Inguinal Hernia

Dr. Ashok Jaisingani

Surgical Anatomy

Superficial Inguinal Ring: It is triangular

aperture in the aponeurosis of the external
oblique muscle and lie 1.25 cm above the
pubic tubercle. Normally the ring will not admit
the tip of little finger.
Deep Inguinal Ring: It is U shape
condensation of transversalis fascia and it lies
1.25 cm above inguinal (Pouparts) ligament.
The transversalis fascia is the fascial envelope
of abdomen and competency of deep inguinal
ring depends on the integrity of this fascia.

Inguinal canal

Infants: In infants the superficial and deep

ring is almost superimposed and the obliquity
of the canal is slight.
Adult: In adult the inguinal canal is 3.75 cm is
long is directed downward and medially from
the deep to superficial inguinal ring.
In male inguinal canal transmit the spermatic
cord, ilioinguinal nerve & genital branch of
genitofemoral nerve.
In female round ligament replace the
spermatic cord.

Direct & Indirect Inguinal Hernia

Indirect Inguinal hernia is most common hernia of all

especially in young.
Direct inguinal hernia become more common in the
elderly.
An indirect hernia travels down the canal on the outer
(Lateral & anterior) side of spermatic cord.
A direct inguinal hernia comes out directly forward
through posterior wall of inguinal canal.
The neck of indirect inguinal hernia lateral to inferior
epigastric vessels
The neck of direct inguinal hernia usually emerge medial
to the inferior epigastric vessels except in saddle bag or
pantaloon type (have both lateral & medial component)

Differentiate between Inguinal & Femoral

Hernia
An inguinal hernia can be differentiate from
the femoral by ascertaining the relation of
the neck of the sac to the medial end of the
inguinal ligament & pubic tubercle.
Inguinal Hernia: The neck lie above and
medial to the medial end of inguinal
ligament & pubic tubercle.
Femoral Hernia: The neck lie below and
lateral to the medial end of the inguinal
ligament & pubic tubercle.

Indirect (Oblique) Inguinal Hernia

Indirect inguinal hernia is most common in
young
In first decade of life inguinal hernia is more
common on right side in male, this is
associated with later descent of right testis
& higher incidences of failure of closure of
procesus vaginalis.
In adult male 65% of inguinal hernias are
indirect and 55% are right sided
The hernia is bilateral 12% of the cases

Types Of Indirect Inguinal Hernia

There are three types of indirect inguinal
hernia;
1- Bubonocele: (hernia is limited to inguinal
canal)
2- Funicular: (The processus vaginalis closed
just above the epididymis), the content of
sac can be left separately from the testis
(lie below the hernia)
3- Complete (scrotal): Rarely present at
birth commonly encounter in infancy. The
testis appear to lie within the lower part of
hernia.

Clinical Examination
The patient is instructed to look at the
ceiling and cough, if the hernia will comes
down, the examiner look and feel for
impulse and address following question.
Is the hernia right, left or bilateral?
Is it an inguinal or femoral hernia?
Is it a direct or indirect inguinal hernia?
Is it reducible or irreducible hernia?
Is
the inguinal hernia is complete or
incomplete?
Looks for contents.

Clinical Features

Indirect inguinal hernia is 20 times more common in males than

females.
The patient complain the pain in groin or pain refer to testis when
perform the work or strenuous exercise.
On coughing a small transitient bulging is seen and feel together
with expansile impulse.
When the sac is limited to inguinal canal, the bulge may be better
seen by observing the inguinal region from side or looking down
to abdominal wall.
An indirect inguinal hernia on coughing comes down and persist
until it is reduced
In large hernias there is sensation of the dragging & weight on
mesentery, may produce epigastric pain.
The indirect inguinal hernia is translucent in infancy and early
childhood but never in adult hood

Differential Diagnosis In Males

Vaginal Hydrocele
Encysted hydrocele of cord
Spermatocele
Femoral hernia
Incomplete descended testis in inguinal
canal
Lipoma of the cord

Differential Diagnosis In Females

Hydrocele of the canal of Nuck
Femoral Hernia

Treatment
Surgery is the treatment of the choice
Surgery is either open or laparoscopic
Truss
is used when the operation
contraindicated or when operation
refused.

is
is

Herniotomy And Repair (Herniorhaphy)

It is consist of
1- Excision of hernial sac
2- Repair of transversalis fascia and internal
ring
3- Further reinforcement of posterior wall of
inguinal canal.

Direct Inguinal Hernia

In adult male 35% of inguinal hernias are
direct
At presentation 12% of patients will have
contralateral hernia, and there is four fold
increase in risk of contra-lateral hernia.
A direct inguinal hernia is always acquired,
the sac passes through a weakness or
defect of transversalis fascia in posterior
wall of inguinal canal.
Women practically never develop direct
inguinal hernia (Brown).

Predisposing Factors
Smoking
Occupation that involve straining and heavy
lifting
Damage to illioinguinal nerve (Previous
appendicectomy) is another cause

Characteristic Feature Of Direct Inguinal

Hernia
Direct hernia do not often attain a large size
or descend into scrotum
In contrast to indirect inguinal hernia, direct
inguinal hernia lies behind the spermatic
cord
The sac is often smaller than mass, the
protruding mass consist of the extraperitoneal fat.
As the neck of sac is wide, the direct
inguinal hernias do not strangulate or
strangulate rarely.

Funicular Direct Inguinal Hernia

(Prevesical Hernia)
This is narrow necked hernia with prevesical
fat and portion of bladder that occur
through a small oval defect in the medial
part of conjoined tendon just above the
pubic tubercle.
It occurs principally in elderly
Occasionally it become strangulated
Operation should always be advised until
there is definite contraindication.

Dual (Saddle bag, Pantaloon) Hernia

This type of hernia consist of two sac that
straddle the inferior epigastric artery,
One sac being medial and other one lateral
to this vessel.
This condition is not rare & is cause of
recurrence

Strangulated Inguinal Hernia

Strangulation of inguinal hernia occurs at
any time during life, occurs in both sex
equally.
Indirect inguinal hernia strangulate more
commonly, but not so often direct variety
because of wide neck of sac.
More often the strangulation occurs in pts
who have worn truss for long time & those
with partially reducible or irreducible
hernias.

Constricting Agents
The Neck Of Sac
The External Inguinal Ring In Children
Adhesion Within Sac

Contents Of Strangulated Inguinal Hernia

Usually the small intestine is involved in
strangulation with next most common that
involved in strangulation is omentum.
It is rare the large intestine to become
strangulated, even when the hernia is of
sliding type.

Strangulation During Infancy

The incidences of strangulation during
infancy is 4% (Gross).
The
ratio
of
girls
to
boy
is
5:1
More frequently the hernia is irreducible but
not strangulated.
Most cases of strangulated inguinal hernias
occurs in females infants and contents will
be ovary or ovary plus fallopian tube.

Pre operative Treatment Of Strangulated

Hernia
Resuscitation with adequate fluids
Empty stomach with nasogastric tube
Give antibiotic to contain infection
Catheterize to monitor hemodynamic state
Operation:
Inguinal herniotomy for strangulation

Conservative Measurement
These are indicated only in infants, the child
is given analgesics & placed in gallows
traction.
In 75% of the cases the reduction is
effected and there appear to be no danger
of gangrenous intestine
Forcible
reduction must be avoided &
should not be attempted.

Maydls Hernia (Hernia in W)

It is
rare
type
of
the
hernia.
The strangulated loop of W within abdomen,
so local tenderness over the hernia is not
marked.
At operation two comparatively normal
looking loop of intestine are present in the
sac.
The strangulated loop will become apparent
if traction is exerted on the middle of the
loops occupying the sac.

Sliding Hernia

It result from slipping of posterior parietal

peritoneum on the underlying retroperitoneal
structure.
The posterior wall of the sac formed by sigmoid
colon, mesentery on left, caecum on right &
some time by either side portion of bladder.
Mostly sac consist of caecum, appendix or the
portion of the colon.
A small bowl sliding hernia occurs approx. 1 in
2000 cases
The sac-less hernia occurs 1 in 8000 cases

Clinical Features

A sliding hernia occurs almost exclusively in men

Five out of six sliding hernias are situated on the
left sides
Bilateral sliding hernias are rare
The patient is nearly over the 40 year of age
It should be suspected in very large globular
inguinal hernia descending well into the scrotum.
Occasionally the large intestine strangulated in
sliding hernia, more often non strangulated large
intestine large intestine is present behind the sac