Hernias and

Scrotum
 Dr. Hiwa Omer Ahmed
Assistant Professor in General
Surgery
 DEFINITION
• ”…..an abnormal protrusion of a viscus
through its containing wall”
 EPIDEMIOLOGY
• All ages
• Both sexes
• % Incidence: Inguinal 80%
Incisional 10%
Femoral 7%
 Risk factors
• Sex; Nearly 10 times more men than women have
inguinal hernias,
• Family history. Your risk of inguinal hernia
increases if you have a close relative, such as a
parent or sibling, with the condition.
• Certain medical conditions. Having cystic
fibrosis, a life-threatening disorder that causes
severe lung damage and often a chronic cough,
makes it more likely you'll develop an inguinal
hernia.
• Chronic cough. A chronic cough, such as
occurs from smoking, increases your risk of
inguinal hernia.
• Chronic constipation. This leads to
straining during bowel movements — a
common cause of inguinal hernias.
• Excess weight. Being moderately to
severely overweight can put extra pressure
on your abdomen.
• Pregnancy. This can both weaken the
abdominal muscles and cause increased
pressure inside your abdomen.
• Certain occupations. Having a job that
requires standing for long periods or doing
heavy physical labor increases your risk of
developing an inguinal hernia.
• Premature birth. Infants who are born
sooner than normal are more likely to have
inguinal hernias.
• History of hernias. If you've had one
inguinal hernia, it's much more likely that
you'll eventually develop another — usually
on the opposite side
Inguinal hernia
Femoral hernia
 Umbilical hernias
• are congenital defects. Most newborn
umbilical hernias close spontaneously by
the second year of life. Patients with ascites
have a high incidence of umbilical hernias.
Umbilical hernia
PUH
 Epigastric hernias
• . occur in the linea alba above the
umbilicus.
 Spigelian hernias
• protrude near the termination of the
transversus abdominis muscle at the lateral
edge of the rectus abdominis muscle.
 Incisional hernias
• occur at sites of previous incisions. Hernias
occur after 14% of abdominal operations
Incisional hernia
Lumber hernia
 Lumbar hernias
• occur superior to the iliac crest or below the
last rib. F. Obturator hernias pass through
the obturator foramen and present with
bowel obstruction and focal tenderness on
rectal examination
Hiatus hernia
 CLASSIFICATION
• Position: Inguinal/femoral etc
 CLASSIFICATION
CONGENITAL ACQUIRED.
• Preformed sac • Primary: Natural week
• E.g. Patent processus points eg femoral
vaginalis canal.
• Secondary: Injury e.g.
surgical wounds.
 AETIOLOGY
Increased abdo Weakened Abdo wall:
pressure: • Increasing age
• Heavy lifting • Malnutrion
• Chronic cough • Collagen disorders
• BPH • Smoking
• Constipation • obesity
• Ascites
 ANATOMY
• To understand inguinal and femoral hernia
it is necessary to understand the anatomy of
the inguinal canal.
Inguinal Ligaments
Inguinal canals
Right Inguinal canal
 INGUINAL CANAL
• The inguinal canal is an oblique muscular
passage through the lower abdominal wall
and transmits the passage of the spermatic
cord in males and the round ligament in
females. It runs parallel and superiorly to
inguinal ligament.
Inguinal canal
BOUNDARIES OF INGUINAL
CANAL
• FLOOR: Inguinal ligament
• ANTERIOR WALL: External Oblique
• POSTERIOR WALL: Transversalis fascia
• MEDIAL-POSTERIOR WALL: Internal
oblique and transversalis (when they fuse
become conjoint tendon.)
 CONTENTS OF CANAL
3 ARTERIES:
• Testicular Artery
• Artery to Vas
• Artery to cremaster
3 LAYERS OF FASCIA:
• External spermatic fascia
• Cremasteric fascia
• Internal spermatic fascia.
3 NERVES:
• Genital branch of
genitofemoral nerve
• Sympathetic fibres
• Ilioinguinal nerve
3 OTHERS:
• Vas deferens
• Panpiniform plexus
• Lymphatics
Spermatic canal contents
 ANATOMICAL DEFINITION
INDIRECT DIRECT
• Lateral to IEA • Medial to IEA
• Outside Hasselbach • Inside Hasselbach
triangle. triangle.
• Therefore hernia goes • It is a bulge in fascia
from DR SR scrotum. transversalis.
• Therefore, indirect • Therefore if bulge
hernias are controlled @
medial to fingers at
deep ring
deep ring it is direct.
 HERNIAS
• Note that scrotal swellings are usually
indirect.
• However, large directs can cross superficial
ring and enter the scrotum. This is rare.
• An indirect and direct hernia occurring
simultaneously is termed a pantaloon
hernia.
 EXAMINATION
• Hernias must be examined with the patient
standing and in supine
• Start with any posision.
• Always examine both groins.
 Types of hernia
Obliteration of tunica vaginalis
 Examination
• Patient in standing and supine position

• INSPECTION
• Visible swelling( don’t consider bilateral
Malgiagne‘s bulging as hernia)
• Visible cough impulse
• Easily reducible
• Reappear on straining, standing or coughing

• Elucidate Fothergill and Carnet signs

•
• PALPATION
• Examine as amass and then
• Palpable cough impulse
• Reduce
• Occlusion test
• Three Finger test ( Zimman’s test)
 Assess the following:
• Position
• Temperature
• Tenderness
• Shape
• Size
• Tension
• Composition
• Expansile cough impulse
• Reducible: ? Control @ deep ring. Which way
does it reappear?
 PERCUSSION AND
AUSCULTATION
• ? Bowel sounds

• Remember always examine the other side!

Herniography
 Treatment
• Meclo ;
• DIIH with wide neck
• Umbilical hernia up to 4 years of age
• In unfit patient
 Surgery
• According to age;
• * up to 7 years ;>> Herniotomy
* 7-17 :> Herniotomy _+ Lytle repair
* 17 & on; > Herniotomy & hernioraphy or
hernioplasty
 Herniotomy
• Oblique inguinal Incision
• Finding the sac on anteriolateral aspect of the
spermatic cord
• Dissection of the sac
• Returning of the content of the hernia to the
abdomen
• Transfixation of the neck of the sac
• Ligation
• excision
 Herniorrhaphy
• Herniorrhaphy. In this procedure, an incision in
the groin done called oblique inguinal incision the
protruding intestine pushed back into the
abdomen, then repairs the weakened or torn
muscle by sewing it together
1. Lytle repair
2. Bassini or modified Bassini
3.Schouldise repair
4. Muscovige repair
 Hernioplasty
• In this procedure, the surgeon inserts a piece of
synthetic mesh to cover the entire inguinal area,
including all potential hernia openings. The patch
is usually secured with sutures, clips or staples.
Hernioplasty can be performed conventionally,
with a single long incision over the hernia. But it's
often done laparoscopically, using several small
incisions rather than one large one. the other
incisions. Your surgeon then performs the
operation using the video camera as a guide.
Laparoscopic hernia repair
synthetic mesh
 PREVENSION
• You can't prevent the congenital defect that
may lead to an inguinal hernia,
• but the following steps can help reduce
strain on your abdominal muscles
• and tissues:
• Maintain a healthy weight. If you think
you may be overweight, talk to your doctor
about the best exercise and diet plan for
you.
• Emphasize high-fiber foods. Fresh fruits
and vegetables and whole grains are good for
your overall health. They're also packed with
fiber that can help prevent constipation and
straining.
• Lift heavy objects carefully or avoid
heavy lifting altogether. If you have to lift
something heavy, always bend from your
knees, not at your waist.
• Stop smoking. In addition to increasing
your risk of serious diseases such as cancer,
emphysema and heart disease, smoking often
causes a chronic cough that can lead to or
aggravate an inguinal
• hernia.
• Don't rely on a truss for support.
Contrary to what you may have heard, wearing
a truss isn't the best long-term solution for an
inguinal hernia
• A truss won't protect against complications
or correct the underlying problem, although
the doctor may recommend wearing one for
a short time before surgery or for unfit
patient.
 DIFFERENTIAL DIAGNOSIS
1. Inguinal hernia
2. Sapheno varix
3. Femoral LN
4. Lipoma
5. Femoral aneurysm
6. Psoas abscess
7. Rupture Adductor longus with haematoma
 Comparisons
DIRECT INDIRECT
1. Extends to
scrotum
2. Direction of Straight back Up & Lateral
reduction

3. Controlled by
pressure over deep
ring

4. Direction on To original Down & Medial

release position
 Comparisons
INGUINAL FEMORAL
1. Position Superior and medial Inferior and lateral
relative to PT
2. Palpation Soft Firm

3. Percussion ? Resonant Dull

4. Auscultation BS ++ BS +
 FEMORAL HERNIA
• Femoral Sheath=Femoral artery and vein
drag peritoneum below inguinal ligament.
• Femoral canal=is the medial part of femoral
sheath.
 Anatomy
• . In femoral hernias, the abdominal viscera
and peritoneum protrude through the
femoral ring into the upper thigh. The
femoral ring is limited medially by the
lacunar ligament of Gimbernat, laterally by
the femoral vein, anteriorly and proximally
by the inguinal ligament, and posteriorly
and distally by Cooper's ligament
 FEMORAL RING
• Anterior border: Inguinal ligament
• Posterior border: Pectineal Ligament
( ligament of Astley Cooper)
• Medial border: Lacunar ligament
• Lateral border: Femoral vein
 features
• Femoral hernias may present as a tender
groin mass, and small-bowel obstruction
may sometimes occur
 Physical examination
• The hernia sac manifests clinically as a
mass in the upper thigh, curving craniad
over the inguinal region. It may appear
while the patient is standing or straining and
may disappear in the supine position.
Types of femoral hernia
 complications
• . Femoral hernias account for 5% of all
hernias, and 84% of femoral hernias occur
in women. Incarceration or strangulation
occurs in 25% of femoral hernias
 Treatment..
• A Cooper's ligament repair (McVey)
through the inguinal approach is
recommended