Inguinal Hernia Dr. Ashok Jaisingani

Superficial Inguinal Ring: It is triangular aperture in the aponeurosis of the external oblique muscle and lie 1.25 cm above the pubic tubercle. Normally the ring will not admit the tip of little finger.

Deep Inguinal Ring: It is U shape condensation of transversalis fascia and it lies 1.25 cm above inguinal (Poupart’s) ligament.

The transversalis fascia is the fascial envelope of abdomen and competency of deep inguinal ring depends on the integrity of this fascia.

Surgical Anatomy

Infants: In infants the superficial and deep ring is almost superimposed and the obliquity of the canal is slight.

Adult: In adult the inguinal canal is 3.75 cm is long is directed downward and medially from the deep to superficial inguinal ring.

In male inguinal canal transmit the spermatic cord, ilioinguinal nerve & genital branch of genitofemoral nerve.

In female round ligament replace the spermatic cord.

Inguinal canal

Indirect Inguinal hernia is most common hernia of all especially in young.

Direct inguinal hernia become more common in the elderly.

An indirect hernia travels down the canal on the outer (Lateral & anterior) side of spermatic cord.

A direct inguinal hernia comes out directly forward through posterior wall of inguinal canal.

The neck of indirect inguinal hernia lateral to inferior epigastric vessels

The neck of direct inguinal hernia usually emerge medial to the inferior epigastric vessels except in saddle – bag or pantaloon type (have both lateral & medial component)

Direct & Indirect Inguinal Hernia

An inguinal hernia can be differentiate from the femoral by ascertaining the relation of the neck of the sac to the medial end of the inguinal ligament & pubic tubercle.

Inguinal Hernia: The neck lie above and medial to the medial end of inguinal ligament & pubic tubercle.

Femoral Hernia: The neck lie below and lateral to the medial end of the inguinal ligament & pubic tubercle.

Differentiate between Inguinal & Femoral Hernia

Indirect inguinal hernia is most common in young

In first decade of life inguinal hernia is more common on right side in male, this is associated with later descent of right testis & higher incidences of failure of closure of procesus vaginalis.

In adult male 65% of inguinal hernias are indirect and 55% are right – sided

The hernia is bilateral 12% of the cases

Indirect (Oblique) Inguinal Hernia

There are three types of indirect inguinal hernia;

1- Bubonocele: (hernia is limited to inguinal canal)

2- Funicular: (The processus vaginalis closed just above the epididymis), the content of sac can be left separately from the testis (lie below the hernia)

3- Complete (scrotal): Rarely present at birth commonly encounter in infancy. The testis appear to lie within the lower part of hernia.

Types Of Indirect Inguinal Hernia

The patient is instructed to look at the ceiling and cough, if the hernia will comes down, the examiner look and feel for impulse and address following question.

Is the hernia right, left or bilateral? Is it an inguinal or femoral hernia? Is it a direct or indirect inguinal hernia? Is it reducible or irreducible hernia? Is the inguinal hernia is complete or

incomplete? Looks for contents.

Clinical Examination

Indirect inguinal hernia is 20 times more common in males than females.

The patient complain the pain in groin or pain refer to testis when perform the work or strenuous exercise.

On coughing a small transitient bulging is seen and feel together with expansile impulse.

When the sac is limited to inguinal canal, the bulge may be better seen by observing the inguinal region from side or looking down to abdominal wall.

An indirect inguinal hernia on coughing comes down and persist until it is reduced

In large hernias there is sensation of the dragging & weight on mesentery, may produce epigastric pain.

The indirect inguinal hernia is “translucent” in infancy and early childhood but never in adult hood

Clinical Features

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

canal Lipoma of the cord

Differential Diagnosis In Males

Hydrocele of the canal of Nuck Femoral Hernia

Differential Diagnosis In Females

Surgery is the treatment of the choice Surgery is either open or laparoscopic Truss is used when the operation is

contraindicated or when operation is refused.

Treatment

It is consist of 1- Excision of hernial sac 2- Repair of transversalis fascia and internal

ring 3- Further reinforcement of posterior wall of

inguinal canal.

Herniotomy And Repair (Herniorhaphy)

In adult male 35% of inguinal hernias are direct

At presentation 12% of patients will have contralateral hernia, and there is four fold increase in risk of contra-lateral hernia.

A direct inguinal hernia is always acquired, the sac passes through a weakness or defect of transversalis fascia in posterior wall of inguinal canal.

Women practically never develop direct inguinal hernia (Brown).

Direct Inguinal Hernia

Smoking Occupation that involve straining and heavy

lifting Damage to illioinguinal nerve (Previous

appendicectomy) is another cause

Predisposing Factors

Direct hernia do not often attain a large size or descend into scrotum

In contrast to indirect inguinal hernia, direct inguinal hernia lies behind the spermatic cord

The sac is often smaller than mass, the protruding mass consist of the extra-peritoneal fat.

As the neck of sac is wide, the direct inguinal hernias do not strangulate or strangulate rarely.

Characteristic Feature Of Direct Inguinal Hernia

This is narrow necked hernia with prevesical fat and portion of bladder that occur through a small oval defect in the medial part of conjoined tendon just above the pubic tubercle.

It occurs principally in elderly Occasionally it become strangulated Operation should always be advised until

there is definite contraindication.

Funicular Direct Inguinal Hernia (Prevesical Hernia)

This type of hernia consist of two sac that straddle the inferior epigastric artery,

One sac being medial and other one lateral to this vessel.

This condition is not rare & is cause of recurrence

Dual (Saddle – bag, Pantaloon) Hernia

Strangulation of inguinal hernia occurs at any time during life, occurs in both sex equally.

Indirect inguinal hernia strangulate more commonly, but not so often direct variety because of wide neck of sac.

More often the strangulation occurs in pts who have worn truss for long time & those with partially reducible or irreducible hernias.

Strangulated Inguinal Hernia

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

Constricting Agents

Usually the small intestine is involved in strangulation with next most common that involved in strangulation is omentum.

It is rare the large intestine to become strangulated, even when the hernia is of sliding type.

Contents Of Strangulated Inguinal Hernia

The incidences of strangulation during infancy is 4% (Gross).

The ratio of girls to boy is 5:1

More frequently the hernia is irreducible but not strangulated.

Most cases of strangulated inguinal hernias occurs in females infants and contents will be ovary or ovary plus fallopian tube.

Strangulation During Infancy

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

Pre – operative Treatment Of Strangulated Hernia

These are indicated only in infants, the child is given analgesics & placed in gallow’s traction.

In 75% of the cases the reduction is effected and there appear to be no danger of gangrenous intestine

Forcible reduction must be avoided & should not be attempted.

Conservative Measurement

It is rare type of the hernia. The strangulated loop of W within abdomen,

so local tenderness over the hernia is not marked.

At operation two – comparatively normal looking loop of intestine are present in the sac.

The strangulated loop will become apparent if traction is exerted on the middle of the loops occupying the sac.

Maydl’s Hernia (Hernia – in – W)

It result from slipping of posterior parietal peritoneum on the underlying retroperitoneal structure.

The posterior wall of the sac formed by sigmoid colon, mesentery on left, caecum on right & some time by either side portion of bladder.

Mostly sac consist of caecum, appendix or the portion of the colon.

A small bowl sliding hernia occurs approx. 1 in 2000 cases

The sac-less hernia occurs 1 in 8000 cases

Sliding Hernia

A sliding hernia occurs almost exclusively in men Five out of six sliding hernias are situated on the

left sides Bilateral sliding hernias are rare The patient is nearly over the 40 year of age It should be suspected in very large globular

inguinal hernia descending well into the scrotum. Occasionally the large intestine strangulated in

sliding hernia, more often non – strangulated large intestine large intestine is present behind the sac

Clinical Features