Hernia REVISION NOTES FOR NEET PREPARATION

Protrusion of a viscus or part of viscus through
a normal or abnormal opening in wall of its
containing cavity
TONY SCARIA 2010 KMC

 c/c coughing
 Straining
 Obesity
 Smoking
 Peritoneal obesity
 Intrabdominal malignancy
 Ascites
 Peritoneal dialysis

 Sac
 Mouth
 Neck
 Body
 Fundus
 Covering

 Can be
 OMENTUM  OMENTOCELE
 INTESTINE  ENTEROCELE
 PART OF CIRCUMFERENCE OF INTESTINE  RICHTERS HERNIA
 BLADDER
 OVARY  PAEDIATRIC
 MECKELS DIVERTICULUM  LITTRES HERNIA

NECROSED
LOOP WITH IN
PERITONEAL
CAVITY

 MC TYPE OF HERNIA INDIRECT INGUINAL HERNIA
 MC TYPE OF FEMALE INDIRECT INGUINAL (NOT FEMORAL HERNIA)

• DEEP INGUINAL RING
• 1.25CM ABOVE MIDPOINT OF
INGUINAL LIGAMENT
• INVERTED U SHAPED
• SUPERFICIAL INGUINAL
RING
• SUPEROLATERAL TO
PUBIC TUBERCLE
• TRIANGLE SHAPED

MIDINGUINAL POINT 
FEMORAL ARTERY
• MID POINT OF
INGUINAL LIGAMENT
•  DEEP RING

Floor
Imagine the right side inguinal canal viewed from the front as a box
with anterior & posterior walls, a roof & floor. The arrow indicates
that structures can run through it from lateral to medial – e.g. in
males it transmits the spermatic cord, and in females, the round
ligament of the uterus.
Medial
Lateral

Inguinal canal
Floor
Medial
Here are the posterior wall, which has the DEEP inguinal ring
situated laterally, and the floor. (Roof and anterior wall removed).
Deep inguinal ring
Lateral

Inguinal canal
Floor
Medial
Here are the anterior wall (which has the SUPERFICIAL inguinal
ring situated medially), and the roof.
Superficial inguinal ring
Lateral

Inguinal canal
Floor
Spermatic cord
exits through
the superficial
inguinal ring
Medial
Spermatic cord enters the
inguinal canal through the
deep inguinal ringDeep inguinal ring
Lateral

Inguinal canal
Medial
The anterior wall is made up of the external oblique
muscle throughout, and is reinforced by the
internal oblique m. laterally.
The transversus abdominus m. lies even more
laterally as part of the anterior abdominal wall.
Lateral
Dr C Slater, Department of Human Biology, University of Cape Town

Inguinal canal
Floor
Spermatic cord
Medial
Lateral
The transversus abdominis and internal
oblique mm. combine to form the
CONJOINT tendon that arches over the
contents of the inguinal canal
The conjoint tendon attaches to
the pubic crest, reinforces the
posterior canal wall medially and
also forms the ROOF of the canalConjoint tendon

Posterior wall of the inguinal canal
Deep inguinal ring
Medial
The posterior wall is formed by transversalis fascia (orange)
throughout and the conjoint tendon (red) medially. The wall is
particularly weak over the deep inguinal ring
Lateral
Conjoint tendon medially
Posterior wall

Floor of the inguinal canal
Floor
Medial
The floor is formed by an incurving of the inguinal ligament, which
is part of the external oblique muscle, forming a gutter. (Medially
it forms the lacunar ligament which is not illustrated).
Lateral

Roof and anterior wall of the inguinal
canal
Medial
The anterior wall of the canal is formed by external oblique muscle
(orange) throughout and by internal oblique muscles (red/black/white)
laterally. This wall is weak medially because of the “hole” in the external
oblique muscle (= superficial inguinal ring).
Lateral

Inguinal
hernia
Direct
indirect
Through hesselbachs
triangle in posterior wall
of inguinal canal (medially
by lateral border of rectus
sheath,below by inguinal
ligament,laterally by
inferior epigastric artery)
Through deep ring along with
spermatic cord,lateral to inferior
epigastric artery

Deep ring
Whole of
inguinal canal
Superficial ring

Weak post wall of
inguinal canal
(hesselbachs triangle)
Part of inguinal canal
Superficial ring

Indirect inguinal hernia Direct inguinal hernia
1.any age from childhood to adult 1.Common in elderly
2.Occurs in a pre-existing sac 2.Always acquired
3. Protrusion through the deep ring; herniation occurs later 3.Herniation through posterior wall of the inguinal canal
4.Pyriform /oval in shape; descends obliquely and downwards 4.Globular/round in shape;
descends directly forward bulge
5.Can become complete by
descending down into the scrotum
5.Rarely descend down into the scrotum
6.Sac is antero-lateral to the cord 6.Sac is posterior to the cord
7.Ring occlusion test no impulse after occluding the deep ring 7. impulse even
after occluding the deep ring
8.Invagination test shows impulse on the tip of the little finger 8.Invagination test shows impulse on the pulp of the little finger
9.Zieman’s test impulse
on the index finger
9.impulse on the middle finger
10.Commonly unilateral may be bilateral 10.Commonly bilateral
11.Obstruction/strangulation
are common
11.Rare but can occur
12.Sac should be
opened during surgery
12.Sac is not necessarily
opened unless obstruction
is presentTONY SCARIA 2010 KMC

 MOST COMMON OF ALL HERNIA
 B/L IN 12 % CASES
 MORE COMMON INYOUNG
 NARROW RING INCREASED RISK OF COMPLICATION

Inguinal
hernia
incomplete
bubonocele
funicular
complete
Sac is confined
to
inguinalcanal
Sac crosses
superficial
ring but not
reaches
bottom of
scrotum
Reaches
bottom of
scrotum

 THROUGH PATENT PROCESSUS VAGINALIS

 INAGINATION ALSO OCCURS IN
FEMALES
 PORTION OF PROCESSUS
VAGINALIS WITH IN INGUINAL
CANAL  CANAL OF NUCK
 USUALLY OBLITERATES IN 8TH
MONTH

 DIRECT HERNIA IS ALWAYS ACQUIRED
 PRATICALLY NEVER SEEN IN FEMALE
 WIDE MOUTH  RARELY GETS STRANGULATED
 NEVER DESCEND UPTO SCROTUM

 WEAK AREA OF ANTERIOR
ABDOMINAL WALL
 BASE  INGUINAL LIGAMENT
 MEDIALLY  LATERAL BORDER OF
RECTUS ABDOMININIS
 LATERALLY  INFERIOR EPIGASTRIC
VESSELS

MEDIAL TO OBLITERATED
UMBILICAL ARTERY IS
SRENGTHENED BY CONJOINT
TENDON  LESS CHANCE OF
HERNIA
LATERAL TO OBLITERATED
UMBILICAL ARTERY IS WEAK
 MORE CHANCE OF
HERNIA

DIRECT INGUINAL
HERNIA IS MEDIAL TO
INFERIOR EPIGASTRIC V
INDIRECT INGUINAL HERNIA IS
LATERAL TO INFERIOR
EPIGASTRIC VESSELS

BOTH DIRECT & INDIRECT
INGUINAL HERNIA

 ZEIMANS TEST
After reduction
Index finger = deep ring
Middle =superficial inguinal ring
Ring finger=saphenous opening
Impulse on coughing on deep ring =indirect inguinal
hernia

 EXTRAPERITONEAL
 INTERNAL SPERMATIC FASCIA
 CREMASTRIC FASCIA
 EXTERNAL SPERMATIC FASCIA
 SKIN

 STANDING POSITION
 ABSENT IN CASE OF STRANGULATED & INCARCERATED HERNIA
1. MOMENTARY BULGE IN SUPERFICIAL RING ON COUGHUING
2. ROOT OF SCROTUM B/W INDEX FINGER & THUMB IS SEPARATED ON
COUGHING

 Distinguish b/w direct, indirect or femoral hernia
 Can be used only when the swelling is completely reduce
when there is no visible swelling
Index finger deep inguinal ring (1/2 “ above mid inguinal point)
Middle finger superficial inguinal ring (superomedial to pubic tubercle)
Ring finger saphenous opening (4cm blw & lateral 2 pubic tubercle)
Hold the nose & blow or cough

 EXTRAPERITONEAL TISSUE
 FASCIA TRANSVERSALIS
 CONJOINT TENDON
 EXTERNAL SPERMATIC FASCIA
 SKIN

Impulseon
Index finger
Middle finger
Ring finger
Direct inguinal hernia
Indirect inguinal hernia
Femoral hernia

 In presence of swelling  coughing  expansile impulse on coughing
Movement of swelling is not a criterion
bcz as these swellings move with
coughing
Encysted hydrocele of
cord : localized swelling
of spermatic cord
Undescended testis

 Reduces on lying down  direct hernia
 Flexes the thigh
 Adduct the thigh
 Rotate internally
 Using taxis
 Reduces with gurgling=>ENTEROCELE  Difficult to reduce initially but last
part slips of easily
 First part reduces easily last part difficultomentocele
Relaxes
superficial
inguinal ring +
oblique muscles

 After reduction of hernia in recumbent position
 Using little finger  rt. Hand side for rt. Side
lt. hand side for lt. side
 Invaginate skin 4m the bottom of scrotum & the little finger is pushed to
palpate pubic tubercle
 Finger is then rotated & pushed further up in to superficial inguinal ring
 Nail will be against spermatic cord pulp will feel walls of ring
 Normal ring transmits only tip of finger ,>1 finger}abnormally large

Finger goes
directly
backward=direct
hernia

Finger goes upwards,
backwards,outwards=
indirect

Impulse on
coughing
Pulp of
finger
direct
tip indirect

 Standing position after reduction of swelling
 Using thumb pressure over the deep inguinal ring (1/2 “ above mid inguinal point)
& is asked to cough
 Occlude direct hernia but not direct hernia
 Similarly on saphenous opening= femoral hernia

 Swelling appears even when deep ring is occluded=direct hernia
 No swelling when deep ring is occluded = indirect hernia

INDIRECT
DIRECT

Type I
INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children,
small adults
Type II
INDIRECT HERNIA; internal ring enlarged without impingement on the floor of the
inguinal canal; does not extend to the scrotum
Type
IIIA
DIRECT HERNIA; size is not taken into account
Type
IIIB
INDIRECT HERNIA that has enlarged enough to encroach upon the posterior inguinal
wall; INDIRECT SLIDING OR SCROTAL HERNIAS are usually placed in this category
because they are commonly associated with EXTENSION TO THE DIRECT SPACE; also
includes PANTALOON HERNIAS
Type
IIIC
FEMORAL HERNIA
Type IV
RECURRENT HERNIA; modifiers A–D are sometimes added, which correspond TOTONY SCARIA 2010 KMC

 IRREDUCIBLE
 OBSTRUCTED
 STRANGULATED
 INFLAMMED
 HYDROCELE OF HERNIAL SAC

 NECK OF HERNIAL SAC BECOMES OCCLUDED BY
ADHESION OR BY OMENTUM  RETENTION OF FLUID OF
FLUID SECRETED BY PERITONEUM OR HERNIA SAC

MANAGEMENT OF HERNIAL SAC
• HERNIOTOMY
INGUINAL FLOOR
RECONSTRUCTION
• PRIMARY TISSUE REPAIR
(HERNIORRAPHY) IN PATIENTS
WITH GOOD MUSCLE TONE
• HERNIOPLASTY IN PATIENTS
WITH POOR MUSCLE TONE
• ANTERIOR TENSION FREE REPAIR
• LAPAROSCOPIC

 HERNIOTOMY
 SUFFICIENT FOR CHILDREN &YOUNG ADULTS
 Dissecting out and opening of hernia sac
 reducing any contents ,transfixing neck of sac & removing the remainder
 NO NEED TO OPEN UP CANAL IN CHILDREN BECAUSE SUPERFICIAL AND DEEP RINGA
ARE SUPERIMPOSED ……THERE FORE NO NEED OF REPAIR

PRIMARY TISSUE REPAIR
(HERNIORRHAPHY)
 NO USE OF ANY PROSTHETIC
MATERIAL
 Disadvantage  higher recurrence
rate
 BASSINIS REPAIR ‘
 SHOULDICE REPAIR
 McVAY (COOPER )LIGAMENT REPAIR
 HALSTED REPAIR
HERNIOPLASY
 SYNTHETIC MESH IS USED
 ANTERIOR TENSION FREE REPAIR
 LESS RECURRENCE  MOST
COMMONLY USED
 LICHENSTEIN
 PATCH & PLUG REPAIR
 LAPAROSCOPIC & PERITONEAL
REPAIR
 TAPP
 TEP

 Is frequently used for indirect inguinal
hernias and small direct hernias
 The conjoined tendon of the
transversus abdominis and the
internal oblique muscles is sutured to
the inguinal ligament

inguinal and femoral
canal defects
The conjoined tendon
is sutured to Cooper’s
ligament from the
pubic cubicle
laterally

 DOUBLE BREASTING OF ALL THREE LAYERS
 The first suture line
 is started at the pubic tubercle using 3-0 continuous polypropylene, and the white line is
approximated to the free edge of the inferior transversalis fascial flap.
 The 2nd suture line :
 At the internal ring the suture is tied and then continued medially by approximating the
free edge of the superior flap to the shelving edge of the inguinal ligament.When the
pubic tubercle is reached, the suture is tied and divided.

 The third suture line is started at the level of the internal ring where the conjoined
tendon is approximated to the inguinal ligament and tied when the pubic tubercle
is reached.
 Using the same suture, the fourth suture line attaches these same structures to one
another and is tied at the level of the internal ring.

 The cord is replaced within the inguinal canal, and the external inguinal
aponeurosis is reapproximated with continuous 2-0 absorbable sutures

 WEVED SIMILAR TO MESH IN CRISS
CROSS PATTERN

 CHEMICALLY INERT
 NOT CARCINOGENIC
 NO FOREIGN BODY REACTION
 NOT MODIFIED BY PHYSICALLY BY TISSUE FLUID
 RESISTANT TO MECHANICAL STRAIN
 EASILY STERILISED
 PLIABLE & MOULDABLE
 NO ALLERGY & HYPERSENSITIVITY

 LAPAROSCOPIC REPAIR IS BASED ON STOPPAS REPAIR

 GPRVS (Giant Prosthesis for
Reinforcement of Visceral Sac)
 OVER FRICHAUDS
MYOPECTINEAL ORIFICE

 osseo-myo-aponeurotic tunnel.
 medially
 lateral border of rectus sheath;
 above
 the arched fibres of internal oblique and transverse abdominis muscle;
 laterally
 by the iliopsoas muscle;
 below
by the pectin pubis and fascia covering it.
It Is through this tunnel all groin hernias occur.

 PERITONEAL SPACE IS ENTERED BY
CONVENTIONAL LAPAROSCOPY 
PREPERITONEUM IS ENTERED BY
INCISING PERITONEUM AGAIN

 WITHOUT ENTERING
PERITONEAL CAVITY

 TRIANGLE OF DOOM
 TRIANGLE OF PAIN
 CIRCLE OF DEATH (CORONA MORTIS)

• INJURY TO EXTERNAL
ILIAC VESSELS IS
FATAL
• GENITAL BRANCH OF
GENITOFEMORAL N IS
ALSO INJURED NERVE
STAPLING IN THIS AREA NERVE
ENTRAPMENT & PAINFUL NEURALGIA
• FEMORAL BRANCH OF
GENITOFEMORLA NERVE
• LATERAL FEMORAL CUTANEOUS
NERVE
• ANTERIOR FEMORAL FEMORAL
CUTANEOUS NERVE OF THIGH
• FEMORAL NERVE
PERITONEAL REFLECTION

 MEDIAL TO TRIANGLE OF DOOM
 VASCULAR RING FORMED BY
 COMMON ILIAC
 EXTERNAL ILIAC
 INTERNAL ILIAC
 INFERIOR EPIGASTRIC A
 OBTURATOR ARTERY
 ABBERENT OBTURATOR AREA
 TORRENTIAL HE IF TORN

 PAIN  C/C
 RECURRENCE
 SEROMA HAEMATOMA
 ISCHEMIC ORCHITIS
 TESTICULAR ATROPHY
 BLADDER INJURY
 OSTEITIS PUBIS
 WOUND INFECTION ‘
 INJURY TO ILIOINGUINAL NERVE  ANAESTHESIA IN PENIS & SCROTUM
 MC NERVE TO BE INJURED

NARROWING OF
INTERNAL RING
 MOST
IMPORTANT
STEP TO
PREVENT
RECURRENCE

 Use of TRUSS: when surgery is contraindicated/ is refused
 Used only for reducible hernia
 After reducing the hernia (applied before the patient gets up and when it is
reduced), rat tailed spring truss with perineal band (to prevent slipping ) to
prevent small or moderate sized hernia
 Increased risk of strangulation
NOT RECOMMENDED USUALLY

 RETROPUBIC SPACE
 EXTRA PERITONEAL SPACE
 B/W PUBIC SYMPHYSIS & URINARY
BLADDER

 RETRO INGUINAL SPACE
 LATERAL TO RETZIUS SPACE
 EXTRAPERITONEAL SPACE
 SITUATED DEEP TO INGUINAL LIGAMENT

 ALMOST ALWAYS INDIRECT
 15 % B/L
 D/T PATENT PROCESSUS VAGINALIS
 RISK OF INCARCERATION
 Rx
 INGUINAL HERNIOTOMY

 Formed ant by fascia transversalis posteriorly by
fascia iliaca
 Initial 4cm of femoral artery enclosed in this sheath

 FEMORAL CANAL

 OCCURS THROUGH FEMORAL CANAL
 MORE COMMON IN MULTIPAROUS WOMEN
 RARE IN MALES & NULLIPAROUS WOMEN
 RIGHT >> LEFT
 NEVER CONGENITAL ALWAYS ACQUIRED
 MORE COMMONLY STRANGULATED
 NARROW & RIGID NECK

SAC LIES UNDER
FASCIA COVERING
PECTINEUS
MUSCLE
LAUGIERS HERNIA
THROUGH A GAP IN
LACUNAR LIGAMENT
LAUGIERS HERNIA
THROUGH A GAP IN
LACUNAR LIGAMENT

 CONTAINS LN OF CLOQUT & LYMPHATICS

1.5cm WIDE
1.5cmLONG

Femoral
canal
Saphenous
opening

Umbilicalhernia
Umbilical hernia in
infants & children
Para umbilical
hernia of adults

CONGENITAL UMBILICAL HERNIA
 IN INFANTS
 CLOSE PSONTANEOUSLY BY 2
YEARS
 IF PERSIST MORE THAN 5 YRS
REPAIRED SURGICALLY
ACQUIRED UMBILICAL HERNIA
 IN ADULTS
 MORE COMMON IN FEMALES
 STRANGULATION IS UNCOMMON
 IN CONDITIONS ASSOCIATED WITH
INCREASED INTRA ABDOMINAL
PRESSURE SUCH AS PREGANNACY
OBESITY ASCITES OR C/C
INTRABDOMINAL DISTENSION

 INDICATIONS FOR SURGERY
 SYMPTOMATIC
 INCARCERATION
 IF ENLARGES IN SIZE
 SURGICAL TREATMENT
 PRIMARY SUTURED REPAIR
 PROSTHETIC MESH > 2CM

 Through umbilical cicatrix
 Spherical in shape
 Increase in size in crying

 Not through umbilical cicatrix but through linea alba
 Above (supraumbilical)
 Below (infraumbilical)

 Common in females (indirect inguinal hernia is commonest hernia in female)

 STRANGULATION IS MOST COMMON WITH FEMORAL HERNIA

 HIGHEST RISK WITH FEMORAL HERNIA
 COMMON AT EXTREMES OF AGE
 IN STRANGULATED HERNIA FUNDUS OF
SAC IS OPENED FIRST BEFORE
CONSTRICTION AT NECK IS RELIEVED
 TO PREVENT CONTAMINATION OF
PERITONEAL CAVITY BY UNHEALTHY
SEPTIC FLUID

 PART OF SAC (USUALLY POSTERIOR WALL) IS FORMED BY CONTENT (WALL OF
VISCUS)
 Retroperitoneal structures
 Viscera are liable to be injured if hernia sac is resseced during surgery
 Content of sliding hernia
 On left  sigmoid colon
 On right  caecum
 Left is more common than right  sigmoid is the commonest content
 Other contents  appendix urinary bladder uterus fallopian tube ovary or ureter

Umbilicus.
C, D,
Median umbilical ligament (obliterated urachus).
Medial umbilical ligament (obliterated umbilical
arteries).
Lateral umbilical ligament containing inferior (dee
epigastric arteries
Falciform ligament

 THROUGH SPIGELIAN FASCIA
 APONEUROTIC LAYER B/W RECTUS MUSCLE
MEDIALLY & SEMILUNAR LINE LATERALLY
 NEARLY ALL SPIGELIAN HERNIA AT OR
BELOW ARCUATE LINE

 ENTERS THROUGH DEFECT CAUSED
BY INFERIOR EPIGASTRIC ARTERY
 INTERPARIETAL HERNIA 
POSTERIOR TO EXTERNAL OBLIQUE
 DEVELOP IN 4 TO 7 DECADES
 DIAGNOSED BY CT OR US
 Rx
 SURGICAL REPAIR

 RX FOR LUMBAR HERNIA
 DOWDS SURGERY

 MIDLINE THROUGH LINEA ALBA
 ANYWHERE B/W XIPHOID UMBILICUS
 MOUTH OF HERNIA IS TO SMALL
 MOST COMMNLY CONTAIN PREPERITONEAL FAT
 MAY BE CONGENITAL  DEFECTIVE MIDLINE FUSION OF OF LATERAL
ABDOMINAL WALL ELEMENTS
 MORE COMMON IN MEN

 OBTURATOR CANAL
CONNECTS PELVIS TO THIGH
 OBTURATORY A V & N PASS
THROUGH THE FORAMEN
 WEAKENING OBTURATOR
MEMBRANE  ENLARGEMENT
OF CANAL  INTESTINAL
STRANGULATION &
HERNIATION

 MOST COMMON IN FEMALES
 ELDERLY LADIES
 SKINNY OLD LADY OR FRENCH LADY
 HOWSHIP ROMBERG SIGN
 PAIN IN ANTEROMEDIAL ASPECT OF THIGH
THAT IS RELEIEVED BY THIGH FLEXION
COMPRESSION OF OBTURATOR NERVE D/T
HERNIA

 INTERNAL HERNIA OCCURING THROUGH
WINDOW IN TRANSVERSE MESOCOLON
AFTER RETROCOLIC
GASTROJEJUNOSTOMY

OMPHALOCELE GASTROCHISIS

 CONGENITAL DEFECT IN ABDOMINAL WALL

 Failure of all or part of the midgut to
return to the abdominal cavity during
early fetal life
 Outer } amniotic membrane
 Middle } whartons jelly
 Inner } peritoneum exomphalos
Exomphalos
minor
Exomphalos
major

 Umbilical cord attached to SAC
 Contains SI… LI & part of liver

 Exomphalos major may burst
 So emergency Sx is needed

 A/W
 PREMATURITY
 IUGR
 PULMONARY HYPOPLASIA
 60 – 70 % INCIDENCE OF ASSOCIATED ANOMALIES
 CARDIACMOST COMMON ASSOCIATION
 CHROMOSOMAL ABNORMALITIES 13 18 21

 CLOACAL EXTROPHY
 BECKWITH WIEDEMANN SYNDROME
 CANTRLLS PENTOLOGY

TYPE DIAMETER OF DEFECT
TYPE 1 <2.5 cm
TYPE 2 2.5 – 5cm
TYPE 3 > 5 cm

 REPAIRED ELECTIVELY
 LARGE DEFECT (EXOMPHALOS MAJOR) CORRECTED AT BIRTH)
 SMALL & INTERMEDIUM HAV EBETTER PROGNOSIS

 FETAL GUT IS EXTRUDED THROUGH DEFECT IN ABDOMINAL WALL
 DEFECT IN ANTERIOR ABDOMINAL WALL THROUGHWHICH INTESTINAL
CONTENTS FREELY PROTRUDE
 NO OOVERLYING SAC
 SIZE OF DEFECT <4CM
 DEFECT IS LOCATED AT JUNCTION OF NORMAL SKIN & UMBILICUS
 ALWAYS LOCATED TO RIGHT OF UMBILICUS
 EMERGENCY SURGICAL CORRECTION REQUIRED

 RASP BERRY TUMOUR
 PARTIALLY OBLITERATED VITELLOINTESTINAL DUCT TOWARDS UMBILICAL END
  PROTRUSION OF MUCOSA OUT  RASPBERRY LIKE APPEARANCE
 RX
 IF PEDUNCULATD  LIGATURE AROUND ADENOMA GRADUALLY DROPS OFF
 IF TUMOR REAPPEARS UMBILECTOMY

 IN FIRST FEW WEEKS OF LIFE
 TREATED BY LOCAL APPLICATION OF SILVER NITRATE

 PATENT Urachus  commonest
 Urachal cyst
 Urachal umbilicus sinus
 Vesico urachal diverticulum

 Associated with urine leakage through umbilicus on straining
 Rx
 Urachetomy + closure of ddefect in bladder with absorbable suture

 In lower one third of urachus

 Discharge from umbilicus not associated with straining
 often discharges mucus

 Hamartomas
 Fibrous neoplasms arising from musculo aponeurotic structures
 Slow growing
 Diffusel infiltrative
 Tend to recur locally
 Rarely metastasis
 Associated with tissue injury or trauma
 Common in post partum women in surgical scar
 Associated with FAP Syndrome

 Surgery with wide margin of resection
 High chance of recurrence
 Imatinib favourable response

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Hernia REVISION NOTES FOR NEET PREPARATION