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Hello, everyone. Um Thank you so much for coming to this medical education lecture and it's part of the General Surgery series. Looking at Hernia Repair, it's going to be delivered by Mr Fras. I'm sorry. Um Thank you so much for coming. Um Fras, I'm just gonna quickly so I've just put the lecture on live so everyone can see you now. Um And you're welcome to introduce yourself and start whenever. Um, thank you so much, everyone for coming. Hi. Hi, good morning, everybody. Thanks for joining in giving up the time on your, um, Sunday mornings. Um, I'm a general surgeon with a colorectal interest up in Scotland. Um, been working in NHS, uh uh for about a decade now. Um basic training back home from Pakistan, then worked in the Middle East for a bit and then now here so quite a wide experience, um different ways things work. Um And therefore I could potentially relate, um uh do a lot of uh things uh where, you know, in different systems, where people do things differently uh to what we do here in, in NHS nowadays. So today I will be um uh sure. Yeah, absolutely. I'll, I'll, I'll try and answer the question as much as I can at the end. Um, so, uh, today I will be talking about inguinal hernias. Um I thought, uh, since, uh, uh it was mentioned that uh, uh there'll be a lot of, uh medical students uh predominantly. So I thought I'd start at the start and, um, begin, um, with a bit of basics on the inguinal hernia uh to see where it comes from why they happen, give an overview of the anatomy and pathophysiology. Um some ways to diagnose the hernias. Uh What are the treatment options and strategies? How, how, how do we operate on them? And um you know, what do we do actually with an algorithm uh develop an algorithm to see if we can, you know, uh get a basic idea of how we manage those hernias. Um I, in the end, I've put some cases up for discussion. Um if, if there is time, then we'll quickly run through them. Uh Just so everybody has got a feel of how we tend to manage these uh hernias, right? Um So I'll start with a small, with a short video. Uh And I find that really useful because uh generally uh people will um you know, they get caught up in a lot of hernia. Um you know, in going a little deep ring and superficial ring and, you know, exam um and how to uh examine them, but, you know, all of that becomes really intuitive and easy if you put a quick overview of the uh of the mm uh of the development of the inguinal canal. Great. Um So we'll go back to the uh presentation now. It's pretty um intuitive and straightforward. Um All right, still going. So, uh it is pretty straightforward and intuitive in that uh testicle. Uh uh and, you know, ovaries, they develop intraabdominally and the testicle has then to descend extraabdominally into the scrotal sac. Um And, and the reason for that we all know is that if it stays at a higher temperature, uh then there is more uh chances of a tumor developing in the testicles. And therefore, they, they have evolved into this uh mechanism where they hang outside a couple of degrees below the body temperature. So, um during childhood, um because especially at the emb phase as the testicle is going to be descending, the there is a potential defect in the peritoneal cavity and in the muscles on the abdominal wall and they are pretty much aligned with each other. So the testicle has the least uh tortuous way to come out of the abdominal cavity. But as people grow older, they mature into adulthood, there is a differential uh development of the muscles. So the deep ring, which was the defect in the peritoneum and the, and the facial transverse, carrying the peritoneal um evasion into it, then, you know, sort of gets transferred laterally whereas the superficial ring, which actually allows the testicle to come out into the scrotum moves a bit medially and this um and, and, and therefore, you know, they have uh um a connection or a canal between them which forms eventually into the inguinal canal. And the reason why this inguinal canal is so important is that because it is an interiorly covered by uh external oblique, uh epineural and um you know, superiorly and posteriorly by other muscles. Uh when uh there is increased abdominal intraabdominal pressure and the muscles stretch, they form a valve like mechanism. Um And the fact that these two defects are not aligned anymore, stops other viscera and uh contents of the peritoneal cavity from coming out um and herniating quite freely all the time. And it is the failure of this mechanism for whatever reason that allows hernias to develop. And therefore, when we are diagnosing, uh we have to, you know, sort of be aware of the locations where these defects can happen. And when we are repairing these hernias, we have to be aware that we are effectively trying to reconstruct a mechanism where uh by the laxity uh or weakness in this mechanism is rectified and we try it in the best possible way. Now, um it is um you know, ii put these diagrams, this is probably the bane of uh you know, it was the bane of my medical student life. Uh But certainly, uh now a lot of people get confused when you get examined and you know, when you're talking about a lot of uh these uh these landmarks. Uh So there is this um anterior, superior ilex spine laterally and the pubic tubercle medially. Uh So these are the area, these are the two points where the inguinal ligament is attached and inguinal ligament is the lower intern portion of the external oblique, epineural. As we all know that abdominal cavity is an interiorly covered by these three muscles, uh external oblique, internal oblique and transversus abdominis. And in the midline, the rectus rectus abdominis muscle and, and then immediately there are uh they have got these big epineural uh sheets. Uh uh the uh the the tendons which are expanded and flat to provide a cover. Now, the external obi uh turns into um the epineural fairly early. And the area where it is in the inguinal canal is effectively most uh almost tendinous, a flat tendon. And the lower part of that is in turn to provide the inferior um or floor of the um sorry, the inferior um part of the inguinal canal. And it is in this sort of concavity that the spermatic cord lies uh the top part of it, uh or the cranial part of it is covered by a combination of uh internal oblique and transversus abdominis that combine to form a conjoint tendon posteriorly as in the abdominal side of it uh is covered. Uh by is is formed by the facia transversalis and medially by the arcuate ligament. That is just a bit of thickening of fascia medially, uh which is quite strong and hold stitches quite easily. Um And so, so this is, and this is the inguinal canal, uh the inguinal canal in its medial um end has uh towards the pubic tubercle, has the triangular shaped external ring, uh which is the defect in the external oblique epineural and through which the spermatic cord comes out. And in the, somewhere in the middle of that inguinal canal, we have another defect going into the peritoneal cavity. And that uh is the oval shaped uh deep inguinal ring. Now, the location uh how to locate that deep inguinal ring and superficial inguinal ring. The superficial inguinal ring is just superior and lateral uh to the uh pubic tubercle and deep inguinal ring is the uh is the middle part of the inguinal ligament. Um And that, that is where this is as opposed to the mid inal point, which is the point between anterior superior a spine and the pubic symphysis in the middle of that slightly more medial to the uh the middle point of the inguinal ligament. And that represents the passage of the femoral artery. And then, you know, if, if the patient's not got a very high BMI, it's easy to palpate the femoral artery there. And um you know, in addition to these uh anatomic landmark, you can always uh um uh figure out where that lies with the uh just palpating the uh the artery there. And it's best, it's easiest to palpate that artery close to the growing increase because uh there is less fat, uh subcutaneous fat in that area, right? Uh So that's a basic overview of the general um anatomy of the inguinal um uh canal going on to the next slide. Um I suppose the other um big thing that always comes up is uh what is a spermatic cord? So, spermatic cord basically is um you know, um in males, a combination of uh the uh uh goal arteries, spermatic arteries and um the testicular artery and the testicular vein that goes away from it, testicular vein. Obviously, you know, forms in the uh in the, in, in the scrotum as a PPA form pre. So lots of small veins joined together and they continue to Colace up and up and they form a plexus of veins in the spermatic cord itself and further up in the abdominal cavity, they cholest to form one vein or two veins and they run along the testicular artery. Um So we've got the testicular artery there and we've got the peform plexus uh there. And then obviously, there are some nerves, uh the nerves would be um genital branch of the genito febrile nerve. Um as well as the inal uh I ingo nerve that both of these run in the um in the uh uh spermatic cord. And then there is obviously that sympathetic plexus and a vast difference uh which also joins. Uh So the two main structure would be these, uh the three main structures would be these blood vessels and the vast difference. And then uh you know, these two nerves and Gonal nerve and uh uh genital branch of the genital femoral nerve. And then uh you know, the small other bits and uh bits and bobs uh that uh that come around some, some, some lymphatics and some um uh some uh synthetic uh uh nerves. The these these structures as they come out from the uh abdominal cavity to the effectively outside, they sort of get wrapped by the structures that they pass through. So, for example, they've got an external spermatic fascia, which effectively is from the external oblique ail neurosis, then preic fascia which are muscle fibers from the internal oblique ail neurosis. And then uh there is obviously internal spermatic fascia, which could, which could have the facia transversalis, which is the deep fascia uh or um external um uh this, this is the facia that lines the abdominal cavity from inside. Uh and it lies just superficial to the uh peritoneum. So there are these three wrappings and then there's, you know, the blood vessels and then there is the wasp and you know, a couple of nerves there. Um there is this uh um you know, aid for the memory uh which is there, it's basically crude and I find that sometimes these uh these, these, these, these crude aids, you know, they work best because they said stick in the mind. Um Right. Um So that was the, this, this diagram shows the structures as we see them. When we are looking from the front. I tried to keep them on the left side, you know, the left inguinal canal as much as possible. So, you know, we can make a mental um uh mental picture out of that. So, but uh now in the era of laparoscopy, we can see a lot of these structures from behind as well. So to flip it around, if we go and look at these uh these structures from behind and again, on the left side, you see that there is this vast difference coming immediately um and entering the deep inguinal ring. And then these blood vessels, the testicular artery and these bunch of veins around it entering the same defect. And the area where they entered that defect is just lateral to the last branch of external oblique, epineural, sorry, external iliac vein and artery. And that is the inferior epigastric artery, inferior epigastric artery is a very good uh an important surgical landmark. Because anything uh any hernia that comes through a defect which is lateral to the inferior epigastric artery would be um would be uh indirect hernia and anything that comes immediately would be a direct hernia And obviously, you know, when we are looking at it, in this view, we also see that the iliac artery and iliac or external iliac artery and external iliac vein also go behind. And this thing where my cursor is pointing, I hope you can see the cursor. Um this thing where, where my cursor is pointing is the iliac, is the inguinal ligament and just posterior to that um is what we call the femoral canal. Uh through which uh the artery and the vein, the external artery and the external vein enter uh the lower limb, the medial uh part of that um uh femoral um canal is basically an empty space filled with some lymphatics and some fat and some, some some loose areolar tissue. And that can, that is another area of potential defect where um uh hernias can form. And these would be the femoral hernias. So, as you can see that when we are looking at, from looking at this, from outside, we only see the external ring and the deep ring, uh the superficial ring and the deep in ring. But whereas when we see it from inside, we can also access uh for example, the femoral ring and a femoral canal as well, which gives us a slight advantage in terms of when we manage to manage these things surgically, why do hernias form basically anything that increases the pressure in the abdomen on a chronic long term basis. So, you know, coughing, COPD constipation, lower urine tract or prostatism. People tend to, you know, strain for their urine. Um, if there is a high BMI and lots of whistle fat pregnancy, uh, and you'd be surprised that, you know, uh, uh, uh, quite a lot of patients do tend to develop hernias. Um, uh, more commonly admittedly umbilical hernias during pregnancy because of this chronic in intraabdominal increase of, uh, pressure and the stretching of abdominal wall. Uh but hernias can happen if uh you know, during pregnancy as well and sometimes they regress afterwards. Um and if there is obviously intense repetitive physical activity. So manual workers, roofers, builders, um and people who tend to be quite intense in their gym workouts, um they tend to have um uh you know, more hernias. Um This obviously is exhibited by smoking. I've tried to, you know, show this diagram of why smoking harms this, but effectively smoking harm causes more hernias because it messes with the collagen synthesis and remodeling. And therefore this connective tissue becomes weakened and that mechanism, the external oblique, internal, oblique, transverse abdominis valve mechanism uh gets weakened because the facia is not as strong, there is laxity and then, you know, um uh with a coupled with some increase in a intraabdominal pressure and weakening of this protective mechanism. Uh the hernias form and then obviously um an injury uh can cause a hernia of a surgery. Um Previous surgery for any other reason can be an injury as well. So I I've mentioned appendicectomy. But you know, um nowadays, we do most of her appendicectomy uh laparoscopically. But when we were doing them open, we used to use the grid an incision. And if that incision extended laterally, it could cut the or damage the ileo and Gonal nerve. Now, I Gonal nerve at that level has got a motor as well as a sensory component. Whereas in the um in the, in the spermatic cord, I Gonal nerve only has a sensory component. And therefore, when we do an appendix, when we used to do an appendicectomy in a, with a really big incision where we had to cut the muscles, uh the nerve would get damaged and therefore the muscles down below the external oblique, internal oblique would get laxed. And that laxity of muscle again, messes up the valve mechanism and therefore, predisposes people to hernia. And you still get a people, a lot of people, a few people with uh inguinal hernias who have had appendicectomy with large incisions before. Uh Now how do these uh hernias present themselves? Uh These hernias, uh most commonly are swellings in the groin. Uh that can sometimes, uh you know, look a bit unsightly. Uh it can, it can uh distress, people feel a bit, uh a bit out of control. It can interfere with their work if they're doing hard physical work. Um Sometimes it can present with pain and uh especially in young patients who, who have got uh manual labor type work or who are working out in gym. The hernia tends to start with a bit of stretching of the fibers of deep ring and superficial ring uh as the hernia progresses and that can cause some pain. Um One thing to remember about pain is that not all people who present with pain, um and may or may not have hernia uh to be fair. You know, some of the patients will have a very small, very, you know, it takes a lot of examination and uh straining them to elicit the hernia. Uh and some may have an obvious hernia, but remember that not all pain is coming from the hernia. One of the most common causes of pain in the groin is what's called a Gilmore's groin or a groin strain. What happens here is that uh there is just like a sprain everywhere or a strain anywhere else. Uh You can have a bit of tear of the structures that attach to the pubic tubercle and there the inguinal ligament um uh up top and from the lower limb, the tendon of a ductal longus. So if somebody's got a poor gait or heart manual labor or if they've got back problems, they tend to uh unusually or, or some limb issues or walking issues or balance issues, they could tend, or maybe they carry a heavy weight, they tend to walk in a less neutral fashion, putting strain on the groin that results in some tearing of tendons, uh some some fibers in that in, in the medial part of inguinal ligament or upper part of a ductal los tendon. The hallmark of that would be that the pubic tubercle would be the most tender point on examination. And if you carefully palpate the inguinal canal, the medial part of it might be more tender or the ductal longus tendon, upper part of the ductal longus tendon might be a bit more tender as well. Um And remember, it is, it is important to discuss with the patient in these cases that while there are maybe other reasons to fix a hernia and goal hernia. If they have one, the pain might still remain there and it might not be fixed because that is one of the uh most uh um you know, most frequent cause of patient dissatisfaction afterwards. Um that they have unrealistic expectations in terms of their pain. The hernias can also present with the complications so they could stop getting reduced, maybe initially reduced UC and then no, no reducibility, uh they could get stuck, become quite painful. Uh And that could just present with pain. Uh They could have obstruction. And when we say obstruction, obstruction means obstruction of the structures that are herniating. Uh So for example, if the bowel is herniating, then it's obstruction of the bowel. So patient presents with bowel obstruction and once they've uh represented with bowel obstruction, a workup or a careful examination may reveal a hernia. Um, a very important thing to remember here is that, um, it is not uncommon for people to present with vomiting and occasionally diarrhea. I would say, you know, if somebody is obstructed, the distal bowel has to empty itself. So they can have quite vigorous movements and get some diarrhea initially. So they could present with vomiting and a little bit of loose motions and they could get shunted onto a ward, which is not surgical. Um And nobody has actually examined the groins to see if there is a tiny femoral or inguinal hernia there, which is uh which is stuck and it probably got a bit of bowel in it. Uh And that gets discovered a few days later when the patient becomes really unwell. Uh So as part of, you know, the, the the top tip would be that as part of my clinical examination, regardless of the situation. If I'm examining the abdomen, I would always tend to start with the groins and then move on to the rest of the abdomen. Because once you get caught up in examination, examining the rest of the abdomen, you know, you always tend to forget the hernia, um uh examining the hernia lot, especially if there's an exciting finding uh in the upper abdomen or elsewhere. And you know, this, this thing gets left behind. Um and, and obviously, you know, the last and uh but not the least, the most important complication is strangulation. Uh where um omentum or bowel, large bowel, small bowel uh can uh herniate into the herniate into the uh into the sac and then get stuck. And as you can see in the diagram, sometimes the neck can be quite narrow and that can impair the blood supply cause the uh structure that is heavy to be ischemic or even gangrenous. The aim would be that the patient should never get to this stage and we should pick it up fairly early in the game uh before the strangulation has happened. And the hallmark, you know, obviously would be that uh if the patient is thin or not too big, then all that inflammation uh from the ischemia and gangrene has started to filter through and there will be inflammatory skin changes onto the and there'll be quite a lot of tenderness and pain uh that the patient has uh mainstream of diagnosis is clinical examinations. You know, you generally don't need um uh imaging uh to diagnose a hernia. And we keep talking about um you know, a reducible swelling, which means that you get the patient to stand up uh face the other way in this day and age. Uh you know, especially with COVID and all that. And um and you know, look at the patient from this side ideally at the level of the groin area, ask them to cough uh initially and then palpate and see if you got a positive cough impulse. Um And then, you know, uh most of the hernias would tend to be reducible. You could reduce them uh in the direction of they came out. That is, uh you know, if you in the scrotum, you could reduce them up, uh and then laterally uh in the direction that they came out. So they go back the same way. Um uh There, there, there is obviously this talk about an indirect hernia. So you reduce the hernia, uh reduce the hernia and uh I'll, I'll keep flipping between the slides. So sorry about that. But I think it's important to just go with the diagram. So you uh reduce the hernia block the deep ring and get the patient to cough. And if the hernia um comes back um medial to your uh area where you block, that's likely to be a direct hernia. And if it is hitting on your finger where you blocked it, it's likely to be an indirect hernia. Some people include the femoral um opening in this uh test as well. Uh And as the medial end of this uh inguinal ligament is attached to the pubic tubercle um just above and uh um superior electoral to that would be the uh uh uh superficial uh ring, superficial, uh ring and inferior and electoral to that about four centimeters down. Uh In a standard patient would be the in the femoral canal opening. So some people put a finger or a thumb there as well and see if it uh if, if, if the cough impulse hits there as well. Um But having worked in clinical practice, I think uh when you take these patients to theater and you operate them, uh uh the clinical impression can be right or it can be wrong with equal frequency. Uh So a lot of people uh while it is important, you know, in terms of uh clinical examinations and um especially when you're going to be evaluated or tested in your uh respective medical colleges, um it may not be um you know, um clinically that important to distinguish between a direct and indirect hernia. Uh It is important to distinguish between a femoral and um and an inguinal hernia because the approach to open surgery will be different. Uh but it may not be very important to distinguish between a direct and indirect. Uh an ultrasound can be used when there is ambiguity in diagnosis. Uh patients got a high BMI and similarly a dynamic CT and an MRI might be useful as well to delineate the hernia. Uh if the clinical examination is ambiguous. Um but you know, more than 90% of these patients or 95% of these patients don't require any imaging clinical impression. Uh is uh clinical examination is enough um to decide on management. There has been a lot of talk about uh classification of these hernias and there is like a whole ton of these classifications out there in the system. Uh None of them are completely perfect. This is what the international current recommendations. This is, this is European classification that has gained currency. You know, it says whether it's hernia or a recurrent hernia, uh 0123, basically, you know, 1.5 less than 1.5 centimeter, uh three centimeters more than so basically size goes on the horizontal axis and whether it is a lateral, which is an indirect hernia or a medial, which is a direct hernia or a femoral hernia. Uh but none of them are perfect. And I, I'm not entirely sure whether they are widely used. The main thing to decide about a hernia is that is a hernia, is it a femoral or an inguinal hernia? And does it extend down completely to the scrotum or does it not, is it reducible? And is it not reducible? Uh and, and generally, you know, these things can be a, a question in a, in a, in a, in a simple, you know, couple of sentences and that usually describes the hernia pretty well. Um So for management, uh surgery is the mainstay of uh the management of these hernias and we'll get that, get more in more detail about this. When do we not operate on a hernia? So, not operate on a hernia when patients unfit, the hernia is not strangulated and uh there is a high risk of morbidity or morbidity. So, mortality. So patient can't lie flat. They've got very, they are very breathless. They've got congestive heart failure, they are on anticoagulation. There's a whole ton of things that could be put them at high risk for getting an anesthetic or a surgery. And if the hernia is not uh at imminent risk of an emergency, um we just tend to leave them well alone and sometimes within the, um, uh, you know, expected life expectancy of that particular patient, the hernia does not usually both of them. Um, the second, uh, category would be when the, uh, patients are really symptomatic. So, in about, uh, I think about 10 years back there used to be a, there, there was a big movement about, uh, trying to not operate on hernias in an attempt to see if we can, you know, reduce the workload generally about these hernia, hernia, hernia operations. And it was found that most of the patients who have got a symptomatic hernia will, uh, uh, progress, uh, on to worsening symptoms or, uh, some of them will, uh, get, uh, uh, get, um, get complications as well. So it was found that it was, if the patient symptomatic from their hernias been increasing swelling, um, then, uh, then it is best to operate on them. However, if they're minimally symptomatic, the hernia is small, um, or even impalpable and it's just been found on, uh, on an ultrasound, uh, done incidentally or done for pain, then it may be worthwhile, uh, to have a watch and wait uh, policy. And sometimes, you know, the patient really doesn't want an operation for any reasons and you have to respect that so you can't operate on them. Um, people who are symptomatic and who fall in this unfit high risk category. Um, you know, one of the options to do that would be a trust which is to reduce the hernia and put a bit of, uh, uh, gentle pressure. Well, it's not gentle, it's a fair, fair bit of pressure to make sure that the hernia stays in. Um, the problem with this and long term use is that it can, uh, damage the skin. Uh, and sometimes the hernia can, you know, these patients are generally very unfit. They don't have a lot of strength in their arms or hands so they may not be able to reduce it properly and apply the truss on top of it. And there is this risk where, uh, the bowel can be herniated and then a Truss put on top of it and then bowel can, uh, basically, uh, get squashed between the truss and the, and the muscles. Uh, they never lead to a good outcome. Um, so again, you know, this is, um, uh, not used very, very, very commonly and only in, you know, as very selected, uh, um, number of patients why operate on the hernia, uh on these hernias, the main reason to operate on inguinal hernia is what we call the natural, uh um uh natural history of a disease. Uh, if there is no intervention and the natural history for inguinal hernia is that they will increase in size because the, because the risk factors that led them in the first place, they generally tend to stay, it's generally a lifestyle choice. It's generally smoking. It's generally, um, I, you know, um, intraabdominal uh increase in pressure chronically. So these risks generally tend to stay and therefore, uh the uh the chances of hernia gets bigger and bigger increases as the time goes on and they get into complications. So to prevent that from happening, uh generally, um, you know, patients who are symptomatic with inguinal hernias are offered an operation. Um, patients may also want to have their operation because they have pain. But again, I've, uh I've discussed that there could be other causes of pain and if the pain can be attributable to the hernia, remember that people who have had pain, uh who have pain as a symptom, um before their operation are likely more likely to have continue to have some pain afterwards as well. Uh And you know, bulge, increasing bulge can interfere with your daily life work, et cetera. Um uh we have to, um, you know, explain to the patient uh or discuss with them that uh whatever we do, you know, regardless of the best operation, there is a one in 200 chances of uh um uh uh a hernia coming back again. Uh There is a one in 20 chance or 5% chance of uh postoperative pain. Uh And this pain uh beyond three months could be, you know, chronic postoperative pain could be because of uh the nerve damage, the Gonal nerve, genital branch of the genital femoral nerve. Um And then they could also be some inflammatory pain from chronic scarring around the mesh, which could or not, um you know, uh sort of uh the or, or, or, or just, you know, sort of um how I should say wrap the, wrap the nerves around it or press the nerves or squish the nerves and, or call chronic scarring and the resulting chronic inflammation in that area could constantly irritate the nerves. Uh So these things, these things can be there and sometimes these are really hard to fix. But the patient has to be aware that in a minority of uh small minority uh that may impact with their life, uh uh daily work or daily activities at work. The mesh infection is uh really infrequent. Uh one in 500. Um it's becoming less and less as the uh surgical charity and uses of um you know, practices around that have improved. But I realized that there may be some settings where uh the sterility is uh not possible to um uh you know, the standard of ster is not as high as in other places. Um So the mesh infection has to be taken and might require uh prolonged antibiotics or even removal of the mesh. Um So British Society up here um tends to have this um you know, ready made leaflet that you could print out and give to the patients for their information. Um But I realize that there might be, you know, this is about lifestyle and you know, what we tend to do and what is likely to happen. And you know, a lot of details. Um Generally, I find that when you're discussing with the patient, it may take a long time to discuss all of these things. And even then because there is no, there isn't to check that you tend to forget a few bits. So giving the patient out these leaflets are really, really helpful and let them go home and digest all the implication of the hernia on their life and what is likely to happen and takes basically a lot of apprehension out of the process. Um It is, it is available on this British Hernia Society um uh um website. Uh but I suspect that uh you know, it is designed for the, for the general um British uh patient and uh the details might need to be altered, the languages might need to be translated. Uh But a useful starting point and it would be helpful uh if somebody is doing high volume surgery to develop this thing. And for people, um, who are, who are, who are abroad, uh, they may, you know, this, this may be something worth considering to develop, um, a deflect. And if you look around, there might be people who have already done that and, you know, it's easy enough to just take it off. That would be really useful, um, practice to have, have, have a leaflet to be given out to the patients. Um Now, coming to surgery, surgery is the mainstay of hernia repairs. Generally, if a hernia has happened, it's not going to fix itself. Um And uh you know, up until recently when I say recently, I mean, about 2030 years ago, uh there used to be, or even even 40 years ago, there used to be a lot of controversy around the best methods of hernia repair. Um There were a whole of uh names, you know, different surgeons. I use this technique and my boss used that technique and this and that and you know, this technique is better than that technique. I stitch with um uh absorbable sutures, I said would not absorbable suture, I stitch with this and that. Um but gradually now it has coed to uh all these names have disappeared. And generally, you know, cholesterol around um you know, two or three techniques that have become the standard of uh repair. Um The current techniques that we are uh basically uh you know, mostly involved mesh. The vast majority of the patients get a mesh repair. Uh, some patients get, uh, don't get a mesh repair as well. So non mesh, I'll, I'll, I'll go and, uh, start with the non mesh techniques. And then see, uh, because sometimes, you know, you're not able to use a mesh if there is infection, if the, uh, patient has had uh, a necrosis of the bowel and is an emergency surgery or if the patient doesn't want, uh, a mesh put in. Um, so I'll, I'll try and quickly go through, uh, the mesh and non mesh, uh, repairs. Um, when you're talking about mesh, the main, uh, thing to remember is that the mesh should be lightweight, uh, because the lightweight mesh can form to the body contour and are less uncomfortable in the long run, they should have a large pore. So, uh, you know, the, uh, fibrous tissue can grow into it but not, does not form a hard fibrous plate. It should be strong, pliable, easy to handle and, you know, for whatever it is worth, they should, uh, not cause a lot of fibrous reaction. Um, again, you know, you're putting these mesh in. So the, um, uh, connective tissue can grow into it and form a scar to, uh, uh, strengthen the area, but you don't want excessive, um, fibrosis there as well. Um, so people still, you know, debate about the best mesh. There's lots of different materials out there. Um But generally, a lot of people have settled on pro as the most, most, most most used mesh. Uh And if you're putting it in a place where it is likely to be in contact with uh viscus like large bowel, small bowel, then it's they have developed these bilayer meshes which are coated from inside with collagen or silicon that do not allow adhesions to form. And by the time they wear off the mesh has been covered with the fibrous tissue with the scar. So the bowel adhesions can be prevented. Now, uh the most common non mesh repair uh is Bassini repair. Um Now, if we go back to our anatomy, we know that this is the external oblique which is being held by these clamps and external oblique down below the external, which is, which has been cut again. You know, I've tried to get to the left side. So this is the cord coming out uh external cut open. And this is the uh inguinal canal with the cord lifted out. The inferior part, obviously, the external would go down and curve inwards to uh form the inguinal ligament. The repair mean. Uh What what it does is that it stitches, the inguinal ligament, lower intern part of the inguinal ligament to the conjoint tendon, which is the conjoint bit of uh the internal oblique and transversus abdominal. It's a really strong, thick uh bit of uh muscle uh that we can use uh in a permanent suture like uh nylon or proline uh to stitch together, um uh usually interrupted and, you know, sort of, sort of close together that, so it's, it's a really good way. Uh what you are doing is that you are putting extra tissue behind the inguinal canal um over the um you know, sort of floor of the uh floor of the inguinal canal, uh sorry behind the spermatic cord over the floor of the inguinal canal. And at the same time, uh making the deep ring quite snug as well. Um So that takes care, you know, if the deep ring has expanded because of the herniation, uh or, or indirect herniation or the floor is quite lax because of a direct herniation. This takes care of both of these problems. Um So that, that's, it's a really good and it doesn't involve any foreign body um like a mesh which can get infected if there has been um dead bowel in that space, um which has resulted in translocation of bacteria and a bit of pus there. The problem with this is that you uh this, this is, you know, a couple of centimeters and sometimes more if the hernia is big and you're pulling this muscle down below and uh this inguinal ligament up below to cause a little bit of tension. When you have that tension, the blood supply, uh diminishes just uh so uh that uh these can break down um in a minority of the patients. And that was what was wrong with the tissue repairs. And therefore, people shifted on to mesh to prevent that tension uh from developing. One of the ways to stop this tension from developing is to go up uh and immediately uh towards the uh external oblique epineural, which is the tightest part of the whole thing in this area and make a small oblique uh going up to the head, head side incision uh through the external oblique epineural that's called a tender release. And that allows the hernia, the the external oblique epineural to uh slide down uh and be a bit more relaxed. So, uh you know, the muscles can come down and close together now. Um and it's uh but, but, you know, this is a, this is a good technique to know and learn for emergency hernia repairs. And if the patient refuses, absolutely refuses an operation, uh a mesh put in uh because sometimes, you know, they google that and the mesh can sometimes have a lot of bad press um et cetera. Um This, you know, uh should ii don't think a lot of people do that. Uh should I is, is, is, is basically um a very famous technique, you know, it, it's basically got these four overlaps behind and one overlap in front of the aspermatic cord. Um But people, you know, have a lot of proponents and a lot of opponents. People who are proponents say that it's got a very good uh repair technique. A strong repair technique has a low recurrence rate. But uh people who are against it say that when you're trying to uh double breast, a lot of tissue that can generate quite a lot of tension and result in, you know, breakdown. So what they do is that they lift the spermatic cord as we have done here behind this uh retractor on the left. Um And then uh we open the facia fellis which is the posterior most hair, close it with an a nonabsorbable suture. The original authors who develop shoulder technique use steel, but we can, you know, use prolene or some other nonabsorbable suture, generally monofilament to prevent bacterial ingrowth and infections. So, uh double breast uh close that um uh fascia transversalis posteriorly as a double breast, then bring this conjoint tender in the posterior intent part of the inguinal ligament and close that as a double breast uh and then replace the cord and close this uh external oblique, epineural either singly or as a double breast. So it's three layers of double breasted tissues, quite strong, very hard for another hernia to come through. Uh But again, you know, if there is a lot of tension um um then, you know, uh the stitches can break through. Uh so, but I don't think a lot of people use that uh except uh very few proponents, there is a relatively newer um option now available. Uh It's called the s uh repair. Um It's caught on quite nicely and developed in India effectively. What they do is that uh they take a flap of external oblique aponeurosis. Um So, external oblique aponeurosis. So this is um you know, a hernia on the right side. Um So I'm sorry about that, but uh the cord is lifted out here. Uh This is the external oblique aponeurosis, which has been cut. And then while the external oblique aponeurosis is still attached at its lateral side and the medial side, um a centimeter or two centimeters depending on what you need. Uh A strip is basically detached from the rest of the external oblique aponeurosis. And then this stitch is mm stitched to the posterior uh wall. Uh the floor of the canal reinforcing the external oblique aponeurosis and whatever else structures there are and can be, it could be a direct hernia here or indirect hernia. Both are treated. The best thing about this is that this is an autologous, effectively an autologous tissue that is being used no large foreign bodies apart from the stitches there. And it, it works just as well as any other and low recurrence rates. Um So, so that it's a very good technique and again, you know, um could be used in an emergency situation. Now, we come to the mesh repairs, mesh repairs are the mainstay of treatment. They are the standard um, uh, um, basically we, we lift the cord, reduce the hernia, keep them reduced and put a mesh in there. Generally a proline mesh. There are now self gripping meshes as well, but they don't really have any, uh, you know, demonstrated advantages. Uh, people who, who, who quite go with them. Um, uh, we make a small slit in the center and then, uh, you know, the slit goes around the deep rink and uh these are stitched continuously to the inguinal ligament and fixed interruptedly. On the other other side, the two flaps are stitched together and that's a very secure and this is the mainstay of open hernia repair. Nowadays, this is the standard um that we use complications. As I said, you know, you can have infection, you can have the hernia come back again. And uh chronic long term uh pain called dynia are very hard to fix. Um acutely postoperatively, patients can have urinary retention. So just make sure that the patient passes urine before they go home. Um They can have a seroma and, you know, we could injure the blood vessels and nerves that are going around it. We've talked about. Um Obviously, a lot of hernia repair is now shifted like everything else uh to minimally invasive surgery. Uh Invasive surgery is generally two types. One is extraperitoneal, which is de totally extraperitoneal preperitoneal repair and then transabdominal preperitoneal repair. Um with the tip, as you can see on these diagrams and I've tried to make that a bit bit clear is that you go just below the umbilicus, make a small transverse in two or three centimeters, um incise the uh anterior rectus sheath and then retract the rectus abdominal muscle laterally. Now, just below the umbilicus there, the there will still be the posterior rectus sheath, which is available. So you stay in front of the posterior rectus sheath with a retractor retract up and laterally the rectus muscle and, and, and then, you know, uh put a balloon in there, um, that balloon expand and, and put a balloon in there, inflate that balloon and that balloon expands. And as the rectus sheath finishes sort of midway between the umbilicus and the pubic symphysis, um the balloon uh automatically would enter into the external preperitoneal space and that preperitoneal space is where we um operate. Um Whereas the tap repair is when we go like standard laparoscopy, we go in, uh, see the area of the inguinal hernia, uh shave the peritoneum off from somewhere about, uh about the, uh, you know, the level of the hernia, bring it down, expose the hernia and uh put a mesh and all that and repair it from that point of view. This is again, the laparoscopic view, um, again, on the left side. Uh So when you see the laparoscopic view, you can see that uh the uh uh vas comes from medial side, um, uh, vessels come from lateral side. And uh you can clearly access the in the indirect hernia sac, the direct hernia sac and the femoral. And when you put the mesh, the mesh completely covers all these three defects. So the advantage of uh laparoscopic view, uh hernia repair is that you can uh treat all these three potential hernias in the same uh same, same uh setting uh problems problems is that you are working just in front of um uh these giant vessels that go to the lower limb. Uh And um when they go to the lower limb, uh you know, you can damage these vessels cause quite horrendous bleeding, need emergency surgery and blah, blah, blah. So you don't want to go there. The other problem with that is uh this is called what we call the triangle of pain, uh which is a bit lateral to that area and that lateral area is uh effectively, you know, um has these muscles, uh has these nerves, which is the, you know, sort of femoral branch of the genital femoral nerve, um femoral nerve, rectal cutaneous nerve, uh neal cutaneous femoral nerve and all these nerves, if they get uh you know, sort of trapped into the mesh or damaged, can cause lots of severe pain. Um Again, the recurrence rates are comparable to the um but, but the POSTOP um uh POSTOP pain and return to work is quite uh good. Uh Another problem with the uh laparoscopic repair is that the peritoneum can get stretched out, the mesh can get exposed and bulk can get uh uh uh uh ad adhesions with the, with the mesh. Um Sometimes, uh you can have sliding hernias, which is um a bit of the, um, you know, large bowel or bladder, which slides on the retroperitoneum along with its blood supply into the sac. And one part of the sac can be made of this, uh um this uh or organ. And uh the pitfall here is that if you try and open the sac and empty it and push it back in, then um then you can uh damage these structures and cause quite nasty injuries. A Pallo hernia is when the hernia has got two sacs and they are straddling then one the epigastric artery and they can be, you know, uh basically two hernias again, no difference is actually in fixing them or as A L. Um But it is important to be aware that there can be two sets and you need to address both of them uh management algorithm effectively. If it's um primary inguinal hernia. Um the recommended thing is like tensin open repair. Uh If it's a primary bilateral hernia, then a laparoscopic approach is best. Um If it's um and, and, and the most important thing to remember is that if it's a recurrent hernia, if it's a recurrent hernia, then uh if the hernia has been repaired before as an anterior approach. As in an open approach, you should go laparoscopically when it's recurrent. And if it has been previously repaired by laparoscopically, then uh you have to repair it. Uh it's ideal to go as an open approach because both these cases, you know, you don't want to go and mess up in the same plane which has been operated before, is likely to be fibrosed. So you, um you go, you go with the plane that has not been, uh, that has not been, um, that has not been uh um sort of um operated on before. And therefore, uh it's easier to operate and get a more satisfactory um, repair done. So that's basically, um, you know, for, uh for uh if, if the hernia is complete hernia as in going to the scrotum and, you know, patient had, had previous abdominal and um uh pelvic surgery, then uh going from a laparoscopic approach will be very uh difficult. So an open approach is uh is preferred in emergency surgeries. Most of the surgeons will do an open approach. There will be some who will do a laparoscopic approach, but open is uh generally the best and gives, uh, gives best results. Um, postoperatively, the most important thing, the patient should pass water uh before going home and uh they should uh avoid heavy lifting for four weeks. I tend to ask people not to do any heavy lifting for four weeks because, but that is, you know, effectively a little bit of snake oil. I think there's no evidence to say that, uh, patients should avoid heavy work. Uh, the hernia mesh is generally strong enough to take all the, all the weight and should be ok. Um, but it's just useful to let the mesh settle in. Uh, before, uh, they go back to somebody is a heavy, heavy worker, manual worker and all that and when patients go home they should have a point of contact uh what to do and who to call if they get into any trouble. Um Yeah, so I can uh take some questions and um uh if there are any uh if there aren't, then I can show a few pictures and ask the people's opinion on what to do with uh these patients, right? Uh OK, so good. So a subway and only measures are a different category, um different, different category. Um um And II suppose, you know, this is not uh we, we, we tend to use uh subway and only me in terms of incisional hernias. Um So I II would say that uh at this point, we probably just fit with fix stay with our Inguinal approach. And maybe another, another time I could um discuss about sub and onlay measures and you know, inlay measures. And what are the one is um Tenia mentor said, what is a little hernia? So little hernia is basically a hernia which has got uh diverticulum uh, in it, um, uh, in it effect in abdominal wall whereas, uh, Richter's hernia is, uh, something, um, completely different. Um, uh, you know, uh, Richter's hernia is, um, sorry, can you hear me? Ok. Can you hear me? Ok. I, mm. So recta, yeah. Ok. Good. So, rectal hernia is when the bowel is protruding into the hernia. And this could be any hernia, inguinal or whatever, but only one wall of the abdominal wall that bowel is, uh, protruding. Uh, it may be, uh, and, and therefore the patient has got, uh, you know, uh, bowel in a hernia which could be strangulated. But, um, and it could be strangulated, it could be perforated, but because the rest of the bowel is in continuity with each other, there is no symptoms of bowel obstruction. Um, so again, you know, patient could have a strangulation without that obstruction in that setting. Uh, that particular case. Thank you. Uh, um, so that's what a rectus hernia is. Um, and it's not, uh, you know, it's not uncommon. It can, it can happen, especially if the hernia is small patients. And, um, so in terms of eye, I said, in terms of management in a radiological hernia causing them, is there any way to stop its progression without surgery? So, generally, no, uh, if it's a radiological, so you get these patients where, you know, they've had an ultrasound, you've got like a one centimeter hernia with a bit of fat in it. Um, it depends on the symptoms. So, if the patients got pain and no hernia and no other symptoms, I would just tend to wait and watch. Um, if there are any modifiable symptoms. So if the patients got a high BMI, if patients got COPD chronic constipation, if they're a heavy manual worker, uh if, if these things can be modified, it might progress to slow the progression down. Um, but it's hard to say whether it would or it wouldn't. Uh There may be some uh you know, some problems with the collagen synthesis that has led to this hernia. Uh but I would be uh hesitant to treat an uh hernia which is not causing a lot of symptoms. But um has been seen on an ultrasound scan when the my my rationale to that is that if you do ultrasound, you know, you can find even um if there is a lax deep ring, uh you can find and get the patient to cough and if they cough vigorously enough, there is a bit of extraperitoneal fat that's going to protrude in that hernia anyway. And that some people can report on an ultrasound as a hernia may or may not be clinically significant and you're subjecting the patient to an operation, a mesh with complications and whatnot based on that. So I would tend to wait until patients got a lot of symptoms, a lot more symptoms and a bigger hernia before going in for an operation. Uh but no, you know, apart from modifying the risk factors, avoiding smoking, um I'm not sure whether there is anything else I can do in a unilateral her. Do we, we do. Uh So 10 says we do open and with bilateral, we do laparoscopy. So that's a recommendation. Yes. And this recommendation is based on the fact that um when we do two open hernias, bilateral open hernia repairs, uh uh the cost of doing these two hernias roughly comes to the cost of um uh doing the uh the, the laparoscopic one and with laparoscopic, with the same incisions, uh that is um uh infraumbilical mid and uh small transverse and 25 millimeter ports. We can uh um repair both these hernias at the same time. If it's bilateral a unilateral, there is less clear advantage of laparoscopic versus open hernia repair. So people do open hernia repair and the cost is higher if you're using a balloon uh to dissect the extraperitoneal plane. Uh Now, obviously, you know, there are people who do that without a balloon. So I tend to do my t hernias, the extraperitoneal ones without a balloon. Uh And therefore the cost is less of an issue once you've got the stack and you've got uh uh your other stuff uh um which can be reused. So, uh yes, bilateral unilateral hernia can also be done laparoscopically. People do much better, less pain because we don't use t so uh faster return to work. But during the hernia, based on the fact that it's, you know, it's, it's uh much less expensive than a laparoscopic repair. Uh The recommendation would be to do um uh do an open uh with bilateral, do a laparoscopic but it's not, you know, like, uh like all, um like all operations. It's, it's not um how do I say it's not clear cut and these things are evolving and shifting as, as time goes on. Uh So I don't generally tend to deal with the pediatric age group, but pediatric age group, uh the strangulated hernia will have um quite clear marked skin changes, systemic toxemia and uh um bowel obstruction there. Um um They tend to have quite a bit of abdominal distension, tend to go down really quickly. Um And uh you know, the that is more of a emergency um than uh than uh than, than adults, you know, they need to be, they have a uh uh lesser reserve. So they need to um be taken to theater and fixed really quickly. Is there any says is there any metastasis going with the hernia? Should we do anything metastasis going with the hernia? So, I don't understand, but i it it is, is it possible that it could be talking, is talking about any metastasis in the inguinal canal? Um It obviously, uh or, or, you know, in the hernial sac and yes, that can happen ovarian tumors, transperitoneal malignancies, it can happen. Um, generally we won't do anything about it. Uh, unless, uh, it is in the danger. It is, it, it's looking like that it's strangulated or it's, uh, um, it's symptomatic. We address the primary tumor. Um, if the tumor is, you know, when, when there is transperitoneal metastasis, unless it's something like a low risk ovarian um, cancer which is treatable, um, or may, may benefit from, uh management patient at that point would be, you know, uh would have other problems in just their inguinal hernia. Uh So I've talked about uh difference in management hernia in pediatric patients. Uh Yes, pediatric patients have um uh very short inguinal canal. And therefore, um in pediatric patients, especially younger patients, we tend to just do what we call herniotomy. So we make a small incision maybe a couple of centimeters about where the hernia can be palpable. And then um uh Oh, ok. Sorry. So we are in pediatric patients, we tend to make a small engine over the hernia, find the hernia sac empty it, reduce the contents, uh transfix, the hernia, close it and then let's reduce it. We don't open, tend not to open the uh inguinal canal. And we don't put measures in because measures tend to um uh block the uh differential development. And the expectation is that as time goes on, as time goes on the uh um uh inguinal canal will develop more and more and uh the differential development will stop any further hernias from coming, um coming, coming, coming on. Um So that's it. I think, um I would just, you know, while, if, if you got a couple of minutes, I just want to see that we've got this patient, uh who's got a small hernia in the right groin. Um As is, um, um what would people do about this, uh hernia? Would they go open like tensin versus a laparoscopic uh tap or tap repair? Ok. So the issues around this uh patient would be that he's got a midline uh laparotomy done in the past. Yeah, absolutely. Than so midline laparotomy done this far. So the good thing would be that this is um so, so yes, that would be absolutely the right answer. It's an open hernia because of the midline that brought me the access to the extraperitoneal plane or peritoneum might be difficult. So, for, for practical purposes, it will be an open one. Let's go to the next one. This is a small bilateral inguinal hernia. Um probably direct. Um What would we do with this kind of hernia? So, I, yeah, so I think the uh laparoscopic is the one, the small um uh thing here. Um I would take that as a skin crease and not a previous pty incision. If patient had had a Tyle incision, then um I would uh be cect in doing a laparoscopic one. Probably do an open one. But if no Pyle incision, then uh it would be uh laparoscopic uh and bilateral mesh placement. Now, this hernia uh again, bilateral hernia. Uh but this one seems quite big and going down to the scrotum, I've not put the scrotal um uh you know, picture in there. Um But um what would people do with this one? Yes. Um So just, just to finish this one. I would, I would say that this one, I would do an open procedure for him uh for this patient because the hernia is quite big and laparoscopically big hernia which are going down into the scrotum tend to be difficult to reduce and tend to have complication if they've got bowel. So I do an open one now for obstructed, um my own has asked restricted for obstructed inguinal hernia. What technique is better than nylon darning or modify? So, yes, nylon darling. I've done a lot of nylon darling. And you know, this was what we were taught um back home. Um But I've II, you know, II think, I think it is, it is, it is a good, good enough repair works really well. Um But uh Bassini has got a better um modified Bassini is better. Uh for this reason being that you're putting AAA thick, chunky bit of tissue uh to support the posterior wall. Um Whereas the darning would require a lot of um po implication of the facia transversalis and then the darning, there's a lot more, uh, foreign tissues and less, uh, uh, autologous tissues. II, and now, at this point in time I would go for a bisi, a modified bis rather than a dining darning for the, um, again, uh, this hernia quite big. Um, looks like an elderly patient. Um, judging by the, uh, tiger of the skin, um, going down to the scrotum. Ok. So, I'd, I'd imagine that, uh, a lot of people are thinking of open uh hernia repair. Um Generally, you know, when, when, when, when you do laparoscopy or uh TP you're raising the intraabdominal pressure, obviously. And that um uh that has its own implication if somebody's got a bad heart or congestive cardic failure. Um Yeah. So, um uh II II, agree with you. Uh May honor. I've done a lot of ding, you know, when I, when I learned hernia repair back home ding was the mainstay and we used to do a lot of that. Um And, and we used to be funnily, you know, judged on how beautiful and even the dining dishes are. Um, it's, it's quite a nice technique. Um But I think it's, you know, now I think that it, um it, it does represent uh uh you know, um the worst of uh both uh both world in that. Uh you know, you are, you are basically constructing um uh a makeshift mesh um without the advantages of the mesh, you know, it's not, um, it's not got the um the structure of a mesh um without actually, you know, using some local tissue to strengthen the posterior wall. Uh Now, I think differently, but yes, I agree that darning is a, is a very nice technique and if somebody knows how to do it well, it works beautifully in majority of the cases. Um Yes, open repair this hernia, obviously, you know, you do occasionally come across this um elderly uh patient who come with this giant hernia. And um, you know, uh they've been managing it for years. Um And, and now they want it fixed. The last one that I had said that he couldn't see the uh penile shaft and therefore, was unable to pee properly. Can I get his hernia fixed for that reason? And I said to him that look, you know, you're, you're, you're 70 plus and you've got a whole ton of uh comorbidities. He was on anticoagulation for a previous CVA minimal um exercise tolerance. And if the issue here is in this hernia that if you reduce even half of this content in a very unfit patient, then their uh diaphragms get pushed up and they get into respiratory compromise. In a young fit patient, you probably get a hernia operated much before it came to this point. Um But uh if the patient is moving their bowels and they are not obstructed and no evidence is strangulated, I would be very hesitant um and, and try and manage this uh in a non operative way for as long as possible, they probably do more harm to the patient trying to operate here. Uh You can do a perfect operation. Uh but the patient may never come off the ventilator afterwards, right? So somebody was asking what does a strangulated hernia look like uh strangulated hernia looks something like this, if there is a strangulation in there and then uh um you know, skin changes and that tends to be spreading quite spread quite rapidly. Um And you know, the the ultimate uh uh thing to do is to get him them an operation. And sometimes, you know, you can't reduce the hernia or um very, very occasionally, you know, you have to convert to a midline necrotomy rather than a supine goal in. But most of the vast majority of them can be managed supine. Uh Right. OK. So we've had our questions. Um um Is there any other question that I can answer? Ok. I suppose everybody wants to now go and enjoy the uh the, the Sunday. So yes. Uh so I think I do. Patients tend to refuse surgical treatment a lot. Um Yes, they, they do tend to query a lot, especially people who don't, you know, who are hesitant about measures because the gynecological use of the mess has had very bad press, they Google mesh and then they find out that there's a lot of issues rated with the mesh and then you have to, you know, reassure them that this mesh is put differently. And that uh pamphlet that I said, you know, if somebody develops a local pamphlet or modifies this one in the local language, you know, if you give that out to them and let them think about it, then when they come back again, uh to decide about the hernia, a lot of these questions already been answered. So that's really the best way to, uh, to do that with. Append how long, uh, surgery. I don't know. Tishia II don't know how long, you know, it can be never and it can be a decade afterwards. Uh, but people who have had big, big, um, muscle cutting, Rutherford M and incisions, uh, they tend to have more, not, uh, not all of them will have that hernia, but they tend to have more hernias. Um Right. Thank you very much. Um, everybody for attending, giving up a bit here Sunday. Uh I hope you have a good rest of the day and enjoy yourself. Um Thanks for turning up guys. Great. I'll, I'll, I'll leave you then. Bye-bye. Perfect. Thank you so much, everyone for coming, um, and attending the session. Make sure you fill in the feedback and follow medical education to get notified about future events as there'll be lots and lots coming up. Thanks everyone. All right. Take care