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i)             Whether, there is any difficulty in diagnosing case of Hernia Clinically, especially, Strangulated Incisional Hernia?

ii)            Whether, a normal, reasonable MBBS doctor/Gynecologist /Surgeon can miss to diagnose hernia and Torsion ovarian cyst?

The OP-3 answered: It is commonly difficult to diagnose clinically, the Strangulated Hernia.

18. We have perused the written arguments submitted by the OPs, para (h), which is relevant, reproduced as below:

Laparotomy revealed that the patient had a strangulated hernia, which could not be detected either by physical examination or by investigatory tests. It is possible that hernia goes undetected on physical examination. Laparotomy is thus an investigatory as well as curative method, and exactly determines the cause of abdominal pains   We are not convinced, but rather surprised by such submissions made by OP-1 & 3 and their counsel. In addition, it is surprising and beyond our imagination that How, a qualified Sonologist has failed to diagnose, Hernia? his USG report dated 14.08.2000, is also erroneous one. It appears that mind of OP-1 was a prejudiced, hence she repeatedly diagnosed the patient as, Torsion Ovarian Cyst instead of Strangulated Hernia.

Medical Literature-Diagnosis of Hernia:

19. To ascertain, whether the diagnosis of incisional/ strangulated hernia is difficult, we have referred to standard medical books on operative surgery, and medical literatures,. The relevant extracts are reproduced below:

HERNIASigns and Symptoms A hernia is the protrusion of an organ, organic part, or other bodily structure, through the wall that usually contains it.

Most hernias are diagnosed by the presence of a bulge in the abdominal wall. A physical change occurs in a patient's habitus. These persons usually have little discomfort or pain, unless the hernia is incarcerated or strangulated. However, a close review of their history will reveal that many persons with hernia have experienced vague pain or discomfort, particularly with physical activity.

Diagnosing an Incisional Hernia Incisional hernias happen after an abdominal surgery and may seem to appear and disappear, which is referred to as a "reducible" hernia. The hernia may not be noticeable, unless the patient is involved in an activity that increases abdominal pressure, such as coughing, sneezing, pushing to have a bowel movement, or lifting a heavy object.

The visibility of a hernia makes it easily diagnosable, often requiring no testing outside of a physical examination by a physician. The physician may request that you cough or bear down in order to see the hernia while it is "out".

Routine testing can be done to determine which area of the body is pushing through the muscle. If the hernia is large enough to allow more than the peritoneum to bulge through, testing may be required.

When is, Incisional Hernia, an Emergency?

A hernia that gets stuck in the obstructed position is referred to as an incarcerated hernia. While an incarcerated hernia may not be an emergency, medical care should be sought, as it can become an emergency, quickly.

20. Thus, it is clear that the incisional strangulated hernia is easily diagnosable by the patients symptoms and signs. At, first instance, in the month of May 1999, the patient was examined by OP-1, having acute abdominal pain. Again, on 14.08.1999, patient was presented with acute abdomen with sweating and vomiting. She has relied entirely upon the USG report. Even, by Per vaginal (PV) examination, she concluded as a case of torsioned ovarian cyst. Hence, it is a case of failure to diagnose/wrong diagnosis. It is pertinent to note that, at the first instance itself, in May 1999, the patients abdominal pain was not properly assessed by OP-1. There might be possibility of incisional obstructed hernia at that time. Subsequently, there was recurrence on 14.08.2000, which further progressed to obstructive/ incarcerated hernia and finally presented as Strangulation, on 14-15.08.2000 leading an emergency situation.