This on-demand teaching session covers the medical fundamentals of abdominal hernias and would allow medical professionals to gain a better understanding of the causes, classification, and treatment of hernias, as well as the basics anatomy of the abdominal cavity. It is a two-part series delivered by Doctor Alexander Habte, with years of experience as a medical graduate, general practitioner and surgeon, and research fellow at a Global Surgery Foundation. Attendees will learn about the weaknesses in the abdominal wall that can lead to a hernia as well as the complications of abdominal hernia and its surgical management, such as mesh. This is an invaluable learning session for all medical professionals.


Dr. Alexander Habte Habtemariam is a GP and Surgeon by practice from Eritrea, currently serving as a research fellow at the esteemed Global Surgery Foundation.

A graduate of the esteemed Orotta School of Medicine in 2020, with invaluable experience as a practitioner in general surgery and acute surgical care at a military hospital in Eritrea. Dr. Alexander's expertise in hernia care is of notable significance, having performed multiple successful surgeries during his tenure as a General Practitioner.

Dr. Alexander’s passion extends beyond the operating room, as he nurtures a deep-seated interest in specializing in general surgery and acute surgical care, all the while maintaining a steadfast focus on the global surgical landscape. His commitment to bridging the gap in healthcare accessibility resonates deeply with his experiences, including leading surgical teams in underserved communities.

Learning objectives

Learning objectives: 1. Identify the anatomy of the abdominal wall and its weaknesses 2. Understand the causes of abdominal hernia, its types and classifications 3. Analyze clinical history and examination findings in a hernia 4. Evaluate complications of abdominal hernia 5. Describe surgical and non-surgical management of hernias including its complications
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone hear me? I can hear you. Can you hear me? Yeah. Yeah. Good, good, good, good. Sorry, I had to, I had to quickly jump on this, um, um, the mod. He's having a bit of, um, uh, an eco um, getting to connect. So I just, um, he just phoned me now that I think his gadget is, um, acting up somehow. So, um, we would start II, I won't be available, um, all through the, the teaching because I'm presenting in an event. I just have to come out. So if, if we carry on, um, I might, I might be able to come in, um, at intervals. Um, and hopefully you should be able to get, get, um, a better connection very soon. So, um, let's see how many of those are here. Now, let's see whether we can start. Um, all right. I think there are 123455 attendees. Ok. Um, should we just give it four minutes or three minutes? Let's start, um, say 10 past to allow others to join? I guess some others might have been trying to join before now. Possibly. Yeah, they couldn't because, um, the event wasn't live yet. So, um, good day everyone. Um, you know that, um, a general surgery lead and, um, today we shall be taking the first part of, um, abdominal wall Herne and that's gonna be delivered to us by, um, Doctor Alexander. So he's, um, going to introduce himself in a beat and he's gonna have the stage in a beat. We're just gonna wait a bit more for all of us to join in. I think we are getting a bit more than we wear when I Yeah, that's it. Yeah, so just two more minutes and we will join. Um So Alexander, you, you, you, you practically would be driving these in case um in case um the moderator is unable to join still. So you, you, you, you have the flow already so you just, you just carry on. OK? You just carry on and um if there is any issue just, just drop me a message directly. Iiiii I will, I will try as much as possible to get my phone very close to myself. But the challenge is I'm I'm gonna be driving very soon, driving back to my base. So I might not be able to do much, but obviously um I think a call will be better but I'm very sure you, you should be all right. Um Regardless. OK. The can you share your screen now? Let's see. Yeah, I'm I'm trying to get Yeah, so I can, I can see your screen very clearly. Can you? OK. Is it in the, is it in a slide show or in a presenter's presenter's view? It's in the presenter's view now? Oh OK. So I guess I'm gonna need to put it in a slide show. Yeah. Yeah. So I think it's in a slight show now. It's still not full. Yeah, it's, it's full. So we've got it full now so I can see it very clearly. So once, once, um once I, I'm just gonna un mute and um pick up my video, well, I might still be in the background but because I will be in transit, the connection might be, might be fluctuating. So I might go, go off at any point, but you should still have this page. It shouldn't affect anything. Ok. All right. All right. It's um 10 past eight now and uh we shall start. Ok. Uh Yeah, you've got the stage. Um, Doctor Alexander up. Thank you. Yeah, kindly kindly take over. Thank you very much. Uh Good evening everyone. I hope uh all is well on your end. Uh So we're going to be having a webinar series that is a two part series uh based on uh abdominal hernias before we dive in into the topic today. Maybe a little introduction about myself. My name is Doctor Alexander Hap. I'm uh a medical graduate from uh or school of Medicine class of 2020 uh in the past three years of my tenure, I've been acting as a general practitioner and also a surgeon by practice. And um in the past three years of my tenure, I've actually handled uh multiple abdominal hernia cases. Uh Currently, I'm also a research fellow at a Global Surgery Foundation. And uh there I am involved in multiple uh global surgery uh initiative researches. So uh we will start our two part abdominal series uh right now. So um the learning objective of uh to this uh entire series will include uh to, to know and understand the basic anatomy of the abdominal wall and its weaknesses. The causes of abdominal hernia, types of hernia and classifications, clinical history and examination findings in a hernia, complications of abdominal hernia, and then the nonsurgical and surgical management of hernia including mesh and then finally complications of uh all these hernia surgeries. So, before um anything else, I think it's much better to have a, a clear brief review of the basic anatomy of the abdominal cavity. Now, uh the abdominal cavity is a complex structure made up of muscle bone and facia. Uh Now, the uh roof of the abdominal cavity is made up of the diaphragm and it is uh this part that divides the negatively pressurized uh thoracic cavity from the positively pressurized the abdominal cavity. Now, any defect within this diaphragm will bring about uh a hiatal hernia or a diagno hernia and then the floor of uh the abdominal cavity is uh occupied by the bony pelvic brim with a muscular central region known as the perineum. And any weaknesses in this muscular structure will bring about the propulsion of either the urinary bladder, the gyn organs or the anal canal is a term referred to as of that topic is within the cover of this uh series. What we will cover is the uh hernia or the protrusions happening the uh lateral and ventral walls of the abdominal cavity. So, um the best view of an abdominal cavity is through a transection or a transverse ct cut at about 10. Now, if you can see the posterior with the abdomen is highly vascularized and because of this, it's a very rare that you'll see a hernia on the posterior side of the abdomen. However, there are two important triangles that are just by design known as the superior and inferior lumbar triangles where a rare uh hernia occurrence might occur. Uh then laterally, there are three thin muscle fibers known as the trans abdominis, internal oblique and external oblique. And these muscles will just cross around the fibrous. And this is what would give the secondary uh function of the abdomen that is the mobility. So this is what will help you flex extend and rotate to a certain degree anteriorly. Uh It is made up of the rectus muscles which will, which will extend from the ribs up into the pelvis. And these rectus muscles are so thick that it's very rare that any herniation will occur through these muscles. However, there is a connection, the two pairs of uh rectus muscles known as the linear alba where uh a protrusion of abdominal or constituents might occur, which are the epigastric hernia and the umbilical hernia. Now, let's try to define uh an abdominal hernia, abdominal hernia or also known as an external hernia is the bulging of a part of the contents of the abdominal cavity through a weakness in the abdominal wall. Now, I should emphasize on the word weakness. So there has to be a weakness for which the abdominal uh content of the abdominal cavities would bulge through. Now, what would cause the abdominal hernia? Now, uh it was a contemporary belief that an excessive intraabdominal pressure will cause a hernia. Now, uh through further studies which was actually done in among uh weight lift, Olympic weight lifters that the once they were studied for a certain amount of years, it was found that the incidence of hernia within those population group was right about the same of that of the general population. So now, the contemporary belief is that excessive intraabdominal pressure is more of an aggravating factor than a causative one. Now, what would cause a hernia, like we said is a weakness in the abdominal wall? So what would cause this weakness? There are multiple reasons for that. The first one would be basic design weakness. So, like you've seen in the image before that, the muscles are all inter twisting and crisscrossing. So there might be a region left only with a facia rather than any muscle, uh buttressing and the structure. So at this point, uh with excessive intra-abdominal pressure, a hernia might occur. So these two structures which are the lumbar triangles and the posterior wall of the inguinal canal are just the basic. The weaknesses by design, the second point or the second cause of weakness is weakness due to structures entering or leaving the abdomen. This will include the inguinal canal which the spermatic cord in males and the round ligament in females would actually pass through. And because of that, an indi indirect inguinal uh hernia could occur through the esophagus. A hiatal hernia could occur in areas where the femoral vessels will pierce the abdomen. A femoral hernia could occur, obre nerve, uh passing through could uh bring about obst hernia and the sciatic nerve hiatus could also bring about the sciatic hernia. A third cause of weakness is developmental failures. So, one of the most important causes here is the patent processes, vaginal list. Now, uh usually developmental failures are uh failures to fuse or failures to actually connect uh properly. So this is the reason for most of the congenital hernias. So, one of the most important congenital hernias is the indirect congenital hernia caused due to uh patent processes. Vaginal li umbilical hernia could actually have two causes. So there's either a failure of development of uh development or failure of, of uh obliteration and also weakness due to structures passing through it in your throat. Epigastric hernia, uh failures of the two rectus muscles uh fusing properly through the linear alba can bring about it and failure of uh deaf formation bring about dera hernia. Other causes of weakness would be genetic weakness of collagen and sharp and blunt traumas, weakness due to aging and pregnancy and also primary neurological muscle diseases. All right. So let's move on to pathophysiology of hernia formation. Now, it has been shown that a hernia is no more common in Olympic weight lifters than in the general population, which has suggested that the high pressure is not the major factor in causing the hernia, but it is the major uh aggravating factor. Now, there is a good uh evidence to support that hernia is actually a collagen disease. Now, the collagen uh inciting this uh disease would be collagen type one up to three, which are actually uh fami passed down. Now, this is also supported by histological evidence and also the relationships between hernia and other diseases related to collagen such as the aortic aneurysm. Another reason to support the collagen disease theory is that hernia is also seen more commonly in pregnancy due to the hormonally induced laxity of the pelvic ligaments. It is also more common in el elderly people where there is an excessive degeneration of the fibrous tissue a third reason would also be uh uh the highly association of hernia with smoking as smoking severely reduces the or a affects the degeneration of the connective tissue. All right. How are um hernias classified? Now, hernias are basically classified anatomically into external and internal hernias. The term internal hernia is uh open to scrutiny as uh by definition, hernia should be protrusion into the external world. That's why the term external hernia appears. However, an internal hernia will consist that of a hiatal hernia and diaphragmatic hernia. And also another term known as internal hernia, where it is usually a complication of uh bowel surgeries where adhesions will form into a narrow neck or a narrow uh circle where a bowel could get trapped. And uh similar patho pathologies or pathophysiology of a hernia would occur. But within the internal uh within the uh peritoneum. All right. So external hernias are further subdivided into groin hernia and ventral hernias. And then groin hernia will be further subdivided into inguinal hernia and femoral hernia. And then ventral hernias will involve e epigastric hernia, umbilical hernias, elian hernia, incisional hernia, and also lumbar hernia. Note that the lumbar hernia is actually occurring at the posterior side of the wall, but it is still classified as a ventral hernia. All right, let's move on to the constituents or uh what makes up a hernia or uh in other words, anatomy of a hernia. So in a classic presentation, a hernia will have a fold of peritoneum which is the sac and it will have a defect within the abdominal cavity, which is just called the defect. And then it will have a neck region and a body region. Now, the size of this defect is uh pivotal in uh progression of the disease. So, if it's a very small defect, the chances of it being strangulation uh and uh later on uh death and necrosis is very high. But if the defect is like this very large, usually the presenting symptom would be a painless uh swelling that comes and goes usually gets aggravated by vessel, the liver such as cuff or straining in the stool or during urination. Now, here's a very good picture of the most common hernias, which is the inguinal hernia. So you can see here, this is the defect, which is a very small opening. You see this narrow long tract would be the neck of the hernia. This is the sac of the hernia while this will be the body of the hernia, which is consisting of a small bowel. And as you can see from the color in need, it looks like it's a little bit engorged with reddish skin discoloration and this is indication of strangulation. All right, let's move on to a hernia progression. So hernia could progress from occult or something that is usually just detected during physical exams to a reducible uh hernia in which there is really no pressure to be applied to be reduced or a reducible by pressure in which a patient might need to apply a little bit of a pressure to put back the abdominal contents. Then it will turn into an irreducible hernia. Now, irreducible hernias could be incarcerated where there is really no vascular compromise, but just at this point, it is just that the contents cannot go back into the abdomen. Now, usually when this happens, the first thing that happens is that there will be a venous congestion. And then at this point, skin color discoloration and swelling of the intact organs will occur. And then after that, the next step would be arterial occlusion which will bring about stang. And at this point, this is an emergency and you need to go right away into the or where resection anastomosis and also correction of the hernial defect needs to happen. All right. So how do we approach a patient with a hernia? So usually the diagnosis is straightforward clinical and we would rarely apply any uh investigation modalities. So, in the history, it's pretty, pretty much straightforward and self diagnosis is uh pretty common because the disease is actually very common and we well known. Now, the patients usually uh are aware of a lump in the abdominal wall under the skin and usually the presenting symptom is a painless swelling anywhere in the abdomen. A severe pain should alert the surgeon to a high risk of strangulation. And one should also determine whether the hernia reduces spontaneously or needs to be helped. This is just to let you know that if there is a pressure being applied or it's actually not being reduced, then there is more likely that the, the there's more likely chance that the bowel would be strangulated and then might need an urgent surgical care. Now, the patient should be asked about symptoms that might suggest bowel obstruction. And it is also important to know that if this is a primary hernia or whether it's a recurrence after a previous surgery. Now, the importance of this is that in a recurrent uh hernias, a surgical approach might uh another surgical approach might need to be uh considered in a man with an inguinal hernia. Usually, if it's uh an acquired inguinal hernia, it is uh most likely associated with increased intraabdominal pressure. So, a history of prostatic symptoms should be uh inquired and like I stated before, in increased intra-abdominal, my uh pressures might not be the cause, but it is a very common aggravating factor. So, if you cannot address this aggravating factor, you're only opening up the patient for a recurrent surgical condition or a recurrent hernia. So you need to address uh or at least check if there's any history of prostatic symptoms and that needs to be addressed either before or right after the inguinal hernia surgery. Now, intake of anti anticoagulants such as warfarin is just important in the impact of the surgery or the outcome. And because uh the hernia operations can be performed as a day case, it is uh important to actually just assess the mobility levels and the ability to withstand the anesthesia by the patient. All right, physical examination. Now, this is usually in uh exams. Now, the patient should always be examined lining initially and then the patient should be examined standing up. Now, the science behind this is that a patient while lying down his intra-abdominal pressures are very low. So you might not be able to see a hernia. But during that lying down position, a patient might be asked to do a valsalva maneuver such as cuffing while where a bulging might occur. But when a patient stands, the abdominal uh pressure will be increased and then the you might actually see an increase in a hernia size or a bulging occurring, which was not uh visible before. Now, there is a condition known as diver recti. What this is is it is the literally diver or the distancing of the two rectus muscles. Now, this is not a hernia, this is just a weakness in the uh Leia out. So how this is tested is that the patient is asked to be supine and then is just simply will lift his head. Now, what this would do is it will tense up the two rectus muscles and then you can actually detect that there is a widening of uh the two muscles. Now, overlying skin is usually inspected for any color changes which might indicate strangulation, which would actually need an urgent surgical care. Now, um the cuff impulse is usually the pinnacle of the physical exams. However, it is not diagnostic or even an exclusion of diagnosis because there could be cases where uh a positive cuff impulse might not be associated with a hernia. One good example is uh Sao vari or the varicosity of the saphenous vein. And also uh in hernias where the defect is very small or narrow and usually associated with a bony margin, such as the femoral hernia, a cuff impulse might not be transmitted from the abdomen to the hernia. So even an absence of a cuff impulse might not even exclude the diagnosis of a hernia. So it is also very pivotal to check uh the contralateral side as multiple defects are very common in hernias. All right. So when do we investigate abdominal hernias? Like I said before, abdominal hernias are pretty much straightforward at clinical diagnosis and it's very rare that you actually might need it. But in an occurrence of a clinical uncertainty, the investigations of radiological, uh the radiologic investigations are uh aus uh I've listed here every radiology, uh investigation with its ups and downs or with its pros and cons. Now, uh plain radiograph is of tal value for external hernias. It is a, it has actually no value but it will diagnose internal hernias such as deaf hernias or uh hiatal hernias. When you do a chest x-ray ultrasound scan is usually our go to investigation modality because of its low cost and noninvasive uh nature. However, it is operator dependent and needs to be taken with a grain of salt. CT scan is highly uh applied in incisional hernias. Uh and it's usually important to delineate the number of defects within that incision site. Uh and also check if there are multiple adhesions and if there's any other associated uh pathology such as ascites or partial hypertension, MRI is the most sensitive and specific of the investigative modalities. However, because it's very expensive, we rarely uh utilize it. Uh the most important uh differential uh differentiating. Uh It's, it's highly important in differentiating uh sportsman groin, which is actually a uh orthopedic condition. Contrast radiology, rarely used, but sometimes it's important for uh diagnosing a direct inguinal hernia, especially if it's the bladder that is involved and then very rarely uh laparoscopic diagnosis uh could also be uh attempted if uh there is a belief of an occult inguinal hernia. All right. Now that we've seen the whole clinical picture of uh hernias. Let's go about the management principles of the hernias. Now, uh there are three basic principles for managing every hernia. One is eliminate or control factors that have favored the evolution of the hernia. Now, as I stated before, the fa the factors that favor evolution of a hernia are increase intraabdominal pressure. And then the causes of these increased intra-abdominal pressure could be excessive cough due to COPD. It could be uh excessive straining due to constipation could also be excessive straining due to urinary tract obstruction. So these things need to be eliminated or at least fact uh controlled to a certain degree before uh hernia. Uh correction is done. The second principle is to totally remove the sac or at least interrupt the communication between the abdomen and the hernial pouch. And this is where the hernial correction will come into place. And then the third is to correct the to correct any associated facial defect and to reinforce this either with an autogenous fascia or a synthetic substitute. All right, surgical approaches. Now, all surgical repairs uh follow the same basic principles. The first one is reduction. Now, this is the pinnacle of every hernia surgery that is you have to reduce whatever was whatever was protruded throughout the abdominal wall defect. Now, before reduction, you need to check if there is any uh nonviable tissue as it needs to be resected and removed. And then uh anastomosis or bowel repair is uh done if it's necessary. Uh And then the next step, which is more of an old school approach is the excision and closure of the peritoneal sac. Now, where I am uh working at, we are still old school, we still do the uh open approach. So, excision and closure of the peritoneal sac is ubiquitous where I work. However, the contemporary or the current belief is that you could just reduce everything, including the excessive peritoneal sac into the uh abdomen and then close the defect. Now, the downfall of not excising is that uh the sac might collect fluid, which is uh we will call uh a seroma later on, which is actually a very common complication. However, this seroma usually resolves by itself and it's a rarely uh uh uh reoperation is needed for that uh such a case. So the current practice is to just either if you're using a laparoscopy to pull everything in even including the sac or if you're using an open uh approach to just push everything in including the sac. Now, the third step is reapproximation. Now uh be careful with reapproximation cause reapproximation of the walls of the neck of the hernia is done only if it's possible to do it without any tension. So, uh as a junior surgeon, sometimes we press on reapproximation and we would like to, we would try to do reapproximation at all costs, but usually you do more harm than good by uh reapproximating with tension as this will cause very severe pain, post-operatively. And not only that uh there is going to be a tension necrosis and then uh recurrence is very common. Finally, which is actually the main stay currently being practiced is the permanent reinforcement. Now, this permanent reinforcement could be done either with nonabsorbable sutures or it could be done with a mesh. So depending on where you are. So I am based in a low-income country. So I still use the nonabsorbable sutures. But in a well off country or at least well off institution, you might choose a mesh. All right now, uh mesh uh are actually becoming a ubiquitous uh material for uh hernia uh reinforcement surgeries. So I think it's very important for us to discuss a little bit about a mesh. So um the term mesh refers to prosthetic material, but it could also be biologic, which is either a net or flat sheet, which is used to strengthen a hernia repair. Now, mesh can be used to either bridge a defect to plug a defect or to augment a repair. Now, a well placed mesh should have a good overlap over around all the margins of the defect. The minimum requirement is two centimeters. The ideal one is five centimeters. What is strictly prohibited is to actually just put the mesh uh at, at the edges of the defect and then trying to suture it. This is completely prohibited and then let's discuss what an ideal mesh looks like. Now, the term ideal here is uh used because this type of mesh is nonexistent. There are some that approach it but there is none that actually takes off every of the checklist here. So an ideal mesh should possess good handling characteristics in the or it should invoke favorable host response and it should be strong enough to prevent a recurrence. It should place no restrictions on post implantation function. It should perform well in the presence of an infection. It should resist shrinkage or degeneration over time. It should make no restrictions on the future access. It should block transmission of infectious disease and it should be inexpensive and be easy to manufacture. So as you can see, there is a lot of checklists to be ticked here. And it's very rarely that you would find that uh a mesh will take off every of these. So let's discuss the types of mesh. So meshes are actually classified based on different characteristics. So based on growth structures, we will have two types of meshes. This is the net mesh and then the flat sheets. Now the growth structure here is just the. So a net mesh will look like a net. So it will have holes which are actually porous while a flat sheet might actually have holes, but it is nonporous. So this is the key words here, net mesh is porous while the flat sheets are not the other difference is that because of this porosity, a net mesh will actually allow a fibrous tissue growth within these spaces because the flat sheet is nonporous. It should, it does not allow any host tissue ingrowth within the spaces. But what it would be is it would be encapsulated within a fibrous tissue. Now, because uh the net mesh is actually allow tissue and growth fixation of a mesh is not necessary. So what we would do is just create a little friction on the area where you would want the mesh to be attached. And it's uh good enough to actually hold the mesh. However, flat sheets always require a very strong nonabsorbable fixation. Then net meshes are actually prone to ahe information while uh flat sheets are actually prone to mesh migration, which are actually very common uh complications. Uh when you're using meshes, as you can see here, the price of these meshes is through the roof. Net meshes costing as uh high as 4000. While flat sheets costing as high as $1200. Now, this is a pictorial presentation. Uh the one on the left side of the screen. Uh If you could see my pointer is uh the net uh mesh. While this is the fat cheek, as you can see, there are tiny holes but they are not porous. All right. Another way of classifying it is based on its constituents. So we could have synthetic mesh and we could have a biological mesh. Now, a synthetic mesh is actually the one that is most in use now. And the only reason for that is relatively it is cheaper than the biological mesh. And uh they're usually made up of either polyester polypropylene or ptfe and they are not absorbable while biological meshes are actually sheets of sterilized, de cellular, non immunogenic connective tissues. And they're derived from either animal dermis, human dermis bovine pericardium, uh or the intestinal mucosa. And then the one thing here is that they are degraded with time. All right, final classification of the types of mesh. So, based on weight and porosity, we can actually have a heavy weight and a light weight. Now, there is a cut off of weight given that is anything above 80 g per meter square is considered as a heavy weight and anything below 40 g per meter square is considered as a light weight. Now, the point of this, the the division is not about the weight. It's more about uh the uh it's more about the space, the spaces between uh these meshes. So a heavy weight is more of a flat sheet. It has uh it rarely has any spaces between uh those pores. So it will actually have a more tissue reaction and collagen deposition. While uh uh more spaces between those uh pores are between those holes and then there will be less tissue reaction and it is uh and there will be less tissue reaction and collagen deposition. Now, because of uh huge tissue uh reaction and collagen deposition, heavy weight, uh meshes are prone to uh phenomena known a known as mesh shrinkage. Now, what would happen is a lo as in due time, the meshes will actually decrease in size, something to as low as 50% of their size and even some have actually been recorded to go be below that. So at this point, if the mesh is decreasing to half its size, it's rarely doing a function. And then a recurrence will be eminent but a lightweight because of uh the less tissue reaction, it is less pro prone to uh mesh shrinkage and because of those spaces in between, it is more flexible and it is very comfortable to use. All right. So there has been recent updates on uh mesh that could be used for low and middle income countries. And these are the mosquito nets. Now, uh these are the two notable research that I've been able to find, but I've noted that there were multiple other research on PUBMED. So mosquito net have actually been deemed safe to use an inguinal hernia repair and this research has been repeated in multiple low and middle income countries and it actually uh has found multiple successes. Now, I should specify that the mosquito nets should be made of polyester and they should be non treated. Uh All right. So I decided to the, this is a Swedish and Ugandan study which have actually shown uh multiple successes and this is another one done in Cameroon. All right. So now that you know, mesh, how do we position it or how, how is it used? So, the pinnacle of uh reinforcement or tress in the abdominal wall defect is uh the strength of that repair depends on host tissue ingrowth. So what we want is we want that mesh to lay over the defect and then the host tissue reaction to occur where that collagen or fiber deposition will actually strengthen that defect. So a mesh should be placed on a firm and a well vascularized bed of tissue for a generous overlap on the defect. So there are three ways you can put it, which we would call an onlay, an inlay and a sub lay. Now, these are usually used on different planes, which I could actually show you better here uh pictorially. So an onlay is from the name it's placed on the defect. So it is placed in between the subcutaneous tissue and above the facial layer. So is the onlay space, an inlay is very rarely done, but it's sometimes practiced for a large umbilical hernias and also for indirect inguinal hernias. So it's literally used as a plug. We will just put uh a very round and cone shaped uh mesh within that defect where we we would actually just uh deposit collagen and then seal off that defect. Now, a subway can actually have three spaces that is right underneath this muscle before the facia or it could be behind the facia before the peritoneum, which is the extraperitoneal structures or it could also be intraperitoneally. Now, uh the subway spaces are usually the ones used during laparoscopic approach. However, if you're practicing an open surgery, you can use all these spaces to your will. All right. So, before we jump into inguinal hernia, recap, abdominal cavity is a complex structure made up of muscle bone and facia. And it is capable of withstanding high pressures from causing a hernia. But there is uh multiple causes of an abdominal hernia. A majority of them being weaknesses in the abdominal walls. Now, hernia has been highly associated with collagen diseases. Most hernias are clinically diagnosed. Not all hernias require surgical management. The ideal mesh doesn't exist and the ones that closely resemble to it are very expensive, but there is a new promise uh uh arising with the use of mosquito nets as a mesh. All right. So we are done with the basic principles and the basic um points of the abdominal hernias. Let's move into inguinal hernias at this point. I can stop maybe to take a couple of questions if you have them or should I just move on? Anyone can unmute and speak if you have questions, just um type them in the chat box. I think I can speak. Yeah. Hold on. I have to stop sharing my screen if that's the case. All right. So uh should I just go on any point? Yes. Yes, I guess you can go on. So. All right. OK. Good. So let me go back to the screen. All right. OK. So let's go on with uh inguinal hernias. Now, inguinal hernia usually referred to as, as a rupture by patients is actually the most common of the hernias. Approximately 75% of abdominal wall hernias will occur in the groin. And that is including uh femoral hernias. And the lifetime risk of an inguinal hernia is 27% in men and 3% in women and of the inguinal hernia repairs. 90% are performed in men while 10% are performed in women and in men, you'll see a bimodal distribution of the incidences of inguinal hernias with peaks before the first year of age, which is usually just a congenital hernias. And then after the 40 years of age, which are the acquired hernias. And there are two basic types that are fundamentally different in anatomy, causation and complications which are known as the direct and indirect inguinal hernias. However, they are anatomically very close to each other. The surgical repair techniques are very similar and ultimate re enforcement of the weak anatomy is identical. So we will collectively call them inguinal hernias. We will just uh subdivide them into direct and indirect inguinal hernias. All right, quick review of the uh anatomy of the inguinal canal. So, the inguinal canal is a cone shaped uh canal about 4 to 6 centimeters located right around the ventral surface of the pelvic brim or the pelvic uh basin. Now, uh it extends from an a hiatus known as the internal inguinal ring from deep uh abdominal wall. It will traverse uh diagonally and it will actually exit through an opening or a hiatus in the aponeurosis known as the external inguinal ring. And then that the contents, either it's being the spermatic cord or the round ligament in females will pass through these structures. Now, um if you've seen it because of the crisscrossing of the internal oblique, external oblique and the transversus abdomens muscles and then inferiorly, there is the inguinal ligament and then posteriorly where this is actually the area of this is known as the air triangle of Hassleback, which is actually just covered by the uh transverse dysphagia. But up here, there is the muscle. So if you could uh see the structure as a tube, it is something like this like a shutter of a camera film. So when there is an increased intraabdominal pressure, what would happen is they will naturally just close off like this just like a shutter of a camera. So this is what prevents herniation of intraabdominal organs in a normal adult. However, as time goes by that is increased age and then also the uh aggravating factor of increased intraabdominal pressure occurs. There is one issue that is there is an a, a weakness by design which is known as the triangle of Hassleback, which we'll see uh later on in uh another diagram. So they could, something could burst through that, which would we would call the direct inguinal hernia or it could come up from up here, which is the indirect inguinal hernia, which you can see here, this is the sac of the indirect inguinal hernia. And then if it occurs below this inguinal ligament, this is the sac of the femoral inguinal hernias as you can see. All right. So how do we divide this direct and indirect inguinal hernia? Or sometimes they are also referred to as uh lateral and medial inguinal hernias. So, um the frame of reference for this classification is the inferior epigastric vessels. So, indirect inguinal hernias are located lateral to this inferior epigastric vessels. While the direct inguinal hernias are located in medial to this in uh inferior epigastric vessels. Now, a direct inguinal hernia will pass through the uh defect known as the Hassleback strangle, which are actually made inferiorly by the inguinal ligament medially by the lateral uh edge of the rectus sheath and uh infero uh and also medially sorry uh by uh the inferior epigastric uh vessels. I think we should see this uh picture for uh better clarification. So this is a laparoscopic view of the abdominal canal or at least the inguinal region of the abdominal canal. So this is the inferior epigastric vessel. This is the inguinal ligament, this very thin structure here and not just this, you just see here, that's the inguinal ligament and then this is the lateral margin of the rectus sheath. So this whole yellow area is only covered by a facia and then this is the area of weakness by design where a direct inguinal hernia will occur. You see this blue structure which is lateral to the inferior epigastric vessels. This is where the structures uh of an indirect inguinal hernia might occur. And then below this inguinal ligament is the area where a femoral hernia might occur. All right. So, classification of inguinal hernias. Now, there are actually somewhere close to 40 ways of classifying inguinal hernias that have uh occurred over the past 100 years. Now, uh clinically, it is not relevant to classify inguinal hernias. However, during a research or during a study, it is much necessary to actually have a clear standard of classifying them. Now, I have put down here, which is the most common and actually practical way of classifying hernia, inguinal hernias. That is you by the European Hernia Society guidelines. So we will address P for primary or R for a recurrent L for lateral M for medial or F for femoral. And then the defect size in fingerbreadth assumed to be 1.5 centimeters will be assigned. So a primary indirect inguinal hernia with the three centimeter defect size would actually be addressed. P for the primary indirect, which is lateral L and then three centimeters is two times 1.5. So we will say PL two. All right. So what would cause inguinal hernia? Like I stated before, this is a list that I have gotten from uh Schwartz textbook. But all of these are just what would aggravate an inguinal hernia from occurring. The most common cause, like I said, is hernia is a collagen disease. So any weakness or anything that could cause weakness in the abdominal wall will cause the inguinal hernia. But then it will be aggravated by coughing, chronic obstructive pulmonary disease, obesity, straining pregnancy, old age, any other vessel, a maneuver that could happen, cigarettes, smoking, heavy lifting, physical exertion. All of these will actually be the evolutionary causes of the inguinal hernia. All right, pathophysiology. So, um just like what we discussed before uh inguinal hernias could be uh congenital or acquired. Now, the congenital inguinal hernias will actually actually make up the majority of the pediatric hernias and they are caused by an impedance or a failure of development. That is a failure of the patent, uh failure of the processes vaginally from fusing and obliterating. So, usually in the third trimester, what happens is the testis will begin from right around the umbilical region and it will actually descend down. Now, during this descent, what it will take is it will take a fold of the peritoneal wall down with it. And uh at about 36 to 40 weeks of gestation, it will actually terminate into its permanent position, which is the scrotum. Now, right around this is where the obliteration of the process is vaginal will occur. And then later on, we will term the fall in closing the test is the tonic a vaginal is, however, in about 12% of the population, it will remain patent. Now, because of this patency, the this is where you'll see the formation of uh congenital inguinal hernias because it's patent, any inter vascular in intraabdominal pressure will actually allow some of the bowel contents to go in. Um like I said, because the fusion of this uh uh processes of vaginitis occurs at around 36 to 40 weeks of time. You will actually see very common uh as a very common occurrence in preterm babies because it is uh before the time of fusion that they are getting uh delivered. Now, most other inguinal hernias are actually considered as an acquired defect. However, I would also stress this, that collagen studies have actually demonstrated them to be a here tubal, this predisposition. So, um diagnostic approach on history, inguinal hernias are will present to us from uh an occult one where we will just find it insidiously during a physical examination to a painless swelling or to a very painful emergency case. Now, in most cases, the diagnosis of an inguinal hernia is very simple and the patients will actually know their diagnosis before they come to you because they're very common. And then usually these hernias are reducible, presenting as an intermittent swelling. Often the hernias will reduce on lying down or reappear on standing and then the patient will be complaining of dragging down sensations. Now, much less commonly, which is about which will be about 5% of the the cases they might come to you as a very acute event. A very huge swelling usually uh that occurred while a patient was either doing some heavy lifting or while he was straining in the bathroom or even coughing. Now, at this case, it would become strangulated and then an emergency surgery might need to occur physical examination. Now, physical examination is very essential in the diagnosis of uh inguinal hernia as it is a clinical diagnosis. Now, ideally, the patient should be examined in standing position so that the increase intra abdominal pressure will actually be seen easily be transmiss into the uh hernial defect. Now, there are two important tests to be done here, which is the ring occlusion test and the ring invagination test. So the ring occlusion test usually is done while the patient is lying down, but you could also do it while the patient is standing up. So what we would do is you would measure halfway between the inguinal ligament and go about two finger bits above where that is approximately where the internal inguinal rank occurs. Now, keep in mind, the hernial content must be put back into place before you uh attempt this exam. So while you obliterate this ring or you occlude this ring, a patient will be asked to cuff. So if the swelling bulges again, then it will actually be a direct inguinal hernia because it is coming from the hassle back strangle, not from the deep inguinal hernia. However, if you fail to see any bulging, then uh the hernia must have been an indirect one because it is uh coming out with the um deep inguinal ring. Now, the reagin test uh is also done while the pa is done while the patient is standing up and then the contents will be reduced. And then uh uh the usually the small finger will be advanced through the ring and then the patient will be asked to cuff. And then if you see a mass or if you feel a mass coming or hitting you from the top, that's usually an indirect inguinal hernia. But if you feel it hitting the dorsum of your hand, then it is usually an indirect uh uh sorry, a direct inguinal hernia. Now I say all this, but then it was put to test about the accuracy of delineating uh the indirect from direct by physical exam and it came about 52%. So the consensus is use these exams to diagnose inguinal hernias. It's really not used to delineate them. So even in expert surgeons, which was actually tested, it came about 52%. So you might not just get it. Uh And then it's also important to remember that you should always examine the contralateral side as there is 33% risk of uh a contralateral occult hernia occurring from a person who has a unilateral hernia. All right. So, differential diagnosis, our differential diagnosis will be that of a groin swelling. So, we'll have to think of malignancy such as lymphomas, sarcomas, testicular tumors. It could also all be a primary testicular conditions such as a varicocele, a hydrocele, testicular torsion, ectopic testes or undescended testes could also be Sao vari cysts of the kind of nook in females. Hidradenitis, hematomas or abscess and for femoral artery aneurysms or pseudoaneurysms. All right, investigations, investigations are very rarely done. Usually, investigations will be necessary if the patient is uh of big girth. Uh so the heavier they are, the more confusing, the swelling would be if it is secondary to just a fat de position or actually a hernial swelling. And uh usually the diagno the diagnosis of choice is ultrasound. But the most accurate is the MRI, like I've stated before, these have their uh pros and cons and are usually rarely indicated in uh hernia investigations. All right, management. So, the ideal or at least the definitive management of an inguinal hernia is surgical correction. Uh, there might be a very rare contraindication for uh surgery and that is old age and inability to actually withstand the anesthesia. However, now, uh the current advancements is that a hernia repair could actually be done even with a local anesthesia. So, if a patient is symptomatic or in any kind of emergency, secondary to inguinal hernia, your definitive uh management is uh surgery. Now, some uh surgeons or some clinicians will actually suggest of the use of a Truss if a patient actually refuses to do surgery in an elective case. But uh through further studies, uh Truss is actually now not an advisable choice as it has actually caused a lot of complications rather than the help. All right. So what types of operations uh of inguinal hernias are there? So, as you can see, the list is a lot. So the first is herniotomy. So from the name, what we will do is we will open the sac, reduce the contents, close the sac and then leave it like that. Now, from what I've just said, this is not part of the routine management. However, herniotomy is done in the congenital hernias in an adult patient. It's either of the rest of the other choices. So we will either do an open suture repair. Now, Bassini is one of the most commonly and uh renowned uh procedures and this is the one that I practice uh in uh my hospital. Well, not the burkini but the modified as you need. Now, this is where we will use our tissue reinforcement by using a non absorbable sutures. There are multiple modifications of it known as the and the zarda and then uh we could also do an open flat mesh repair. This is the Lichtenstein. Uh I don't know if I'm saying that name correctly, but this was actually um discovered or at least in the 19 fifties by a surgeon known as Liechtenstein. So, what he would do is he would use a flat mesh after reinforcing or using uh the senior technique. And then he will. But that with uh use of the mesh, flat mesh, now, we could also use an open complex mesh repair. We use such as plugs. This is the only time where an inlay is advisable. So what a plug would look like is a very conical shape or you could just put it into that defect. Now, we would usually use net meshes and then you really don't need to stitch them all you're gonna need to do is do a little friction to irritate the structure so that it will hold. And then uh finally, you'll have the open preperitoneal repair, which is known as the stopper or you could do a laparoscopic repair. Now, laparoscopic repair is a subspecialty and there are two approaches that is the transabdominal extraperitoneal or sorry, the total extraperitoneal approach and then the transabdominal preperitoneal approach. These are the two spaces where I've shown you where we would do a sub lay. All right. So with all these procedures, how do we approach the management? So whenever we come across uh an inguinal hernia, according to the European Hernia Society guidelines, we'll have to check the uh one of three things. So if the patient is presenting to you with a strangulated hernia, this is an emergency, you go straight into surgery. So, because strangulated hernias are prone into causing an infection, you should really consider a no mesh, especially when the risk is very high for an infection. Um, if the patient is symptomatic, you should, uh, urge on an elective surge either on the same day or just, uh, with, uh, an appointment. But if the patient is asymptomatic or minimally symptomatic, we will go for what we would call the watch for waiting where we're just going to observe it and then see and at at any point, the patient becomes symptomatic, then we might urge to do the surgery. Now, a systematic review was done on this and then it actually stated that 75% of patients with uh inguinal hernias will actually require surgery in about 7.5 years of follow up. So, more or less we will go into an elective surgery. However, uh watchful waiting is still uh considered as a management technique. So the elective surgeries will depend either if we're doing unilateral or bilateral. This is just the same thing. We will do a mesh repair or Lichtenstein or uh endoscopic or laparoscopic way. If it's a recurrent one, this is where we need to make sure or at least uh figure out what the approach was in the previous technique. So uh if it's a recurrence after an anterior technique where it wasn't open, and Lichten ST was doing, then maybe you could use an endoscopic where you could just buttress the posterior side of the wall. But if it was a posterior technique where a laparoscopic uh or extraperitoneal or preperitoneal uh mesh or reinforcement was done, then at this point, you might need to do an anterior technique where you would place a mesh anterior or as an using the Lichtenstein technique. So, uh after this, we will actually come to the complications of these surgeries. Now, this is a very exhaustive list of what could happen as a complication. Uh regardless of how common the inguinal surgery is, it is no short of uh complications. So, we would classify them as an early intermediate and late complications. Now, early in uh complications would be occurring within the first uh three days and this would include uh pain bleeding or uh a seroma collection and an intermediate one. It could be seal collection ut I or uh also infection. This will occur in the first seven days from the third to the seventh day. While uh long term uh complications could be the nerve damages, the testicular atrophies or uh also the chronic pain secondary to nerve entrapments. You could go through these complications as it exhaustively listed it. So, thank you everyone. This was uh all I have for today at this point. Uh We were supposed to share a pre uh webinar uh content or questions, but uh maybe we could just do them now. Uh And then I'll address some of the questions. All right. Uh Doctor Andy is saying, uh sorry, let's go back. Ok. Doctor Andy is saying, do you use any prophylactic mesh to prevent paras stomal herniations? Ok. So we will address the paras stomal herniations later. Now, uh the main state or the guideline says not to do it as the risk is somewhere around uh 2% using uh the, the risk of a parasal herniation. Uh Now, I would say um it differs from uh institution to institution, but from where I uh I work at, we will usually don't do a personal. Uh well, we don't use uh prophylactic mesh. Usually mesh is done as a definitive treatment rather than a prophylaxis of anything. All right. Doctor Andy again asked, uh can constipation be pre precipitator? And if so would opioid analgesics be contraindicated? What's your treatment? If paracetamol isn't potent? Enough nsaids are unsafe. All right. So, constipation is a, like I said, anything that will increase the intraabdominal pressure is uh uh an aggravating factor for hernia. So, by using opioids, constipation would be one of the ca side effects. But uh in my practice, we still give opioids. Uh It's very rare that you will actually uh find um constipation to be the main issue post-operatively even if the patient is taking opioids. Uh but we will make sure to give them laxatives. So I would rather go with mm opioid management as a as pain is a very, very uh real issue post-operatively. So I would go with opioid treatment and then maybe a laxative if a constipation is a real issue. Does that answer your question? Doctor Andy Dr Addy, sorry? Ok. So Doctor Addie's first question was in women of childbearing potential. What preoperative counseling is advised about adhesions and incisional hernia plus risks of POSTOP pregnancy and delivery process. So, um pre-op counseling in the form of correction of a hernia or any other surgeries, can you make that question a little bit clear? Ok. So I'll try to answer it, but maybe if you could just uh specify that question a little bit, that will be much better. So usually, uh women of childbearing age during any surgeries are uh counseled on the uh possibilities of an incisional hernia. Now, uh ok. So general surgery and hernia risks during a pregnancy. Yes. So, ok. Um the principle is this during a surgery, you're intentionally dissecting structures of the abdominal wall. Now, even if you correct it in the most pristine way, only up to 75% of strength of that abdominal wall could come back. So there is a, a reduction by 25%. And then to further aggravate this during pregnancy, there is hormonal induced laxity of the ligaments and the muscle structures. So, um women during any surgeries are actually uh informed about it and then uh especially if the woman is multiparous, the likelihood of a hernia is very high, specifically a surgical uh incisional hernia. Sorry. So, uh what, what usually, what we advise is to watch out for any swelling during any pregnancy time. However, that incisional hernia is not addressed during that pregnancy. If it becomes an emergency, there's no other option but to operate. But if it is reducible and it can wait, usually it's done after the pregnancy. The reason behind it being either a compromise to the fetus and not only that the uh evolutionary factor still exists. If this pregnancy is still there, there is laxity. So just correcting it during that pregnancy is just uh not doing anything to benefit the mother. Does that answer your question? Doctor Addie? Thank you so much doctor a any other questions? Maybe there might be some questions that I missed at the top. So maybe if you could just rewrite them. So. Ok. Right. I don't think other questions. I've checked him from the beginning of the chart, you know. Hello. Can you hear me? Yes. Can you hear me? All right. So, all right. So I said, I don't think the other questions. Um I'll check from the beginning of the chart to you now. Sorry. Ola, you're kind of breaking up. Uh All right. Ok. So can you hear me? Is it better now? Is it better? Sorry. Uh You, you keep getting up? I can't hear you. Is it better now? Ok. Now, maybe I can hear you now, can you? All right. All right. So, all right. So I said, um I don't think you have any other questions, but um yes. Yeah. So thank you so much uh for the thank you so much uh for your teaching was session. Yes. And we look forward to the next one. Yeah, we look forward. Perfect. Yeah, it will be in two weeks time somewhere around two weeks, December the second. Yeah. Yeah. Yes. Yes. Ok. Yes. Thank you so much. All right. So if there are no questions, I think we can end the session at this point. Thank you, everyone. I hope this was helpful at any point. Maybe I could drop my email here and then you can contact me with any questions or opinions about what we discussed so far. I would be more than happy to get back to you. All right. All right, everyone. Ok. Thank you, sir. Thank you so much. Yeah, good. Thank. Thank you. Bye bye.