“There is no place to mesh prostheses in inguinal hernia repairs now because no mesh technique of “Dr. Desarda Repair” is available with superior results.”
Bubonocele / Inguinal Hernia
Bubon = groin
Bubonocele is a type of inguinal hernia which is limited in its extent to the inguinal canal.
v Occurs at all ages; M > F
v In 1st decade - right > left ( because of late descent of right testis)
v After that R = L
v Bilateral in 1/3 of cases
v Etiology :
1) Increased Intra Abdominal Pressure due to straining :-
v In children - Measles, whooping cough
v In adults - Smoking, chronic bronchitis, emphysema, hard physical labor, Intra Abdominal malignancy,
v Stricture urethra, chronic constipation
2) Increased Intra Abdominal Pressure due to stretching muscles :-
Ø dull dragging pain referred to the testis - increases on work
Ø If obstructed may have constipation, vomiting, pain
Ø If strangulated may have severe pain, shock, collapse.
v Clinical Findings
Ø piriform swelling - in the inguinal canal
Ø bubonocele does not come into scrotum
Ø Cough impulse + Reducibility +
Ø Neck of the hernia is supero-medial to pubic tubercle
v Special tests
Ø Deep ring occlusion - hernia does not appear
Ø Finger Invagination - impulse at tip of finger
Ø Dr.Desarda's test - Sliding of contents from ring finger to index finger indicates indirect and from middle to index finger indicates direct hernia
v Types :
2. Irreducible (complication of (1))
3. Obstructed -------"---------
4. Strangulated ------"----------
5. Inflamed (the viscus in the hernia is inflamed - e.g. appendicitis, salpingitis)
v Differential Diagnosis:
1. Femoral hernia
2. Direct inguinal
3. Vaginal hydrocele
4. encysted hydrocele of cord
5. Undescended testis
8. Diffuse lipoma of cord.
9. Femoral hernia
10. Hydrocele of
 Principles of treatment :
1. Restore the disrupted anatomy
2. Repair using fascia / aponeurosis NOT muscle
3. NO tension
4. Suture material used should hold until natural support is formed over it. ( i.e. monofilament nylon or polyethylene)
1. Resuscitation - in case of strangulated hernia with gangrene with shock or with intestinal obstruction.
2. Reduction of hernia - includes taxis, & reduction under anesthesia.
3. Repair - of the defect - may be herniorrhaphy or hernioplasty.
v Strangulated hernia -
Ø treat as emergency
Ø treat shock if any. Start IV antibiotics
Ø Incision over the most prominent part of swelling - sac carefully identified & dissected out. Sac opened.
Ø Aspirate all fluid ( highly infectious)
Ø Resect any unviable intestine or omentum
Ø EO aponeurosis & external ring divided. Sac opened throughout the length upto deep ring & a little inside.
Ø Viable contents reduced. Definite repair carried out - any prosthetic repair is contra-indicated.
- Non - Operative approach - in elderly, unfit / unwilling for surgery.
- Use of truss is advised in such cases- Truss must be applied with hernia reduced. Must prevent reappearance of the hernia on straining.
- Surgery - treatment modality of choice.
1 - Herniotomy - may be sufficient in young, muscular individuals and in children.
2 - Herniorrhaphy - in adults with good muscular tone.
3 - Hernioplasty - in elderly with poor muscular tone.
C/I in strangulated hernia - may get infected leading to wound sinuus.
v Herniorrhaphy -
o Dr. Desarda's repair: Giving physiologically dynamic and strong posterior wall should be the principle of any type of inguinal hernia repair to give 100% success rate. Undetached strip of the external oblique aponeurosis is sutured between the muscle arch and the inguinal ligament to give a strong posterior wall which is kept physiologically dynamic by the additional muscle strength provided by the external oblique muscle to the weakened muscle arch.
Ø Lytle's repair (syn : Marcie's repair)- narrowing of the deep ring by suturing medial wall - Tight enough so that cord & little finger just fit in.
Ø Bassini's repair - Suturing of conjoint tendon to the incurved part of inguinal ligament - medial most stitch through the pubic periosteum - sutures taken with non-absorbable sutures - originally done by Bassini using black silk - now monofilament nylon used. - Chances of femoral hernia increased.
Shouldice repair - Double breasting of transversalis fascia -
best tissue repair - at the Shouldice clinic in
Ø Ogilvie's repair - plication of transversalis fascia
Ø McVay's repair / Cooper's repair - Conjoint tendon sutured to the Cooper's ligament - also prevents Femoral hernia formation - closes off the Fruchaud's orifice.
Ø Condon's repair - Conjoint tendon sutured to the ilio-pubic tract.
Ø Halsted's repair - repaired at 3 levels (6 layer repair) - Bassini's + Shouldice + double breasting of external oblique - cord becomes subcutaneous
Ø NYHUS / Cheatle - Henry repair - pre-peritoneal repair - may be combined with prostatectomy. Used for large double hernias (direct + indirect), bilateral hernias, & Recurrent hernias.
Ø Inguinoclysis - only in elderly men with recurrent / very large hernias - obliteration of the inguinal canal with bilateral orchidectomy.
Ø Pantaloon hernia - Treated by 1st converting the hernia into one giant indirect hernia & then treating it as indirect hernia
1] Of the hernia -
v Toxic shock
2] Of the surgery -
v Sepsis ( most common ) - may lead to formation of incisional hernia.
v 2ndary hydrocele - damage to lymphatics
v Testicular ischemia & atrophy
v Division of the vas deferens - especially in children
v Sinus formation - use of non-absorbable sutures
v Nerve entrapment - ilioinguinal N.
v Lymphocele - common after operations for femoral hernia
v Recurrence of hernia.
Hernia - General information
Hernia - General
v Common Hernias : Inguinal, Incisional, Femoral, Umbilical
v Acquired Hernia - Incisional
Hernias due to obesity - Direct inguinal,
v Diaphragmatic hernia - congenital or acquired
Duodenum herniating in the
v Intestine herniating into the lesser sac or hole in mesentery or hole in transverse mesocolon or defect in the broad ligament or Ileocaecal fossae - superior & inferior or retrocaecal fossa
Ø Inguinal - indirect, direct, pantaloon
Ø Umbilical - Exomphalos (major & minor), & child umbilical hernia.
Ø Divarication of Rectii
Ø Spigelian-occurs at lateral border of rectus sheath at level of arcuate line.
Ø Interstitial / Interparietal - 4 types
§ Pro-peritoneal - diverticulum from inguinal or femoral hernia.
§ Intermuscular - common in obese patients - spreads between External Oblique & Internal Oblique - narrow neck - tendency to strangulation.
§ Inguinosuperficial - hernia into the superficial inguinal pouch - associated commonly with an ectopic testis in the pouch.
Ø Lumbar - superior & inferior. May be a phantom hernia - due to local muscular paralysis e.g. polio.
Ø Gluteal - through greater sciatic foramen.
Ø Sciatic - through lesser sciatic foramen.
v Perineal hernia - 4 types
Ø Post - operative - after AP resection of rectum.
Ø Median sliding hernia - complete rectal prolapse.
Ø Antero-lateral - in females - swelling of one side labium majus.
Ø Postero-lateral - through levator ani muscle into the ischiorectal fossa.
v Para-ileostomy hernia
v Para-colostomy hernia
Theories for Hernia formation
BUY A CD FOR $ 20 (Including postage)
(See the actual repair operation performed for direct, indirect & recurrent inguinal hernias)
Donations to " Dr.M.P.Desarda Charitable Trust & Research Institution " are exempt under 80 G of Income Tax Act
1] No mesh, no foreign body
2] No chronic groin pain
3] Full recovery in one week
4] No risky dissection
5] No recurrence
6] No endoscopes