Inguinal Hernia

Indirect inguinal hernia

  • Can occur in any age from childhood to adult.
  • Sup. Inguinal ring is an opening in external oblique aponeurosis
  • Lateral to inferior epigastric vessels
  • Protrusion through the deep ring; herniation occurs later
  • The neck of the sac lies above and medial to the pubic tubercle.
  • Pyriform/oval in shape; descends obliquely and downwards.
  • In children, if inguinal (indirect) hernia is present in one side, then processus vaginalis is intact on other side
  • Can become complete by descend down in to scrotum.
  • Sac is anterolateral to spermatic cord in male.
  • Commonly u/l but can be b/l .Rt sided is more common than Lt side
  • Sac should be opened in surgery .

Direct inguinal hernia

  • Common in elderly
  • Always acquired
  • Herniation through posterior wall of the inguinal canal
  • Globular/round in shape; descends directly forward bulge.
  • Truss cannot prevent progression of Sliding type of inguinal hernia
  • Descent down in to scrotum is rare & less likely to undergo strangulation
  • Sac is posterior to the cord.
  • Commonly b/l.
  • It is not necessarily opened.

According to the extent - indirect IH

  • Incomplete


  1. Bubonocele-sac is confined to the inguinal canal
  2. Funiclar-here the sac crosses the sup inguinal ring but does not reach the bottom of the scrotum
  3. Incompletely descended testis Early repositioning can preserve function,It may lead to sterility, if bilateral & May be associated with indirect inguinal hernia
  4. Complete (or Vaginal): here the processus vaginalis is patent throghout. The hernial sac is continuous with the tunica vaginalis of the testis. The hernia descends down to the bottom of scrotum and it is difficult to differentiate the testis from the hernia.


  • Complete

Sac descend to the bottom of the scrotum
PRECIPITATING CAUSES:

  • STRAINING
  • CHRONIC CONSTIPATION
  • RESPIRATORY CAUSES(COPD)
  • SMOKING
  • OBESITY
  • ASCITES
  • PREVIOUS SURGERY LIKE APPENDICECTOMY
  • URINARY PROBLEMS LIKE BPH , URETHRAL STRICTURE
  • MULTIPLE PREGNANCIES
  • Weight lifter
  • FAMILY HISTORY

CLINICAL FEATURES:

  • More common in males(20:1)
  • Pat. presents with dragging pain and swelling in the groin which is better seen while coughing and standing.
  • Contents are either small bowel, ,large bowel, omentum or its combination.
  • Usually reducible but can go for irreducibility ,inflammation, obstruction or strangulation.
  • Other symptoms –colicky abd. pain, vomiting, abd. distention and constipation
  • Pain could indicate obstruction in inguinal hernia.
  • Should ask h/o chronic bronchitis, frequency or urgency of micturation,enlargment of prostate
  • Past history


  1. Any past surgical history: Appendicectomy
  2. Previous h/o hernia repair on the same or opp. side

DIAGNOSIS:
INSPECTION

  • Swelling-
  • size and shape
  • position and extent
  • visible peristalsis
  • Skin over the swelling
  • Impulse on coughing
  • Position of the penis

PALPATION

  • Temp. tenderness
  • Position and extent
  • Get above the swelling(scrotal & inguino scrotal swelling)
  • The root of scrotum is held between the thumb infront and other fingers behind in an attempt to reach above swelling. Inguinoscrotal Hernia –cannot get above the swelling Consistency(doughy & granular omentum elastic-intestine)
  • Relation of the swelling to the testis and sprmatic cord
  • Impulse on coughing(Zieman’s technique ): Three finger test
  • Reducibility-taxis


  • A method of reducing hernia. Here pt is asked to flex the thigh of the affected side and to adduct and rotate it internally .The fundus of the sac is gently held with one hand and pressure is applied to squeeze contents while other hand will guide the contents through supf. ring.

Invagination test

  • Done after reduction of hernia. Using little finger skin of the scrotum is invaginated from bottom up to pubic tubercle. The finger is then rotated and pushed up into the supf ing ring.the pt is asked to cough and if the impulse felt on the pulp of finger –direct ; if on tip- indirect.
  • Ring occlusion test
  • Done after reduction of hernia
  • This is a confirmatory test to differentiate an IIH from DIH
  • A Thumb is pressed on the deep ing ring (1/2 inch above mid-inguinal point).Ask the pt to stand. the pt is asked to cough .
  • A direct hernia will show a bulge medial to the occluding finger but an indirect hernia will not.

PERCUSSION

  1. Resonant-enterocele
  2. Dull-omentocele or Epiplocele

AUSCULTATION

  • Peristaltic sound
  • Examine the testis ,epididymis and spermatic cord
  • Examine the other side
  • Examine the tone of abdominal muscles –head or leg rising test or by valsalva maneouvre
  • MALGAIGNE BULGINGS -it indicate pure tone of oblique muscles

PRE-PROSATE ENLARGMENT

  • Aspiration of the sac for diagnosis,X-ray abdomen,USG abdomen are not done in case of obstructed inguinal hernia 
Exam Question

  • Enlarged right hemi-scrotum with a mass that appears to be originating at the level of the external inguinal ring. With the patient completely relaxed, the physician is able to reduce the mass by pushing it back through the external inguinal ring. With the mass reduced, the physician instructs the patient to perform a Valsalva maneuver, upon which a protrusion is felt at the external inguinal ring. Once the mass is reduced, the testicle appears normal in size and consistency, this is suggestive of inguinal hernia
  • Direct inguinal hernia swelling is doughy in consistency , dull on percussion & reducible but reduction is difficult towards the end is suggestive of Epiplocele
  • Pain could indicate obstruction in inguinal hernia
  • Family history of inguinal hernia,Weight lifter,COPD are the risk factors for inguinal hernia
  • Sup. Inguinal ring is an opening in external oblique aponeurosis
  • Indirect inguinal hernia lies Lateral to inferior epigastric vessels
  • For differentiating Inguinal hernia and femoral hernia the landmark will be Pubic tubercle
  • Bubonocele: in this case the hernia is limited in the inguinal canal.
  • In children, if inguinal (indirect) hernia is present in one side, then processus vaginalis is intact on other side
  • Direct hernia is less likely to undergo strangulation
  • Hernia on Rt side is more common than Lt side
  • In case of female commonest hernia is Indirect inguinal hernia
  • Aspiration of the sac for diagnosis,X-ray abdomen,USG abdomen are not done in case of obstructed inguinal hernia
  • Truss cannot prevent progression of Sliding type of inguinal hernia
  • Transillumination distinguishes indirect inguinal hernia from hydrocele
  • Most common type of hernia is indirect inguinal hernia
  • Incompletely descended testis Early repositioning can preserve function,It may lead to sterility, if bilateral & May be associated with indirect inguinal hernia
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