Hernia: Inguinal – Surgical
anatomy, presentation, treatment,
complications
-Minakshi Sharma
Group 479
Introduction
Abnormal protrusion of viscus or a part of it
through a weak point in the abdominal wall
Anatomy of inguinal region
• Superficial inguinal ring-
– triangular aperture in the aponeurosis of the ext oblique muscle .
– Lies 1.25 cm above the pubic tubercle .
– Normally it doesn’t admit the tip of the little finger.
• Deep inguinal ring –
– U shaped condensation of the
fascia trasversalis
– Lies 1.25cm above the
mid inguinal point.
Inguinal canal
• Oblique passage in the lower part of the anterior abdominal
wall.
• Extends from deep inguinal ring to superficial inguinal ring.
• Directed downwards forwards and medially
• About 4cm long
Boundaries
• Anterior – Ext. oblique aponeurosis & conjoined
muscle laterally.
• Posterior – Fascia transversalis & the conjoined
tendon.
• Superiorly – conjoined muscle.
• Inferiorly – inguinal ligament.
Contents
• Spermatic cord
• Ilioinguinal nerve
• Genital branch of genitofemoral nerve
• Females – Round ligament is present instead of spermatic cord.
Spermatic cord constitutes- vas deferens, testicular & cremastic
arteries , pampiniform plexus of veins, lymphatics
Defence mechanism of inguinal canal
• Obliquity of the inguinal canal.
• Shutter mechanism-due to conjoined tendon
contraction
Anatomical classification
• Indirect hernia – more common about 2/3 of
inguinal hernia .
• It is more common in young
• Direct hernia- more common in old
• Indirect hernia – the abdominal contents herniation
occurs through the deep ring into the inguinal canal.
• Comes out through the superficial ring.
• It may extend into the scrotum.
• Depending upon extent it may be complete or incomplete.
• Direct hernia – contents herniate directly through
the posterior wall of the inguinal canal through the
Hesselbach’s triangle
• It is a weakness in posterior wall of the inguinal
canal
• It is bounded laterally -inferior epigastric artery,
medially – lateral border of rectus abdominus muscle
inferiorly – inguinal ligament
Clinical types
• Reducible –contents can be returned into the abdominal
cavity.
• Irreducible – contents cannot be returned into the abdominal
cavity.
• Obstructed – irreducibilty + intestinal obstruction, but the
blood supply is not impaired.
• Strangulated- irreducibilty + intestinal obstruction+ arrest of
the blood supply.
• Inflammed- rare condition. Occurs when contents eg.
Appendix,meckel’s diverticulum is inflamed
Risk factors
In infants:
prematurity
male
In adults:
male
Obesity
Constipation
chronic cough
Heavy lifting
Smoking
Urinary obstructive symptoms
Presentation
• Pain
• Localized pain
• Referred pain
• Generalized pain
• Nausea and vomiting
• Constipation
• Urinary symptoms
Presentation
• At first appearance, it is easily reducible.
• With time it can no longer be reduced, it is irreducible or
incarcerated.
• Strangulation: when visceral contents of the hernia become
twisted or entrapped by the narrow opening.
Strangulation usually leads to bowel obstruction with sudden,
severe pain in the hernia, vomiting and irreducibility.
Nyhus Classification System
Diagnosis- Inspection
• Inguinal hernias are best examined with the patient
standing.
• Coughing may increase the size of the hernia.
• Site and shape of the hernia:
– those appearing above and medial to the pubic tubercle
are inguinal hernias
– those appearing below and lateral to the pubic tubercle
are femoral hernias
• whether the lump extends down into the scrotum
• any other scrotal swellings
• any swellings on the 'normal' side
• scar from previous surgery or trauma
Digital examination of the inguinal canal
Palpation
• Confirm inspectory findings
• Examine the scrotum- Getting above the swelling is not possible
• Consistency, temperature, tenderness and fluctuance.
• One should attempt to reduce the hernia:Ask the patient to
reduce. Otherwise flex and medially rotate the hip and reduce
• If the hernia cannot be reduced the probable identity of the
hernia is: femoral > indirect inguinal > direct inguinal
• Expansile cough impulse
• Deep ring occlusion test- reduce the swelling
• Locate the deep ring 1/2 “ above the midpoint of the
inguinal ligament and occlude it asking the patient to cough.
• Impulse seen- direct, not seen- indirect
• Leg raising test- Malgaigne’s bulgings seen
• Zieman’s method
• Swelling gurgles- enterocoele, firm/granular- omentocoele.
• Always palpate the other inguino-femoral region as herniae
are often bilateral
Percussion
The characteristics of hernias depend on their contents:
– bowel is hyper-resonant and has bowel sounds unless it is
strangulated
– omentum and fat is dull and does not have bowel sounds
Investigations
Ultrasound
• High Test Sensitivity (>90%)
• High Test Specificity
– Distinguish Incarcerated Hernia from firm mass
Herniography
• Suspected hernia, but clinical dx unclear
• Procedure done under flouroscopy following injection of
contrast medium
• Frontal and oblique radiographs are taken with and without
increased intra-abdominal pressure
Complications
Bowel incarceration ( acute, chronic ): The trapping of abdominal
contents within the Hernia itself
Strangulation: pressure on the hernial contents may compromise
blood supply (especially veins, with their low pressure, are
sensitive, and venous congestion often results) and cause
ischemia, and later necrosis and gangrene, which may become
fatal.
Small Bowel Obstruction
Management
Non operative Treatment
• Watchful waiting: for asymptomatic or minimally
symptomatic
Operative Treatment
• Surgery
Surgery
Mesh repairs
Open repair (Lichtenstein, Shouldice, Bassini)
Most commonly performed: Lichtenstein repair
It’s "tension-free" repair
Tension-free repairs
– Desarda
– Guarnieri
Bassini technique,first suture:
• Aponeurosis musculi obliq. ext.
• Musculus obliquus internus
• Musculus transversalis
• Fascia transversalis
• Peritoneum
• Ligamentum inguinale.
Laparoscopic repair
– transabdominal preperitoneal (TAPP)
– totally extra-peritoneal (TEP) repair
Intraoperative view by TEP
Operation.
1. Genital ramus of genitofemoral nerve.
2. Preperitoneal lipom and spermatic
cord.
Laparoscopic mesh surgery, as compared to open mesh surgery
Advantages Disadvantages
•Quicker recovery •Needs surgeon highly
experienced
•Less pain during first days Longer operating time
•Fewer postoperative Increased recurrence of
complications primary hernias if
such as infections, bleeding and surgeon not experienced
seromas enough
•Less risk of chronic pain
Meshes
– Permanent mesh
– Commercial mesh
– Mosquito-net mesh
Complications are frequent (>10%).
– Foreign-body sensation
– Chronic pain
– Ejaculation disorders
– Mesh migration
– Mesh folding (meshoma)
– Infection
– Adhesion formation
– Erosion into intraperitoneal organs
• In the long term, polypropylene meshes face degradation
due to heat effects.
• obstructive azoospermia
Thank You!
