 Good evening, everyone. Greetings from Coimbatore. At the outset, I would like to thank the organizing team of Sonobus, particular Dr. Mani, for inviting me to be part of this wonderful event. Now, you should be wondering why you need an image in investigation for hernia, which is obvious. I will try to justify the role of ultrasound in hernia. Now, hernia is protrusion of an organ out of the body cavity in which it normally lies. So, here the body cavity is the abdomen and the hernia protrudes out, that is hernia. So, abdominal wall, it can be abdominal hernia and the abdominal wall hernia, internal hernia and diaphragmatic hernia. Now, coming to the technique, we have to know the anatomy. It is a dynamic study essential and then the probe is usually high frequency linear probe 512 megahertz. If the patient is obese, then we use the convex probe. We examine at rest and then when the patient is straining to elicit the protrusion and sometimes also an erect posture of the patient. So, abdominal wall hernia, the most common one is the inganel which forms 75 percent of the hernia, which may be indirect in 50 percent and direct in 25 percent. Or it may be a ventral incisional or umbilical hernia forming 10 percent and femoral in a small 3 percent and the rest is formed by the unusual type of hernias which can be the spigelian, the register, obturator and the lumbar hernia. Now, coming to the symptoms, the hernia is seen as a visible lump. There may be local pain due to stretching or there may be pain due to pull of the content like masonry or the symptoms may be due to complications. The abdominal wall hernia occurs in weak spots. What are the weak spots? It can be natural weak spot or it can be acquired. Acquired can be incisional or at the port side following a laparoscopy or following traumatic. The terminology is used in hernia. It may be a reducible hernia where the contents go inside now and then or it may be irreducible. It's also called incarcerated. Obstructed when the content is bowled and it is obstructed and strangulated if there is no blood supply to the content. And the role of ultrasound is in confirmation of the hernia to detect a non palpable or unsuspected hernia and to know the contents, the type of hernia, the defect size for determining the size of the prosthesis, associated conditions and complications and the postoperative follow-up. So, I will cover this lecture in these headings. Now, technically as I said, we should examine at rest and at straining. Straining may be one of these, the valsalva maneuver, head raising, cough or erect posture and you must look for reducibility and tenderness and look for the contents and the vascularity. So, the probe used is usually the linear 5 to 10 megahertz probe to study the abnormal wall in detail or it when the patient is obese we may have to use the convex 3 megahertz probe, the conventional probe. So, at rest you have to see if there is a bulge or if you see the protrusion and when if the hernia is seen at rest then you must press on the hernia to look whether it is reducible as shown in this video. So, you see the protrusion of the contents omantaman bubble and when you press the contents go inside the abdomen. So, it is reducible hernia. So, it is present at rest and then when you press it gets reduced and then you measure the defect size like that or it may be present at rest even then to confirm that it is hernia you ask the patient to strain and look for the impulse or further protrusion of the contents to confirm that it is hernia. And the third situation is it is not present at rest then you ask the patient to strain like cough and then the contents protrude out as seen in this video. So, these are the three parts of the technique and the last one is the head raise. So, here the pictures show the technique of head raise and here you see at rest you do not see any hernia and when the patient raises the head when strains then you see the protrusion of contents through the defect. So, that is seen in the video. So, at present it is not seen when the patient raises the head then you see the protrusion of the contents inside confirming that it is hernia. So, that is the technique then next is the confirmation. So, by the technique you confirm and in certain situations you have to differentiate from a mass and a diversification of recti. So, thereby confirming. So, diversification of recti is the muscles rectus abdominis muscles are separated and the the linea alba in between gets weakened so that the contents bulge outside. So, this has to be differentiated from the hernia of the linea alba where there is a defect and there is protrusion. So, here there is a defect in the linea alba and the contents protruse whereas here there is weakness of the linea alba separation of the recti abdomini and the abnormal contents bulge outside. So, that is the difference between diversification of recti now it is called diastasis recti and you measure the distance between the medial borders of the recti and make it in your report. So, the abdominal wall masses have to be differentiated. So, that is a abdominal wall lipoma and this is an abscess and this is inflamed cysticercosis and that is a rectus abdominis abahematoma and the tumor of the abdominal wall. So, how to differentiate by the characteristics appearance and you these masses will not be reducible and there is no change with straining. So, that is how you differentiate from hernia. Sonography is very useful to detect non palpable or unsuspected hernia. This happens in obese individuals and in interpretal hernia we will see that and in the unusual sites where you do not suspect a hernia like an obturator hernia. So, here this is a very obese individual you see the entire depth is occupied by the abdominal wall and so the bulge will not be seen clinically. So, in such situations ultrasound is really useful you see the hernia with protrusion of the momentum with outlined by little fluid again here momentum outlined by the fluid. So, here ultrasound detects the hernia and then umbilical hernia. So, we come to the umbilical hernia where there is a protrusion of the contents through the umbilicus or by the side of umbilicus. So, here through the umbilicus the momentum is herniated. So, that is umbilical hernia here you see the umbilicus here whereas the hernia has happened by the side. So, that is a para umbilical hernia. So, para umbilical hernia or umbilical hernia can contain bowel loops as seen here. Now, here this is umbilical hernia you see the sag filled with only fluid. So, this happened that is the defect this happens when there is ascites in the abdomen due to the cirrhosis. So, because there is ascites only the ascitic fluid goes into the herniated sag separating the best of the contents of the abdomen entering into the sag. So, that is umbilical hernia containing only ascitic fluid. Now, next up the abdominal hernia is port site hernia. Now, following laparoscopic port insertion there may be hernia through the weak spot here. So, that is the defect and you get the port site hernia containing momentum. Now, this is in the left mid quadrant there again a port site hernia. Now, coming to the internal hernia there are two types the indirect and direct. Now, this is on the left side this is the pubic symphysis and you see the inferior epigastric vessels. So, the indirect hernia you get the hernia the lateral to the inferior epigastric vessels in direct it occurs medial to the inferior epigastric vessels. So, the technique you use you use the 5 to 10 megahertz transducer place it transversely over the internal region just above the internal ligament you will get the section you will see the common femoral artery and vein and so, entero medial to them will be the internal ring through which the indirect hernia will happen or the direct will happen just medial to that to the inferior epigastric vessels. So, that is the technique they are addressed and then straining you see the straining you do not get any protrusion. So, that is normal with cough impulse. Whereas, when there is hernia at rest you see the over loops in there going into the exploital sac the inside of the test is with some fluid. So, that is internal hernia. So, that is the internal hernia present at rest and you can try to reduce it and it will if it is reducible it escape into the see that is the pressure and it gets reduced. So, that is a reducible internal hernia. Now, here it is not present at rest, but when the patient coughs you get the omen thumb bulging into the sac. So, this is again the technique of eliciting internal hernia. So, as I said this is the on the left side. So, this is direct internal hernia you see the pubic symphysis the inferior epigastric vessels and the hernia sac is medial. Whereas, in the indirect internal hernia that is the inferior epigastric vessels pubic symphysis and the hernia sac is lateral to the inferior epigastric vessels. Now, in the present day of laparoscopy this differentiation is not essential. So, this is the direct internal hernia medial and it is due to a defect in the conjoined tender weakness of the conjoined tender and it is always acquired and the neck is wider because it is just a weakness of the tender. Whereas, in the indirect internal hernia it is lateral to the inferior epigastric vessels through the internal hernia. So, it is through a natural weakness and the neck is narrow. So, chance of complications are more and it happens in young individuals and it is through the natural defect. Now, hernia versus a mass in the ingrenial region this is an insisted hydrocele of the spraumatic card. It is seen as a novel cystic mass there will not be any cough impulse and another differential diagnosis persistent process vaginalis where the process vaginalis is not obligated as a result some fluid escapes. So, this neck is very narrow does not allow any hernia, but fluid alone is seen. So, in that case we have to put the patient in earache to rule out hernia. So, if you put the patient in earache or during cough the contents may protrude making a diagnosis of hernia other than a persistent process vaginalis. So, here at present it is not there when you patient coughs the momentum goes into the hernia sac. This is lipoma in the hermetic card a very characteristic appearance and there will not be any change with the cough impulse. This is a copua mass in the ingrenial region this turned out to be a desmoid tumor and another differential diagnosis in the female is sister the canal of neck. You see a cyst in the ingrenial canal that is a DD for ingrenial hernia in a woman. Now, here this is a very rare irregular copua mass in a woman with pain during the periods and this is the mass seen and in color there is flow seen in it and it turned out to be endometriosis. Another differential diagnosis is varicoseal a common differential diagnosis where you get dilated veins, cremastic veins in the somatic card and then this crotum and with color Doppler you will get reflex of flow in these veins confirming that it is a varicoseal. Differential diagnosis for varicoseal will be a lymph varix where you see get on grayskate similar appearance but on color Doppler there will not be any flow or there will not be any reflex of venous flow and rarely you may get the phylarial dance confirming that it is a lymph varix. When in all cases of ingrenial hernia in males we must document the size of the testis because postoperatively there may be a scheme of the testis there is may be reduction. So, to avoid that confusion we must always document the size of the testis when we are reporting ingrenial hernia in a male. The associated condition very common associated condition in a male with ingrenial hernia is undecended testis where you see the scotal sac with the hernia containing omentum and bowel and you see the undecended testis in the ingrenial region no proximal to the contents. Now, coming to the contents. So, you have to report about the contents of the hernia it may be fat it may be omentum it may be a bowel it may be uterus or ovary or it may be urinary bladder. Now, here you see the fatty hernia of linear alba you see the protrusion of the properitoneal fat into the hernia here there is a echogenic omentum forming the content here there are collapsed bowel loops forming the content and here there is herniation of the part of the urinary bladder and here you get the ovary and the fallopian tube as contents in the ingrenial hernia. Very rarely the content may be omentum along with an omental metastasis in a case in a patient who has been operated previously for ovarian carcinoma or it may be rarely a colon distended colon. Now, here there is a bowel such the content and showing the peristalsis confirming that it is bowel or it may be omentum in the ingrenial hernia with the testis. The content here is the ovary in a child you see the bulge there and that is the ovary in the forming the lifting canal hernia or rarely the uterus also may escape besides the ovary and the fallopian tube in a rarely when the hernia is large. So, here there is a hernia containing bowels besides bowels there is also herniation of the urinary bladder with cough you get the bladder with attrusting it is not there I can see the same in the real time you see the herniation of the bladder into the hernia. Now, complications may be irreducibility obstruction and strangulation. So, irreducible hernia may be due to narrow neck or addition of the content and the sac. So, it will be seen at rest and it should be with the pressure it will not reduce. So, it is irreducible because of the irreducibility the neck will be obstructed. So, there will be accumulation of some fluid in the sac. So, here there is a incisional hernia with the bowels and the omentum there is fluid and it is irreducible. This is femoral hernia again containing omentum and fluid and it is not reducible. So, it is present at rest it is irreducible and fluid those are the features. Now, obstruction happens when the content is bowel and when the lead point may be hernia. So, when you see hernia you must suspect obstruction and you must look for dilated loops in the abdomen or in the rivers if you see the small bowel obstruction in the abdomen and you do not see any other cause then you must look for hernia as the cause either way. So, here this is sign of small bowel obstruction you see the dilated loop with two and four peristalsis and when you see that then you trace the loop and if you do not see any cause then look for the hernia sites. Now, obstruction in the hernia can be to the afferent loop or afferent loop or both. So, here you see the schematic is the hernia there is obstruction to the afferent loop as a result the the bowels inside the abdomen are dilated and in the hernia the afferent loop is collapsed and it is obstructed at the neck. So, this is dilated bowels in the abdomen collapsed bowels in the sac and is afferent loop obstruction. Now, here you see dilated loops in the abdomen as well as in the sac. So, abdomen as well as in the sac and you see collapsed efferent loop. So, that is the efferent loop that is the efferent loop collapsed efferent loop. So, that is efferent loop obstruction and then you get to both that is the closed loop obstruction. Now, here you see dilated small bubbles in the abdomen, dilated loops in the urnial sac and so that is real time showing the peristalsis so that is afferent loop obstruction. When the obstruction is to both afferent and afferent loops it is a closed loop obstruction either due to a narrow neck obstructing both the loops or it may be due to volvulus of the loop inside the sac. So, here you will see dilated small bubbles in the abdomen, this proportionate dilatation of the loop in the urnial sac and then you will see the distended loop in the urnial sac will be tense it will not be compressible it will be tense and there will not be any gas because there is proximal obstruction also and it will be apirustaltic because it is tensely distended and obstruction at the neck. So, this is case of ventral hernia with closed loop obstruction. Rarely it may be colonic obstruction you see dilated bubbles in the abdomen, you see dilated colon in the abdomen and in the sac also you see a dilated colon. So, this is internal hernia containing colon which is obstructed. Now, we come to strangulation. So, what are the features? It is irreducible, it will be tender, there will be some fluid in the sac, thick walls of the loop of bowel and if it is loop of bowel it will be apirustaltic and there will be ischemia. On colored opera there will not be any flow. So, dilated small bubbles in the abdomen and this is a case of umbilical hernia if it is irreducible and tender there is some fluid in the sac is the bowel. So, it shows thick walls it is apirustaltic when you put color there is no flow. So, this is strangulation of umbilical hernia containing a bowel loop. So, in contrast only when there is irreducibility you will see flow in the masonry or in the bowel wall. So, that is the difference of strangulation and obstruction. Strangulation can happen even in content is momentum. So, it is irreducible and tender there is fluid in the sac content is momentum and when you put on color there is no flow in the momentum. So, that is the strangulation containing momentum. Now, coming to unusual hernias one is the spigilane hernia the anatomy is you get the lina semilunaris the lateral border of the rectus and lina semicircular is the posteriorly the upper neurosis of the three muscles and divide into the anterior posterior rectal seat. Below the lina semicircular is the upper neurosis the posterior rectal sheath is not present. So, there is a potential weakness there through which the hernia happens. So, that is the spigilane hernia adjunction of semilunaris and the lateral border of the rectus defect in the upper neurosis of the transversus abdominis and it is interoperated between the layers of the muscles of the abdomen. So, there is no bulge it will not be seen as a bulge. So, that is the defect and you see the herniated bowel and that is the superficial muscle because of the muscle there is no bulge. So, that is an interoperatal hernia. So, in spigilane hernia in a male there may be also cryptarchytism that is called Ravindran syndrome as you see here the spigilane hernia on the right and it also contains the undecended testis in the sac. You see the bubbles in the undecended testis. So, this is called Ravindran syndrome and that is the real time showing the hernia containing bubbles and of course the undecended testis in the sac. Now, coming to the femoral hernia now anatomy it is more common in women and you see the ingrenal ligament and below the ingrenal ligament you get the common femoral artery, common femoral vein and medium to that you get the femoral canal through which the hernia happens the femoral hernia. So, here that is the ingrenal ligament the common femoral artery, common femoral vein and that is the femoral canal and through which the hernia happens. So, it happens from it has the neck is posted to the ingrenal ligament and then the sac comes anteriorly whereas in the ingrenal hernia it happens superficial to anterior to the ingrenal ligament and then goes posteriorly into the scrotum. So, that is the difference between femoral and ingrenal hernia. Now, technique for femoral hernia is like for ingrenal hernia and you see below the ingrenal ligament and below the ingrenal ligament you see the common femoral artery, common femoral vein and this is the region of the femoral canal. So, when the patient coughs you must look for the bulge here. At rest you see the common femoral artery the common femoral vein will be compressed by the hernia and that is the hernia medial to the common femoral vein and that is the femoral hernia. You see the real time you see the common femoral artery and the vein. So, that is the femoral artery vein and you see the bulge happening medial to the vein compressing the vein that is femoral hernia. Then we come to the obturator hernia. So, obturator hernia is very rare. It happens in through the obturator foramen nearly multi-pare as women because of the weakness of the muscles where particularly when they lose weight and it happens deep to the pectinous muscle. It is deeper compared to the ingrenal hernia. You see I have used the convex probe because it is very deep. Patient had interstellar obstruction. So, this is the pectinous muscle deep to the common femoral artery and the vein made out by the color Doppler. So, this is the pectinous muscle and the bowel is seen here deep to the pectinous. This is the obturator hernia. Now, rare type of hernia is the Richter hernia where there is herniation of the anti-messentric valve of the bowel. Only part of the circumference of the bowel protrudes to the defect of the abdominal valve does not produce obstruction because the entire lumen is not herniating and this the peculiarity of this hernia is the strangulation and necrosis happens without obstruction. So, the diagnosis is missed and the patient presents with peritonitis. So, this is part of the circumference of the bowel protruding and there is some fluid. So, this is parambolic hernia. You get some fluid. This is a young girl presenting with severe pain and you see the bowel loop and this was showing peristality. So, confirming that it is part of the bowel and the bowel loops in the abdomen were not dilated, abdomen was not distended. So, this is Richter hernia. Another case of Richter hernia, you see the bowel loop in the abdomen normal but part of it is protruding through the parambolic hernia and then you see part it is necrosis and produces a small abscess in the abdominal valve and the layer type is the hernia after the trauma in the lumbar region and there is still more rare is parastomal hernia by the side of stoma like colostomy. You by the side you see the hernia. Ultrasound is also useful in the postoperative follow-up to look for any fluid collection so that it can be aspirated and to look for the processes, addition and recurrence and testicular ischemia. So, here this is immediately after surgery you get a fluid collection that is a seroma which can be aspirated. Little later you see fluid collection, secondary to inflammation, the mesh inflammation you get fluid around the curled mesh. So, menace is already not functioning and then you can get a recurrent hernia by the side of the mesh or deep to the mesh and then you may get bowel getting adherent to the mesh producing small bowel obstruction and this is curled mesh again and which can produce inflammation and with a track to the skin. So, the sinus tract may not heal and the mesh can migrate here you see the mesh is migrated from the enamel region to anterior to the bladder and very rarely it can migrate into the bladder producing recurrent urinary tract infection. You see the mesh which is within the bladder and that is removed by sister's copy. To conclude the role of ultrasound is in confirmation know the type, the contents, the defect size, the reducibility, associated conditions, complications and you have to document the test size in enamel hernia in males and if you see dilated bowels in the abdomen cause is not seen you must look for hernia as the cause. Thank you.