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Hernias and Scrotum
Dr Hiwa Omer AhmedAssistant Professor in General
Surgery
DEFINITION
bull rdquohellipan abnormal protrusion of a viscus through its containing wallrdquo
EPIDEMIOLOGY
bull All agesbull Both sexesbull Incidence Inguinal 80 Incisional 10 Femoral 7
Risk factorsbull Sex Nearly 10 times more men than women have
inguinal hernias bull Family history Your risk of inguinal hernia
increases if you have a close relative such as a parent or sibling with the condition
bull Certain medical conditions Having cystic fibrosis a life-threatening disorder that causes severe lung damage and often a chronic cough makes it more likely youll develop an inguinal hernia
bull Chronic cough A chronic cough such as occurs from smoking increases your risk of inguinal hernia
bull Chronic constipation This leads to straining during bowel movements mdash a common cause of inguinal hernias
bull Excess weight Being moderately to severely overweight can put extra pressure on your abdomen
bull Pregnancy This can both weaken the abdominal muscles and cause increased pressure inside your abdomen
bull Certain occupations Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia
bull Premature birth Infants who are born sooner than normal are more likely to have inguinal hernias
bull History of hernias If youve had one inguinal hernia its much more likely that youll eventually develop another mdash usually on the opposite side
Inguinal hernia
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Dr Hiwa Omer AhmedAssistant Professor in General
Surgery
DEFINITION
bull rdquohellipan abnormal protrusion of a viscus through its containing wallrdquo
EPIDEMIOLOGY
bull All agesbull Both sexesbull Incidence Inguinal 80 Incisional 10 Femoral 7
Risk factorsbull Sex Nearly 10 times more men than women have
inguinal hernias bull Family history Your risk of inguinal hernia
increases if you have a close relative such as a parent or sibling with the condition
bull Certain medical conditions Having cystic fibrosis a life-threatening disorder that causes severe lung damage and often a chronic cough makes it more likely youll develop an inguinal hernia
bull Chronic cough A chronic cough such as occurs from smoking increases your risk of inguinal hernia
bull Chronic constipation This leads to straining during bowel movements mdash a common cause of inguinal hernias
bull Excess weight Being moderately to severely overweight can put extra pressure on your abdomen
bull Pregnancy This can both weaken the abdominal muscles and cause increased pressure inside your abdomen
bull Certain occupations Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia
bull Premature birth Infants who are born sooner than normal are more likely to have inguinal hernias
bull History of hernias If youve had one inguinal hernia its much more likely that youll eventually develop another mdash usually on the opposite side
Inguinal hernia
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
DEFINITION
bull rdquohellipan abnormal protrusion of a viscus through its containing wallrdquo
EPIDEMIOLOGY
bull All agesbull Both sexesbull Incidence Inguinal 80 Incisional 10 Femoral 7
Risk factorsbull Sex Nearly 10 times more men than women have
inguinal hernias bull Family history Your risk of inguinal hernia
increases if you have a close relative such as a parent or sibling with the condition
bull Certain medical conditions Having cystic fibrosis a life-threatening disorder that causes severe lung damage and often a chronic cough makes it more likely youll develop an inguinal hernia
bull Chronic cough A chronic cough such as occurs from smoking increases your risk of inguinal hernia
bull Chronic constipation This leads to straining during bowel movements mdash a common cause of inguinal hernias
bull Excess weight Being moderately to severely overweight can put extra pressure on your abdomen
bull Pregnancy This can both weaken the abdominal muscles and cause increased pressure inside your abdomen
bull Certain occupations Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia
bull Premature birth Infants who are born sooner than normal are more likely to have inguinal hernias
bull History of hernias If youve had one inguinal hernia its much more likely that youll eventually develop another mdash usually on the opposite side
Inguinal hernia
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
EPIDEMIOLOGY
bull All agesbull Both sexesbull Incidence Inguinal 80 Incisional 10 Femoral 7
Risk factorsbull Sex Nearly 10 times more men than women have
inguinal hernias bull Family history Your risk of inguinal hernia
increases if you have a close relative such as a parent or sibling with the condition
bull Certain medical conditions Having cystic fibrosis a life-threatening disorder that causes severe lung damage and often a chronic cough makes it more likely youll develop an inguinal hernia
bull Chronic cough A chronic cough such as occurs from smoking increases your risk of inguinal hernia
bull Chronic constipation This leads to straining during bowel movements mdash a common cause of inguinal hernias
bull Excess weight Being moderately to severely overweight can put extra pressure on your abdomen
bull Pregnancy This can both weaken the abdominal muscles and cause increased pressure inside your abdomen
bull Certain occupations Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia
bull Premature birth Infants who are born sooner than normal are more likely to have inguinal hernias
bull History of hernias If youve had one inguinal hernia its much more likely that youll eventually develop another mdash usually on the opposite side
Inguinal hernia
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Risk factorsbull Sex Nearly 10 times more men than women have
inguinal hernias bull Family history Your risk of inguinal hernia
increases if you have a close relative such as a parent or sibling with the condition
bull Certain medical conditions Having cystic fibrosis a life-threatening disorder that causes severe lung damage and often a chronic cough makes it more likely youll develop an inguinal hernia
bull Chronic cough A chronic cough such as occurs from smoking increases your risk of inguinal hernia
bull Chronic constipation This leads to straining during bowel movements mdash a common cause of inguinal hernias
bull Excess weight Being moderately to severely overweight can put extra pressure on your abdomen
bull Pregnancy This can both weaken the abdominal muscles and cause increased pressure inside your abdomen
bull Certain occupations Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia
bull Premature birth Infants who are born sooner than normal are more likely to have inguinal hernias
bull History of hernias If youve had one inguinal hernia its much more likely that youll eventually develop another mdash usually on the opposite side
Inguinal hernia
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
bull Chronic cough A chronic cough such as occurs from smoking increases your risk of inguinal hernia
bull Chronic constipation This leads to straining during bowel movements mdash a common cause of inguinal hernias
bull Excess weight Being moderately to severely overweight can put extra pressure on your abdomen
bull Pregnancy This can both weaken the abdominal muscles and cause increased pressure inside your abdomen
bull Certain occupations Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia
bull Premature birth Infants who are born sooner than normal are more likely to have inguinal hernias
bull History of hernias If youve had one inguinal hernia its much more likely that youll eventually develop another mdash usually on the opposite side
Inguinal hernia
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
bull Pregnancy This can both weaken the abdominal muscles and cause increased pressure inside your abdomen
bull Certain occupations Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia
bull Premature birth Infants who are born sooner than normal are more likely to have inguinal hernias
bull History of hernias If youve had one inguinal hernia its much more likely that youll eventually develop another mdash usually on the opposite side
Inguinal hernia
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
bull Premature birth Infants who are born sooner than normal are more likely to have inguinal hernias
bull History of hernias If youve had one inguinal hernia its much more likely that youll eventually develop another mdash usually on the opposite side
Inguinal hernia
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Inguinal hernia
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Femoral hernia
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Umbilical hernias
bull 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
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Umbilical hernia
PUH
Epigastric hernias
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
PUH
Epigastric hernias
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Epigastric hernias
bull occur in the linea alba above the umbilicus
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Spigelian hernias
bull protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Incisional hernias
bull occur at sites of previous incisions Hernias occur after 14 of abdominal operations
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Incisional hernia
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Lumber hernia
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Lumbar hernias
bull 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
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Hiatus hernia
CLASSIFICATION
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
CLASSIFICATION
bull Position Inguinalfemoral etc
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
CLASSIFICATION
CONGENITALbull Preformed sacbull Eg Patent processus
vaginalis
ACQUIREDbull Primary Natural week
points eg femoral canal
bull Secondary Injury eg surgical wounds
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
AETIOLOGY
Increased abdo pressure
bull Heavy liftingbull Chronic coughbull BPHbull Constipationbull Ascites
Weakened Abdo wallbull Increasing agebull Malnutrionbull Collagen disordersbull Smokingbull obesity
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
ANATOMY
bull 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
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Inguinal Ligaments
Inguinal canals
Right Inguinal canal
INGUINAL CANAL
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Inguinal canals
Right Inguinal canal
INGUINAL CANAL
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Right Inguinal canal
INGUINAL CANAL
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
INGUINAL CANAL
bull 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
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Inguinal canal
BOUNDARIES OF INGUINAL CANAL
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
BOUNDARIES OF INGUINAL CANAL
bull FLOOR Inguinal ligamentbull ANTERIOR WALL External Obliquebull POSTERIOR WALL Transversalis fasciabull MEDIAL-POSTERIOR WALL Internal
oblique and transversalis (when they fuse become conjoint tendon)
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
CONTENTS OF CANAL
3 ARTERIESbull Testicular Arterybull Artery to Vasbull Artery to cremaster
3 NERVESbull Genital branch of
genitofemoral nervebull Sympathetic fibresbull Ilioinguinal nerve
3 LAYERS OF FASCIAbull External spermatic fasciabull Cremasteric fasciabull Internal spermatic fascia
3 OTHERSbull Vas deferensbull Panpiniform plexusbull Lymphatics
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Spermatic canal contents
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
ANATOMICAL DEFINITION
INDIRECTbull Lateral to IEAbull Outside Hasselbach
trianglebull Therefore hernia goes
from DR SR scrotum
bull Therefore indirect hernias are controlled deep ring
DIRECTbull Medial to IEAbull Inside Hasselbach
trianglebull It is a bulge in fascia
transversalisbull Therefore if bulge
medial to fingers at deep ring it is direct
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
HERNIAS
bull Note that scrotal swellings are usually indirect
bull However large directs can cross superficial ring and enter the scrotum This is rare
bull An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
EXAMINATION
bull Hernias must be examined with the patient standing and in supine
bull Start with any posisionbull Always examine both groins
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Types of herniaObliteration of tunica vaginalis
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Examinationbull Patient in standing and supine position
bull INSPECTIONbull Visible swelling( donrsquot consider bilateral Malgiagnelsquos
bulging as hernia)bull Visible cough impulsebull Easily reduciblebull Reappear on straining standing or coughing bull Elucidate Fothergill and Carnet signsbull
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
bull PALPATIONbull Examine as amass and then bull Palpable cough impulsebull Reducebull Occlusion testbull Three Finger test ( Zimmanrsquos test)
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Assess the following1 Position2 Temperature3 Tenderness4 Shape5 Size6 Tension7 Composition8 Expansile cough impulse9 Reducible Control deep ring Which way does it
reappear
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
PERCUSSION AND AUSCULTATION
bull Bowel sounds
bull Remember always examine the other side
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Herniography
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Treatment
bull Meclo bull DIIH with wide neckbull Umbilical hernia up to 4 years of agebull In unfit patient
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Surgery
bull According to agebull up to 7 years gtgt Herniotomy 7-17 gt Herniotomy _+ Lytle repair 17 amp on gt Herniotomy amp hernioraphy or
hernioplasty
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Herniotomy
bull Oblique inguinal Incisionbull Finding the sac on anteriolateral aspect of the
spermatic cordbull Dissection of the sacbull Returning of the content of the hernia to the abdomenbull Transfixation of the neck of the sacbull Ligationbull excision
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Herniorrhaphy
bull 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 3Schouldise repair 4 Muscovige repair
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Hernioplasty
bull 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 its 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
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Laparoscopic hernia repair
synthetic mesh
PREVENSION
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
synthetic mesh
PREVENSION
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
PREVENSION
bull You cant prevent the congenital defect that may lead to an inguinal hernia
bull but the following steps can help reduce strain on your abdominal muscles
bull and tissuesbull 1048708 Maintain a healthy weight If you think
you may be overweight talk to your doctor about the best exercise and diet plan for you
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
bull 1048708 Emphasize high-fiber foods Fresh fruits and vegetables and whole grains are good for your overall health Theyre also packed with fiber that can help prevent constipation and straining
bull 1048708 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
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
bull 1048708 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
bull herniabull 1048708 Dont rely on a truss for support
Contrary to what you may have heard wearing a truss isnt the best long-term solution for an inguinal hernia
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
bull A truss wont 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 hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
DIFFERENTIAL DIAGNOSIS
1 Inguinal hernia2 Sapheno varix3 Femoral LN4 Lipoma5 Femoral aneurysm6 Psoas abscess7 Rupture Adductor longus with haematoma
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Comparisons
Down amp MedialTo original position
4 Direction on release
3 Controlled by pressure over deep ring
Up amp LateralStraight back2 Direction of reduction
1 Extends to scrotum
INDIRECTDIRECT
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Comparisons
BS +BS ++4 Auscultation
Dull3 Percussion
FirmSoft2 Palpation
Inferior and lateralSuperior and medial1 Position relative to PT
FEMORALINGUINAL
Resonant
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
FEMORAL HERNIA
bull Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament
bull Femoral canal=is the medial part of femoral sheath
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Anatomy
bull 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 Coopers ligament
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
FEMORAL RING
bull Anterior border Inguinal ligamentbull Posterior border Pectineal Ligament
( ligament of Astley Cooper)bull Medial border Lacunar ligamentbull Lateral border Femoral vein
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
features
bull Femoral hernias may present as a tender groin mass and small-bowel obstruction may sometimes occur
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Physical examination
bull 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
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Types of femoral hernia
complications
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
complications
bull 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
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
Treatment
bull A Coopers ligament repair (McVey) through the inguinal approach is recommended
