What is a hernia? External abdominal hernias –

Protusion of the abdominal viscus through a weak spot in the abdominal wall.

Anatomy of the inguinal region

Boundaries of the inguinal canal

Weak spot on the anterior abdominal wall through which the Direct inguinal hernia protrudes.

Bounded by-Medially – Outer border of Rectus AbdominalisLaterally – By the inf Epigastric vesselsBelow – Medial part of the inguinal ligament

Contents of the inguinal canal

Ilioinguinal nerve - Medial part of the canal. it pierces through the internal oblique distributing filaments to it, enters the inguinal canal midway and the accompanies the spermatic cord till the Sup inguinal ring.

Males – Spermatic cord and its coverings and the remnants of the processus vaginalis

Females – Round ligament and the remnants of the processus vaginalis

Contents•DD –ductus deferens•GFN – Genitofemoral Nerve•Testicular plexus of sym nerves•LV –Lymph vessels•PPV –Pampiniform plexus•TA – Testicular artery•Artery to the vas•Artery to the Cremaster

Indirect hernia More common Major cause is a patent Processus Vaginalis Groups –

Bubonocele – Limited in the canal and the processus is closed at the sup inguinal ring. Presents as an inguinal swelling

Funicular – Processus is closed at its lower end just above the epidydimis. Therefore hernia is felt separated from the testis and above it.

Complete – Complete patent processus. Therefore the hernial sac is continuous with the tunica vaginalis of testis. Hernia is in front of at sides of the testis and it cannot be palpated easily. Congenital but detected only in adolescent life.

Peritoneum Extraperitoneal fat Int Spermatic fascia Cremasteric fascia Ext spermatic fascia Superficial fascia Skin

Coverings of an Indirect Inguinal Hernia

Direct Inguinal Hernia

Most important point is that neck is medial to the inferior epigastric vessels while indirect hernia’s neck is lateral to the vessels.

Always acquired with one rare exception

Rarely attains a large size and never descends into the scrotum and rarely gets strangulated because it has a wide neck.

Feature Indirect Hernia

Direct Hernia

Definition Enter at the deep inguinal canal

and traverse the length of the

canal

Protrudes through the posterior wall

of the canal through

Hesselbach’s triangle

Age and Sex Children and young adults;

M>>F

Elderly individuals; females not

affected

Laterality 2/3rds cases are U/L, right side is more common

>1/2 of the cases are B/L

Shape and Completion

Complete » Pyriform

Incomplete » Oval

Always incomplete and is spherical in shape

Feature Indirect hernia

Direct hernia

Reducibilty Doesn’t reduce by itself, has to be reduced by

patient or doctor

Automatically reduces when patient is lying

down

Impulse on coughing

On the index finger

On the middle finger

Invagination test

Impulse on the tip of the

finger

Impulse on the pulp of the

fingerRing

occlusion test

Doesn’t bulge out

Bulges out medial to the

finger

Clinical Features Pain – Dragging or aching type Sensation of heaviness and weight Painful and tender » Strangulated Swelling Others

Intestinal obstruction – if hernia is obstructing the lumen of the intestine. i.e colicky pain, vomiting, abdominal distension

Vomiting is an ominous sign and can indicate infection or impending rupture.

Femoral Hernia

Abdominal contents pass through the femoral ring and come out through the saphenous opening.

3rd most common hernia after inguinal and incisional and is more common in females.

Most liable to get strangulated.

Anatomy Femoral sheath is a continuation of transversalis

fascia into the thigh anteriorly and fascia iliaca posteriorly which fuse near the inguinal ligament.

It is divided into three compartments. The medial most compartment is called the femoral canal and contains efferent lymphatics, sometimes a small lymph node (lymph node of Cloquet) and areolar tissue.

The opening of the femoral canal is called the femoral ring through which femoral hernia occurs. The ring is generally closed by the femoral septum which is extraperitoneal tissue.

To the femoral triangle

The saphenous opening or the fossa ovalis is an opening in the fascia lata 4cm below and Lateral to the pubic tubercle.

Sharp upper and outer margins called falciform process. This process is important because it turns the femoral hernia upwards after it comes out of the opening.

Covered by loose areolar tissue called the cribriform fascia.

Traversed by the long saphenous vein and lymphatics.

Course of a Femoral hernia

Comes out through the femoral ring

Passes through the femoral canal

Comes out through the saphenous opening

Pushed up by the folds and moves up through the subcutaneous tissue of the thigh and can even reach above the inguinal ligament.

Coverings of Femoral hernia

Peritoneum Femoral septum Fatty content of the femoral canal Anterior layer of the femoral sheath Cribriform fascia Superficial fascia Skin

Clinical features and signs Age and Sex – Rare in young people. Majority

between 60 and 80 years. F>>M( but the most common hernia in females is inguinal hernia)

R>L ; B/L is seen in 20% cases. Pain is lesser than that of inguinal hernia and

can go unnoticed until strangulation Swelling- Small globular swelling lateral to and

below the pubic tubercle. More obvios on standing and straining.

Other symptoms – Abdominal colic, vomiting, distension and constipation.

Test Inguinal Hernia

Femoral Hernia

Position Neck of sac is below the inguinal

ligament and lat. to pubic

tubercle

Above the inguinal

ligament and medial to the pubic tubercle

Cough impulse

Indirect » Index Direct » Middle

Impulse is felt on Ring finger

Invagination test

Positive Negative (empty canl)

Ring occlusion

test

Direct » BulgeIndirect » No

bulge

Doesn’t come out