
Shouldice repair, Mcvay's cooper's ligament repair, Abrahamson's nylon
dam, Lichtenstein's tension free hemioplasty and stoppa's preperitoneal
hemioplasty.
With the introduction of laparoscopy there are few inguinal hernias
repaired by preperitoneal patch repair.

The method studied in this study is a new method used for repair of
uncomplicated all types of inguinal hernia. In this method sutureless
hemioplasty done, after posterior wall repair done by tension free sutures.

...AIMS OF STUDY
4

AIMS OF STUDY
To study the efficacy of the sutureless hemioplasty in a case of

inguinal hernia repair procedure.

To study the duration of the surgery in sutureless hemioplasty.
To

study

the

complications

associated

intraoperatively and post operative periods.

with

this

procedure

...REVIEW OF
LITERATURE
6

REVIEW OF LITERATURE
In Latin, hernia is a rupture or tear. In Greek, hernia is a budd,
offshoot, or bulge. The earliest records of inguinal hernia dates back to
approximately 1500BC. The ancient greeks were all aware of inguinal
hernias. Trusses and bandages were generally used to control the
herniation.
In first century A.D., Celsus described operation for inguinal
hernia. Through an incision in the neck of the stem, the hernial sac was
dissected off the spermatic cord, and transected at the external inguinal
ring. The testis usually was excised as well. The incision was generally
left open. He dealt extensively with anatomy, etiology and the treatment
of hernias. He believed that hernia occurred due to stretching and rupture
of peritoneum and thus the efforts were directed at suturing the sac.
In 700 AD, paul of Aegina recommended a mass ligature of the sac
and cord at external ring with excision of sac, cord, and testis distal to the
ligature.
In 1963 AD, Guy de chauliac differentiated between inguinal and
femoral hernia and described the technique of reduction for strangulation.
In 1556 AD, Franco illustrated the use of a grooved director to cut the
strangulating neck of the hernia while avoiding the bowel.
In 1559 AD, Casper Stromayr differentiated direct from indirect
hernia and advised that the testicle need not to be removed during the
operation for the former.
1768 to 1841 AD, Astley Cooper described the superior pubic
ligament so named after him and transversalis fascia and associated it
with formation of hernias.
7

In 1865 AD, Joseph Lister introduced his method of antisepsis by

carbolic spray and dawn of modern surgery began.
In 1871 AD, Marcy (An American surgeon and pupil of lister) was
first to introduce antiseptic techniques in the repair of hernia. He was also
the first to recognize the importance of the transversalis fascia and of
closing the internal ring. He used carbonized catgut to suture the ring.
In 1881 AD, Lucas Championnere reported first case in which the
aponeurosis of the external oblique was slit to reveal the canal, which
allowed dissection and ligation of the sac at the internal ring under direct
vision.
The greatest contribution to hernia surgery was given by Italian
surgeon Edoardo Bassini. His clear insight into the anatomy and
physiology of inguinal region enabled him to dissect and reconstruct the
inguinal canal which was opened widely by splitting the aponeurosis of
the external oblique muscle. He next opened fascia transversalis. He
sutured the internal oblique & transversalis abdominis muscle and upper
leaf of the transversalis fascia in one layer to lower leaf of fascia
transversalis and the inguinal ligament. The aponeurosis of external
oblique was resutured in front of cord.
In 1984 he published a series of 206 repairs with a recurrence rate
of 4% after 5 years of follow up. This gave him a title of "father of
modern herniorrhaphy".
1898 AD, George Lotheissen first reported the technique of
suturing the conjoined tendon to the inguinal ligament (cooper's
ligament) instead of inguinal ligament. This was especially recommended
for strangulated femoral hernia as this repair has added advantage of
8

repairing the femoral ring as well as the inguinal effect. But this method
was not popularized until 1940.
In 1940 Chester MacVay stated that since the fascia transversalis
was not attached to the inguinal ligament and since they were in two
different planes there was no anatomic reason for suturing them together.
In 1953 AD, Shouldice technique of multiple layered closures by
stainless steel wire was introduced. In last years this is probably the most
successful of the "pure tissue" method suturing only the local tissues
without the addition of any prosthetic material which consists of suturing
of transversalis fascia and conjoint tendon to the inguinal ligament in
four layers and then suturing of external oblique aponeurosis by double
breasting it anterior to the cord. The recurrence rate was 1 % with follow
up of 35 yrs.
Myers and Shearburn had confirmed these results in their separate
study.
In 1984 AD, The Berliner introduced new technique for repair
which was less complex, anatomically correct and physiologically sound.
Repair consists of two layered overlap repair of posterior wall of the
inguinal canal (instead of four layer in shouldice repair) and the external
oblique aponeurosis was sutured in the front of cord (instead of double
breasting as in shouldice repair)
In 1986 AD, Lichtenstein sutured lower edge of transversalis
abdominis aponeurosis with fascia transversalis to inguinal ligament. The
tension on this suture line was relieved by relaxing incision on anterior
rectus sheath. He reported recurrence rate of 0.7%. The external oblique
aponeurosis was sutured behind the cord.
9

In 1988 AD, The Wilkinson described the repair in which fascia

transversalis was not slitted and conjoined tendon sutured with nonabsorbable sutures. Now inferior leaf of external oblique muscle behind
the cord and superior leaf of it sutured over inferior leaf. So that the cord
had a V shaped course. He reported a recurrence rate of 1.2%. The
Patchers:
In 1900-1909, Witzel, Goepel(Germany) and Bartlett(US) and
Macgavin (Britain) used silver-wire filigree sheets shaped to fit the size
and contours of gap.
In 1940, Burke introduced Tantalum metal sheets. In 1948,
Throckmorton introduced Tantalum gauze. In 1948, Lam, Koontz &
Jefferson reported some. However metal fatigue caused fragmentation of
this material & followed by recurrence of hernia.
In 1945, Mair used sheets of skin, sheets of fascia as free grafts
from thigh, fascia lata, and abdominal wall. Results were highly
disappointing.
In 1958, usher used woven or knitted mesh of polyamide and
polypropylene. It is cheap, universally available, easily cut to required
shape, flexible and indestructible in human tissues, pleasant to handle,
inert and elicits almost no tissue reaction.
In 1957, Harrison used PTFE for reinforcement.
In 1987, Stoppa described his technique of great prosthetic
reinforcement of visceral sac (GPRVS) where he placed a large prolene
mesh in the preperitoneal plane through midline infra

10

umbilical incision so as to reinforce the whole of the lower anterior and

lateral abdominal wall indicated for those hernias that present a high risk
of recurrence such as recurring hernias, bilateral groin hernias, groin
hernias associated with low incision hernias, pantaloon hernia, large
hernia(recurrent) in which inguinal and cooper's ligament are destroyed,
prevascular hernias, those with collagen diseases such as Ehlers-Danlos
and Marfan Syndome & high risk factors such as old age, obesity or
cirrhosis.
In 1993, Lichtenstein reported simple and tension free mesh
hernioplasty where he used a polypropylene mesh on posterior wall of
inguinal canal without closure of any tissue defect with only 0.3%
recurrences.
Hernia repair is still a controversial subject. Inspite of the superb
results attained at specialized centres devoted to hernia surgery like those
mentioned above, the results of today's hernia repair is far from
satisfactory as indicated by a population based survey which shows
recurrence rates sometimes as high as 10-30%.
Thus it is the responsibility of the surgeon today to adopt a method
of repair which is simple and applicable to any type of hernia and which
gives minimal recurrence.

11

LAPAROSCOPIC REPAIR FOR INGUINAL HERNIA:

In 1977, Ger introduced laparoscopic transperitoneal closure of the
internal orifice of groin hernias by a series of metal clips. Since then
several methods have evolved, but routine clinical application of the
technique began only in 1990.
The most popular method today is the introduction of the
laparoscope and instruments through several ports in the abdominal wall
after induction of pneumoperitoneum under general anaesthesia.
Easter reported laparoscopic repair of inguinal hernia in the
pediatric age group.
The ADVANTAGES of laparoscopic herniorrhaphy are;
-

Bilateral repair can be done at the same operation.

Clinically unsuspected contralateral hernias can be identified and
repaired.

Post operative recovery and return to normal activities is rapid.

DISADVANTAGES:
- Needs general anaesthesia.
- Violation of the abdominal cavity, with future risk of adhesions as
well as new hernias at the site of introduction of the ports.
COMPLICATIONS of laproscopic Hernia :

12

Small and large bowel perforations, bladder lacerations, adhesions, bowel

obstructions, mesh erosion into the bladder, transient testicular pain,
palpable mesh, mesh migration into the scrotum, scrotal hydrocele and
pelvic osteitis.

...ANATOMY OF
INGUINAL REGION
13

ANATOMY OF INGUINAL REGION

Inguinal canal:
This is an oblique passage in the lower part of the anterior
abdominal wall, situated just above the medial half of the inguinal
ligament.
It is about 4 cm (1.5 inches) long, and is directed downwards,
forwards and medially. The inguinal canal extends from the deep inguinal
ring to the superficial inguinal ring.
The deep Inguinal ring:
The deep inguinal ring is an oval opening in the fascia
transversalis, situated 1.2 cm above the midinguinal point, and
immediately lateral to the stem of the inferior epigastric artery.
The superficial inguinal ring:
The superficial inguinal ring is a triangular gap in the external
oblique aponeurosis. It is situated 1 cm above and lateral to pubic
tubercle. It is shaped like an obtuse angled triangle. The base of the
triangle is formed by the pubic crest. The two sides of the triangle form
the lateral or lower and the medial or upper margins of the opening.
It is 2.5 cm long and 1.2 cm broad at base. These margins are
referred to as crura. At and beyond the apex of the triangle, the two crura
are united by intercrural fibers.

14

Boundaries of inguinal canal: Anterior wall:

It is formed by the following:
A. In its whole extent:

B.

1.

Skin.

2.

Superficial fascia.

3.

External oblique aponeurosis.

In its lateral one-third:

The fleshy fibers of the internal oblique muscle.

Posterior wall:
It is formed by the following:
A.

B.

In its whole extent:

1.

The fascia transversalis.

2.

The extra peritoneal tissue.

3.

the parietal peritoneum.

In its medial two-thirds:

1.

The conjoint tendon.

2. At its medical end by the reflected part of the inguinal ligament.

3. Over its lateral one-third by the interfoveolar ligament.

15

Roof:
It is formed by the arched fibres of the internal oblique and
Transverses abdominis muscles.
Floor:
It is formed by the grooved upper surface or the inguinal ligament;
and at the medial end by the lacunar ligament. Structures passing
through the canal:
1. The spermatic cord in males, or the round ligament of the uterus in

females, enters the inguinal canal through the deep inguinal ring and
passes out the superficial inguinal ring.
2. The ilioinguinal nerve enters the canal through the interval between

the external and internal oblique muscles and passes out through the
superficial inguinal ring.
The pectineal ligament (or ligament of cooper) is an extension
from the posterior part of the base of the lacunar ligament. It is attached
to pectin pubis. It may be regarded as a thickening in the upper part of
the pectineal fascia. It continues on the superior pubic ramus along the
pectineal line.
Conjoint tendon:
It is formed by the lower most fibres of transversus abdominis and
rarely internal oblique, taking origin from the inguinal ligament lateral to
deep ring and then arching over it to be inserted into lateral part of lower
rectus sheath.

16

Trans versalis fascia:

It is the part of investing layer of endo-abdominal fascia on the
posterior aspect of transversus muscle in the inguinal region. It is slightly
thicker in this region and is adherent to the transversus abdominis
aponeurosis.
It forms the posterior wall of inguinal canal in the hesselbach's
triangle.
The Hesselbach's triangle:
It is a triangular area bounded superiorly by conjoint tendon,
laterally by inferior epigastric vessels and inferiorly by inguinal ligament.
It is the region through which most of direct hernias occur.
Physiology of inguinal canal:
The presence of the inguinal canal is a cause of weakness in the
lower part of the anterior abdominal wall. This weakness is compensated
by the following factors.
1. Obliquity of the inguinal canal: the two inguinal rings do not lie

opposite each other. Therefore, when the intra-abdominal pressure

rises the anterior and posterior walls of the canal are approximated,
thus obliterating the passage. This is known as the flap valve
mechanism.
2. The superficial inguinal ring is guarded from behind by the conjoint

tendon and by the reflected part of the inguinal ligament.

3. The deep inguinal ring is guarded from the front by the fleshy fibres

of the internal oblique.

4. Shutter mechanism of the internal oblique: this muscle has a tripple

relation to the inguinal canal. It forms the anterior wall, the roof, and
17

the posterior wall of the canal. When it contracts the roof is

approximated to the floor, like a shutter. The arching fibres of the
transversus also take part in the shutter mechanism.
5. Contraction of the cremaster helps the spermatic cord to plug the

superficial inguinal ring (ball valve mechanism).

6. Contraction of the external oblique results in approximation of the two

crura of the superficial inguinal ring (slit valve mechanism). The

integrity of the superficial inguinal ring is greatly increased by the
intercrural fibres.
7. Hormones may play a role in maintaining the tone of the inguinal

musculature.
Whenever there is a rise in intra-abdominal pressure as in
coughing, sneezing, lifting heavy weights all these mechanisms come
into play, so that inguinal canal is obliterated, its openings are closed, and
herniation of abdominal viscera is prevented.
INGUINAL HERNIA
It is protrusion of a viscus from the peritoneal cavity through a weak part
of posterior wall of inguinal canal or widening of deep ring.
Inguinal hernia mainly classified in to two types.
(A). Anatomical Type(B). Clinical Type

18

(A) ANATOMICAL TYPE:

Three types of classification can be made under this heading
1)

According to the extent- it can be either

a)

Bubonocele-when the hernia does not come out of the

superficial inguinal ring.

b)

An incomplete hernia-when it comes out superficial inguinal

ring but fails to reach the bottom of scrotum.

c)

2)

A complete hernia-when it reaches the bottom of scrotum.

According to the content of hernia-can be either

a)

An enterocele-when it contains the intenstine(enteron) It has

elastic consistency, peristalsis may be seen on swelling,
reduction is difficult in beginning and reduced with gurgle
sound.

b)

An

epiplocele

or

omentocele-when

it

contain

omentum(epiploon). It feels doughy and granular ,reduced

easily on beginning but difficult towards end.
c)

A cystocele-when it contains the urinary bladder. Patients

gives history that hernia gets enlarged before micturation
and reduced as urine pass. 3)According to its site of exit-can
be either
a) An oblique(Indirect) hernia-when hernia comes out
through the deep inguinal ring.
b) A direct hernia-when hernia comes out through
Hesselbach's triangle of posterior wall of inguinal
canal.

INDIRECT HERNIA:
19

It comprises more than 80% cases of inguinal hernia

Almost all hernia in children and women are of this type.

It is often complete and descends obliquely downwards and inwards.

Mostly for reduction of hernia manipulation is required and swelling

reappears after any straining affords done like cough.

Mainly two types are seen

Congenital hernia
Acquired hernia
In Congenital Hernia the funicular process of peritoneum remains

patent which normally obliterated. So which increase in abdominal

pressure contents comes out through patent peritoneal process. Thus
congenital hernia reaches the bottom of scrotum very quickly.
In Acquired Hernia as name suggests if does not protrude into a
pre formed sac. Acquired hernia progresses gradually so it does not
become complete at once. DIRECT HERNIA:
It is more common above the age of 40. It frequently incomplete.
The hernia comes out as soon as the patients stands and disappears
immediately when lies down. Direct hernia does not comes out through
the deep inguinal ring but a little medial to ring. It becomes rarely
strangulated as the neck of sac is wide. (B) CLINICAL TYPE:

20

May be of five types.

Reducible hernia-normally uncomplicated hernia is reducible. That
means its contents can be returned into the abdominal cavity, but the
sac remains in its position

Irreducible hernia-in this hernia the contents can't reduce to

abdomen. It is due to i) Adhesion of its contents to each others, ii )
Adhesions of it contents with sac. iii ) Adhesions of one part of sac to
other part, iv ) Sliding hernia, v ) Very large scrotal hernia.

Obstructed or Incarcerated hernia(irreducibility + intestinal

obstruction)- Intestinal obstruction occurs due to occulusion of lumen
of bowel. There is no interference with blood supply with blood
supply of intestine.

Strangulated hernia(irreducibility + obstruction + arrest of blood

supply)- hernia is irreducible without any impulse on coughing. It is
extremely tense and tender on examination.

Inflammed hernia - this hernia may occur when its contents such as
an appendix, a salpinx or Meckel's diverticulum becomes inflamed.
Swelling becomes painful, tender and swollen. Only differentiating
feature from strangulated hernia is that this hernia is not tense and no
intestinal obstruction.

RARE VARIETIES OF HERNIA:

Hernia-en-glissade or sliding herniaIn this type a piece of extraperitoneal bowel usually the caecum on
right side or pelvic colon on left side or urinary bladder on either
side slides down. Usually occur in older men.

21

Richter' HerniaOnly a portion of circumference of bowel become strangulated.

Intestinal obstruction may not present until and unless half of the
circumference of bowel is involved.

Litter's HerniaIt is hernia which contains Meckel's diverticulum.

Maydl's

Hernia(

Hernia-en-W)

or

Retrograde

Strangulation- In this condition two loops of bowel remains in the

sac and connecting loop remain within abdomen and strangulated.
The loops of hernia look like a W.
TREATMENT OF INGUINAL HERNIA:
A) Conservative treatment-mainly done by TRUSS-acts by pressing
anterior wall against posterior wall of inguinal canal. By repeated friction
it causes adhesion of sac with wall of canal. Mainly 'Rat-tailed' or 'Adderheaded' truss used.
Indication:- 1)
2)

In infants often helps in spontaneous cure.

In old patients when surgery is not possible due to
associated general systemic diseases.

3)

Those who refused operative treatment

Disadvantage:- 1) Improper use can lead to obstruction or strangulation

hernia.
2)

Improper cleanliness causes unhealthy skin.

3)

Prolong use can causes attenuation of

musculature.

22

B)

Operative Treatment:- In adults mainly done by

1) Herniorraphy which consist of herniotomy (excision of sac)
with reconstruction of the posterior wall of inguinal canal.
2)Hernioplasty which consist of herniotomy with reinforcement
of posterior wall of inguinal canal by filling defect of posterior
wall by some prosthetic material.

DIFFEERENT

OPERATIVE

METHODS

FOR

INGUINAL

HERNIA REPAIR:-1) Bassini's Repair:

Mainly done in adult patients with weak abdominal musculature.
It is done by reconstruction of the posterior wall of inguinal canal by
approximating the conjoint muscle and tendon to recurved edge of the
inguinal ligament with non absorbable suture like prolene.
Advantage:
1) Widely used method in every setup.
2) Easy and fast method for hernia repair.
3) Less tissue dissection is required.

Disadvantage:
1)

Improper suture taken over posterior wall near deep ring can cause
strangulation of cord structures.

2)

Tension suture over posterior wall can cause cutting of muscle of

ligaments from their tissue will increase rate of recurrence. Various
modification done in Bassini's methods are :

a)

23

Repair of the stretched internal inguinal ring on its medial side if it is too
wide.
b)
Plication of fascia transversalis done in direct hernia.
c)

Halstead modification - here spermatic cord is exteriorized by

suturing external oblique apponurosis behind it.

d)

Willys Adrew modification- hear the spermatic cord is sandwiched

between two layers of external oblique.

2)

Shouldice Operation:
It is basically a multilayered Bassini operation. The Shouldice

hospital uses only 34 or 32 gauze stainless steel wire continuous suture.

Repair of the fascia transversalis and tightening of the internal ring
is basis of the tissue type of repair. Advantage:
1)

Multilayered closure gives good strength to the posterior wall of

inguinal canal.

2)

Recurrence rate is almost <1% noted.

Disadvantage:
1)

The method is complicated and required a great deal of dissection.

2)

Repair not possible in elderly patients with large direct hernia and
patient with recurrent hernia because of transversalis fascia become
weak and ragged.

3)

During operation chances of injury to deep vessels occurs due to

extensive dissection.

3)

The Abrahamson Nylon Darn Repair:

The principle of the nylon darn operation for the repair of inguinal

hernia is to reinforce the weakened or torn posterior wall of inguinal

canal.

24

Simple lattice work of mono filament nylon suture under no

tension, on which is laid a buttress of fibrous tissue, without the normal
tissues being torn or necrosed.
Advantages:
1) Less tissue dissection with reinforcement of
2) This method can be used in recurrent hernia or in any age group.
Disadvantage:
1)

This method is complicated and fine lattice darn work required

experience.

2)

Chance of post operative wound infection is more due to use of

many nylon suture material.

4)

The Lichtenstein Repair:

A knitted polypropylene mesh is recommended for the

reinforcement of all direct and recurrent hernias. A sheet of mesh screen

is laid on to the new posterior wall and secured by interrupted
nonabsorbable sutures to the lacunar ligament and inguinal ligament. The
sheet is split at deep ring and brought around the cord and fixed with one
suture to posterior wall.
Advantage:
1) This method done in any kind of direct hernia or recurrent hernia.
2) This method is easy and widely used in every setup.

25

Disadvantage:
1) Use of inadequate size of mesh can lead to recurrence of hernia.
2) Post operative wound infection and wound gap are commonly
encounter.
5) The Rives Prosthetic Mesh Repair:
Rives recommends placing the sheet of polypropylene mesh in
deeper plane ie. Deep to the transversalis fascia between it and the
peritoneum.
In this procedure slitting of transversalis fascia done and a large
mesh keep beneath fascia and fixed by a series of intrupted suture along
cooper ligament and fascia iliaca.

26

...MATERIAL &
METHODS
27

MATERIAL AND METHODS

This study presents observations made on 40 cases of inguinal
hernia operated in S.S.G. Hospital & Medical College Baroda, by
sutureless hernioplasty method during the period between Jan, 2006 to
Dec, 2006.
Results were compared with the group of 40 cases of inguinal
hernia repaired by sutured hernoiplasty during the same period.
Selection of cases:
Cases for sutureless hernioplasty method were selected from the
cases admitted for inguinal hernia repair at surgery-A unit of S.S.G.
Hospital and cases for comparison were selected from cases of inguinal
hernia admitted in other surgery units of S.S.G. Hospital.
Criteria:
All cases of inguinal hernia which required some form of posterior
inguinal wall repair with reinforcement of the posterior wall were
included in the study for repairing them using the sutureless hernioplasty
method.
Cases of inguinal hernia which were excluded were
1. Congenital hernia and inguinal hernia in patients upto 16 yrs.
2. Recurrent hernias-due to previous surgery cause fibrosis and so proper
plane for mesh placement not available. Similar selection criteria were
applied for selection of inguinal hernia cases repaired by other methods.

28

Pre-operative evaluation:
All patients admitted for inguinal hernias were evaluated clinically
as presented in proforma.
All patients admitted to ward and preoperatively routine blood
examination like Hb, TC, DC, ESR, RBS, Bid Urea and Urine
examination done. Two of patients in our study having chronic cough had
investigated in form of chest x-ray while 4 of our patients having
obstructive urinary symptoms had done ultra sound for prostate
evaluation while 8 of patients having hypertension and IHD had done
ECG and after evaluation patient had posted for surgery. Post operative
regular follow up done.

29

HISTORY PROFORMA
BIO-DATA:
Name: -

Re

Age: -

D0A:

Sex: -

DO

Occupation: -

DOD:

Income:

- Na

P:

Rs.

Religion:
Address:
HISTORY: Chief complaints:
1) Swelling
Site

Size

Extent

Duration

Whether appears spontaneously

yes/no

yes/no

yes/no

Whether reducible or not

How reduced - on lying down
Or By manipulation
2) Pain

yes/no
30

Duration

Character

Whether

ass.

With

Vomiting

Site

3) H/O chronic cough

yes/no

4) Difficulty in micturition

yes/no

5) Constipation

irreducibihty

yes/no

PAST HISTORY:
Previous operations
Complications (if any)
H/S/O chronic bronchitis, TB, diabetes, hypertension.
FAMILY HISTORY:
PERSONAL HISTORY:
Diet

Appetite
Sleep
Micturition

:
:
:

Bowel habit : Addiction :

31

PHYSICAL EXAMINATION:
Vital signs: Temp
Pulse

Respiration

Blood

pressure : Pallor
Other finding

LOCAL EXAMINATION:
INSPECTION:
Site

Size

Shape

Position & extent

Visible peristalsis

yes/no

Impulse on coughing

yes/no

Skin over swelling

Scars

present/absent

Sinuses

present/absent

Reduces by itself

/ By manipulation

32

ON STANDING:
Swelling becomes

more

prominent

Impulse on coughing

appears

: present/absent

PALPATION:
Temperature

Tenderness

Position and extent

To get above swelling

Consistency

Reducibility

Palpable impulse on coughing :

present/absent

present/absent

Invagination test
OPERATIVE FINDINGS:
A.

state of external oblique Aponeurosis

- Strong -Weak

B.

Size Of Cord - normal

-Bulky
C. Type of sac

- Indirect

D. Size of internal ring:

33

Size:

yes/no

POST OPERATIVE COURSE:

- Complications (if any)
a)

Retention of urine.

b)

Pain.

c)

Hematoma.

d)

Stitch abscess.

e)

Fever.

- hospital stay (days)

FOLLOW UP
-

Pain

Scar

Assessment of the procedure.

Recurrence.

34

OPERATIVE TECHNIQUE Pre operative Preparation:

Informed written consent taken.
-

Patients were kept nil by mouth from 10 pm a day before surgery.

Nipple to knee shaving including scrotum were done a day before

surgery.

Tab Diazepam lOmg was given at 10 pm a day before surgery.

Tab Rantac 150mg was given at 10 pm and at 6 am.

Tab Dulcolax lOmg was at 10 pm a day before surgery.

Anaesthesia:
-

Local anaethesia-in patient not fit for any anesthesia due to medical
illness.

Spinal anaesthesia

General anaesthesia

Operative Procedure:
- Under anaesthesia, patient was placed in supine position, painting(with
spirit, betadine and spirit) and draping done.
-

Standard hernia incision was used, about 2 cm above and parallel to

the medial half of the inguinal ligament.

Skin and subcutaneous tissue cut along the line of incision upto
external oblique.

Anterior surface of external oblique was cleared off the superficial

fascia, both fatty and membranous, above and below.
35

Inguinal canal was opened by placing an incision over the external

oblique about 2 cm from inguinal ligament extending from the
superficial ring to about 1 cm past the deep ring.

The upper and lower flaps were raised till the aponeurosis of internal
oblique muscle and rectus sheath were seen superiorly and the upward
curved portion of inguinal canal were exposed. The cord and its
coverings were cleared off the inner aspect of inguinal ligament upto
public tubercle.

The spermatic nerve and ilioinguinal nerve were separated and safe
guarded.

The cord was "skeletonized" by removing its covering.

The indirect sac was separated from the cord structures completely
upto its neck and if direct sac present it buried in to the posterior wall
of inguinal canal.

A snug internal ring was reconstructed after sac was ligated and
transfixed by using suture material.

Posterior wall of the inguinal canal repaired by tension free sutures

and preshaped proline mesh was kept over the posterior wall of the
inguinal canal with encircling the spermatic cord ,depending on the
condition of posterior wall.

The spermatic cord was now placed over the newly constructed
posterior wall.

The anterior wall of the inguinal canal was reconstituted by suturing

the both flap of external oblique using 1-0 prolene continuous sutures
starting from the lateral end reaching medially and ends to have a gap
36

of adequate size so as to create new superficial ring and allow the

passage of spermatic cord.
-

Subcutaneous tissue apposed with 2:0 plain catgut on round body

needle with interrupted suture.

Skin is apposed with ethilon 2:0 poly amide vertical mattress suture or
with vicryl rapide 2:0 on cutting needle subcuticular stitches.

Sterile dressing kept.

37

Post Operative Evaluation and Management:

-

Cap Ampicillin 500mg qds x 7 days

Cap Cloxacillin 500 mg qds x 7 days

Tab Rantac 150 mg 1 bd x 7 days

Tab Brufen 400 mg 1 tds x 7 days

First dressing done on 2nd post operative day usually after 48 hours.

2nd dressing done on 4th post operative day.

3rd dressing done on 6th post operative day.

Sutures removed on 7th or 8th post operative day and patient

discharged.

Patients who were from places within the city were discharged after 1 st
dressing on 2n post operative day if no complications were noted.
Complications observed were:
1)

Retension of urine.

2)

Local pain- persistant

3)

Wound hematoma

4)

Wound infection/stitch abscess.

5)

Fever.

38

Follow up:
Patients were followed up monthly for first 3 months, next the patient
was called after 6 months, 1 year, 1 Yi years after surgery. At every follow
up visit, the scar at operative site was examined, patient's assessment of
the procedure and any signs of recurrence were noted.

39

IMEAGES

40

...RESULT AND
ANALYSIS
41

RESULT AND ANALYSIS:

1.AGE
Age Group in years Repair By sutureless
31-40
41-50
51-60
61-70
71-80
81-90
Total

hernioplasty
8
5
6
7
5
9
40

Repair by other
methods
6
12
11
4
3
4
40

Maximum no. of patient 9(22.5%) were in the age group 81-90 followed
by 8 patient (20%) in the 31-40 age group. And the mean age for our
study is 55.4 years.

42

II.OCCUPATION

Our hospital being a government run civil hospital caters to all

sections of society.

The majority of our patient were agricultural labourers

Only a small proportion- 5(8%) patients had a clerical job.

One of our patient was a 35 year old having duty as army officer.

Repair By
OCCUPATION

sutureless
hernioplasty

Agricultural labourers
Clerical jobs
Army officer
Total

34
5
1
40

43

Repair by other
methods
35
5
0
40

III.

TYPES OF HERNIA
30 patients had direct hernia and 10 patients had an indirect

hernia in our study while 27 patients and 13 patients respectively in

other methods.

Type of Hernia

Repair By sutureless

Repair by other

hernioplasty

methods

Direct

30

27

Indirect

10

13

Total

40

40

IV. DURATION OF SYMPTOMS

Most of our patient had a long history of symptoms predominantly
fullness in the groin and dragging lower abdominal pain.

The mean duration of symptoms was 25.12 months.

Repair By Sutureless
Duration of

hernioplasty

swelling

No. of

15 days - 1 yr
1 yr - 2 yrs
2 yrs - 5 yrs
5 yrs - 10 yrs
Total

patient
30
6
4
40

Percentage
75%
15%
10%
100

Repair by other methods

No. of
patient
31
5
4
40

Percentage
77.5%
12.5%
10%
100

V, SIDE OF HERNIA
Distribution of patients in both studies with there presentation on which
side given as below.
Side of

Repair By sutureless

swelling

hernioplasty
No. of patient

Repair by other methods

Percentage No. of patient

Percentage

Right

18

45%

27

67.5%

Left

20%

10

25%

B/L

14

35%

7.5%

Total

40

100%

40

100%

VI. HISTORY OF PREDESPOSING FACTORS.

2 patients had COPD and were on bronchodilators.

4 patients had symptoms of prostatism with mild prostatic

enlargement.

However majority of 34 patients had no such preceeding

symptoms.

VII. ASSOCIATED CONDITION

Patients

having

associated

systemic

diseases

like hypertention,

diabetes mellitus and IHD are given below.

Associated condition

Repair By
sutureless

Repair by other
methods

Hypertension

Diabetes mellitus

IHD

Total

VIII. TONE OF ABDOMINAL MUSCULATURE

V 34 Patients (all patients above 41 years) had visible malgaigne's
bulging and a poor abdominal muscle tone.
IX. RELEVANT PAST HISTORY.
V3 of our patients had hernia operated on the opposite side. V2 patients
had done appendicectomies earlier.

X. INVESTIGATION.
All patients of our study had done routine investigation in form of
Hb,TC,DC,ESR,RBS,Bld Urea and Urine examination
Two of our patients having chronic cough had investigated in form
of chest x-ray.
Four of our patients having obstructive urinary symptoms had done
ultra sound for prostate and post residual volume.
Total 8 of our patients having hypertension and IHD had done
electrocardiogram.

XI.TYPE OF ANAESTHESIA
Type of Anaesthesia

Spinal
Local
Total

Repair By

Repair by other

sutureless

methods

hernioplasty
39
1
40

40
0
40

Maximum numbers of patients in both studies were operated under spinal

anaesthesia whereas in our study one patient was operated under local
anaesthesia who had severe COPD and IHD.
No relation found between the type of anesthesia and complication
incidence.Robert BEndavid, Maurice arregui et al have suggested that
type of anesthesia used dose not influence recurrent rate.
According to our study there is no difference in the final out come of
surgery when different types of anesthesia are used.
XI.

LOPERATTON.
All patients of our study operated by sutureless inguinal

hemioplasty, and comparative study done with operated by other

methods.

XIII. DURATION OF SURGERY

In initial part of surgery the operative time was on higher side but
as we gained more experience the operative time become lesser till we
reached an average unilateral repair time of 35 minutes.

Duration of

Number of patients

Number of patients

Surgery(Minutes)

Repair By sutureless

Repair by other

30-40

hernioplasty
26

methods
10

40-50

24

50-60

60-70

Total

40

40

XIV. HOSPITAL STAY

After operation our patients were kept in ward for observation.
Hospital stay (days)

Repair By sutureless

Repair by other

hernioplasty

methods

2 days

16

2-8 days

20

28

>8 days

Total

40

40

XV. COMPLICATIONS
During our study only 2 patients had developed wound
infection. While 4 patients had developed wound infection in other
methods and 1 had scrotal hematoma post operatively.
Complications

Repair By sutureless Repair by other

hernioplasty

methods

Urinary retention

Scrotal hematoma

Wound hematoma

Wound infection/gap

Total

XVI. FOLLOW UP
After discharging from hospital maximum number of patients
came for follow up during 6-12 months, and no any recurrence noted
during follow up.

Duration of follow up in
months

Repair By sutureless Repair by other

hernioplasty

methods

6-12

22

19

13-18

13

18

More than 18

Lost during follow-up

Total

40

40

..DISCUSSION

DISCUSSION
The result obtained in our study of 40 cases of inguinal hernia
operated by suturteless hemioplasty method & 40 cases of inguinal
hernias operated by other methods are tabulated and analyzed in
following section.
DAge
The age distribution of patients in our study was as follows:
Table 1

Age Group in years

31-40
41-50
51-60
61-70
71-80
81-90
Total

Repair By sutureless

Repair by other

hemioplasty

methods

8
5
6
7
5
9
40

6
12
11
4
3
4
40

In repair by sutureless hemioplasty group, youngest was 35 yrs old and

oldest was 85 yrs old. In other methods group youngest was 32 yrs and
oldest was 85 yrs. Commonest age group in both group was between 3060 yrs comprising of 19 patients and 29 patients of surtureless
hemioplasty and other methods group respectively.

2) Duration of swelling:
Distribution of duration of swelling among the patients before they
presented to the hospital was as follows:
Table 2
Duration of

Repair By Sutureless

swelling

Hernioplasty
No. of patient

Repair by other methods

Percentage No. of patient

Percentage

15 days- 1 yr

30

75%

31

77.5%

1 yr - 2 yrs

15%

12.5%

2 yrs - 5 yrs

10%

10%

5 yrs- 10 yrs

40

100

40

100

Total

Maximum number of patients in both studies were presented to us

with duration between 15 days to 1 year of time.

3) Occupation
Table 3
OCCUPATION

Repair By

Repair by other

sutureless

methods

Agricultural labourers

34

35

Clerical jobs

Army officer

Total

40

40

Maximum number of patients in both studies were from

agricultural labourers.
Previous studies has stated that the incidence of the groin hernias
is the same in sedentary workers involved in clerical jobs and in those
involved in heavy manual work indicating that strenuous physical
activity alone does not cause hernias. It infact the final factor bringing
on a hernia in those already predisposed to herniation by other basic
causes.
Zimmerman et al claimed that attenuation, fragmentation and
fascicular pattern of inguinal parieties predispose to hernia formation
and occupation has very little to do with hernia repair.

4)

Side of Hernia
Distribution of patients in both studies with there presentation on

which side given as below. Table 4

Side of swelling

Repair By sutureless

Repair by other methods

hernioplasty
No. of patient

Percentage

No. of patient

Percentage

Right

18

45%

27

67.5%

Left

20%

10

25%

B/L

14

35%

7.5%

Total

40

100%

40

100%

Maximum number of patients in both studies having hernia on right side.

Whereas in our study bilateral hernia patients were 14 (35%) as more
compare to other methods which was 3(7.5%).

5)

Predisposing Factors

Distribution of patients with predisposing factors in both studies like

urinary symptoms, bowel disturbance, chronic cough given as below.
Table 5
Predisposing condition

Obstructive urinary symptoms

Bowel disturbance
Chronic cough
Total

Repair By sutureless

Repair by other

hernioplasty

methods

This coupled with the findings of 34 patients being agricultural labourers

involved in heavy manual work supports the recent concept that increased
abdominal pressure from chronic coughing, prostatism, constipation and
heavy manual work plays no role in the development of hernia as
suggested by Robert bendavid and Arreegui et al in 1995.

6)

Associated condition
Patients having associated systemic diseases like hypertension,

diabetes mellitus and IHD are given below.

Table 6
Repair By
Associated condition

sutureless
hernioplasty

Repair by other
methods

Hypertension

Diabetes mellitus

IHD

Total

7)

Type of Anaesthesia
Table 7
Repair By sutureless

Repair by other

hernioplasty

methods

Spinal

39

40

Local

Total

40

40

Type of Anaesthesia

Maximum number of patients in both studies were operated under spinal

anaesthesia whereas in our study one patient was operated under local
anaesthesia who had severe COPD and IHD.
No relation found between the type of anesthesia and complication
incidence
Robert BEndavid, Maurice arregui et al have suggested that type of
anesthesia used dose not influence recurrent rate.
According to our study there is no difference in the final out come of
surgery when different types of anesthesia are used.

8) Type of Hernia
Table 8
Type of Hernia

Repair By sutureless
hernioplasty

Repair by other methods

Direct

30

27

Indirect

10

13

In both studies maximum number of hernia was direct variety.

9) Operative Time
Table 9
Duration of
Surgery(Minutes)
30-40
40-50
50-60
60-70
Total

Number of patients

Number of patients

Repair By sutureless

Repair by other

26
5
5
4
40

10
24
2
4
40

In the initial part of our study, the operative time was on the higher
side.

But as we gained more experience, the operative time became lesser

till we reached an average unilateral repair time of 35 minutes.

The overall average operative time for unilateral hernia repair was 45
minutes repaired by other methods.

10)

Complications
Table 10
Complications

Repair By sutureless Repair by other

hernioplasty

methods

Urinary retention

Scrotal hematoma

Wound hematoma

Wound infection/gap

Total

In our study only 2 patients had developed wound infection whereas

hernia repair by other methods having wound infection in 5 patients with
1 patients having post operative scrotal hematoma.

11) Hospital stay

Table 11
Hospital stay (days)

Repair By sutureless

Repair by other

2 days
2-8 days
>8 days
Total

hernioplasty
16
20
4
40

methods
5
28
7
40

In both studies maximum number of patients having hospital stay

between 2-8 days.

12) Follow up
Table 12
Duration of follow up in

Repair By

Repair by other

months

sutureless

methods

hernioplasty
6-12

22

19

13-18

13

18

More than 18

Lost during follow-up

Total

40

40

Maximum number of patients having regular follow up between period

of 6-12 months and no any recurrence had noted during follow up.

...SUMMARY

SUMMARY

In our study of sutureless inguinal hernioplasty observation

made on 40 cases of uncomplicated inguinal hernia which were selected
from surgery A unit of SSG Hospital and comparative study done with
other 40 cases of inguinal hernia repaired by other methods from other
surgical units of SSG Hospital, Baroda.
Maximum number of patients were from the elder age group
with mean age of 55.4 years.
As our hospital being a government run civil hospital
majority of patients from agricultural labourers group.
Most of our patients presented to us with complaint of
inguinal swelling between the duration of 15 days to 1 year and majority
of them having hernia of right side which was 18(54%) whereas having
bilateral hernia in 14(35%) cases.
All patients admitted to ward and preoperatively routine
blood examination like Hb, TC, DC, ESR, RBS, Bid Urea and Urine
examination done. Two of patients in our study having chronic cough had
investigated in form of chest x-ray while 4 of our patients having
obstructive urinary symptoms had done ultra sound for prostate
evaluation while 8 of patients having hypertension and IHD had done
ECG.

Majority of patients were given spinal anesthesia while only one

patients given local anesthesia in our study.
All patients were operated by sutureless inguinal hemioplasty. No
any emergency operation done for obstructed or strangulated hernia with
this method. An average operative time in our study for unilateral repair
was 35 minutes as compare to other methods having operative time of 45
minutes.
After operation majority of patients having hospital stay between
2-8 days and only 2 patients having wound infection.
Regular follow up of patients had maintained and majority of
patients had given follow up between 3-12 months.
No any major wound complication like wound gap, wound
hematoma occurs during study and no any recurrence had noted during
follow up.

...CONCLUSION

CONCLUSION
At the end of study we had obtained results that inguinal hernia
repaired done by sutureless hemioplasty had

Equal efficacy as other methods use for inguinal hernia repair.

Less operative time as compare to other methods used for inguinal

hernia repair.

Operative procedure become less expensive because of minimum

usage of suture material as compare to the other methods.

No any major intra-operative and post-operative complication had

come across during study with no any recurrence had noted.

...BIBLIOGRAPHY

BIBLIOGRAPHY
1.

Abrahamson J.: Maingots Abdominal operation vol-1, 10th

Edition, page no. 479-572

2.

Amado WJ. Anesthesia for hernia surgery. Surg clinics of north

America 1993;73:427.

3.

Berliner SD, An approach to groin hernia. Surg Clinics north

America 1984;64;197.

4.

Bhattacharjee PK. Surgical options in inguinal hernia: which is the

best, Indian J surg 2006;68;191-200

5.

Bruce J. Forword, In; Nyhus LM, Harkins HN (editors). Hernia. 1 st

ed. Philadelphia: Lippincott;1964.

6.

Ellis H, Harrison W, Hugh TB. The healing of peritoneum under

normal and pathological conditions. BR J Surg 1965. Page No.
52.471.

7.

Ellis H, Heddle R. Does the peritoneum need to be closed at

laprotomy? BR J Surg 1977. Page No. 64-733.

8.

Ellis H, Heddle R. Does the peritoneum need to be closed at

laparotomy? Surg Gyn Obs 197. 133(3)

9.

Ellis H. the cause and prevention of postoperative intraperitoneal

adhesions. Surg Gyn Obs 1971. 133(3): 497-511.

10.

Eskeland G. Regeneration of parietal peritoneum. 1964, page no.

62-459.

11.

Issaq E, Abrahamson J, Elder S, Kedar S.S :Economic & other

advantages in combined prostatectomy & hernia repair. Theor surg
1987;2: 78.

12.

Lichtenstein IL. Herniorraphy: A personal experience with 6321

cases. Am J. surg ; 1987; 153:553

13.

Lichtenstein IL, shulman AG, Amin PK. The cause , prevention

and treatment of recurrent groin hernia. Surg clin. North Am
1993;73:529.

14.

Michaels JA, Reece smith H. Case control study of patient

satisfaction with day care and in patient inguinal hernia repair. J.R.
coll surg (edinb) 1992;37:99

15.

Morris GE, Jarret PEM. Recurrence rates following anesthesia day

case inguinal hernia surg by junior surgeons at a district hospital
Ann. R. Coll surg[eng] 1987;69:97

16.

Nyhus L.M., Condon RE: Hernia, 4th Edition.

17.

Raftery AT. Regeneration of peritoneum: A fibrinolytic study. J

Anat 1979. 129 : 659-664

18.

Smedberg SGG, Broome AEA, Gullamo A. Ligation of the hernial

sac? Surg Clin North Am 1984. Page no. 64-299.

19.

Tons C, Klinge U, kupczk-Joeris D et al. controlled study of

cremaster resection in shouldice repair.Zentralbl, chir.

20.

Wilkinson LH, Floyd VT et al. inguinal hernia- a different

technique contemp surg 1988;32: 47.

ABBREVIATION
IF

One Fingerbreadth

1F

More than One Fingerbreadth

Bid

blood

Direct

G/A

General Anaesthesia

HT

Hypretension

ID

Indirect

IHD

Ischemic heart disease

L/A

Local Anaesthesia

Medium

PTFE

poiytetrafluroethylene

Small

S/A

Spinal Anaesthesia

Strong

Th

Thinned out