Inguinal Hernias

Case: Mr. Strain, a 45-year-old man, who while trying to show his wife how strong he was, strained
to pick up a particularly heavy coffee table. He suddenly felt a sharp pain in his right groin. Later,
he noticed that a painful bulge had developed in his groin which disappeared when he was on his
back. After several months, the pain and the bulge in his groin increased and he finally agreed to
see a physician. On exam, you observe a swelling which begins about midway between the anterior
superior iliac spine and the midline, progresses medially for about 4 cm, and then turns toward the
scrotum.

Definitions
Hernia: Protrusion of any viscus from its normal cavity through an abnormal opening.
Hernias may be described as:
Reducible Contents easily put back
Irreducible Contents cannot be put back
Strangulated Contents are stuck, and there is constriction of the tissues at the neck of the
hernia, leading to reduced venous drainage and arterial occlusion

Types of
abdominal wall
hernias Description Strangulation Risk
Incisional Through an area weakened by prior surgery. Low

Umbilical Congenital defect of the abdominal wall seen in infants Low

as a swelling at the umbilicus.

Paraumbilical Acquired defect above or below the umbilicus. High

Femoral Herniation through the femoral canal which appears below High
and lateral to the pubic tubercle. More common in women than men.

Inguinal Typically seen 'above and medial to the pubic tubercle'. Swelling is Depends
caused by weakness in the abdominal wall in the area of
Hasselbach's triangle.

Epidemiology
• Male > Female by 9 to 1 ratio (indirect inguinal hernia most common for both sexes)
• Lifetime incidence: 5-25% percent of males, 2% of females
• Bimodal peaks before 1 year of age and then again after 40
• Groin hernias (femoral and inguinal) = 75% of abdominal wall hernias
• Inguinal hernias account for 70-95% groin hernias; of these (2/3 of these indirect, see below)
• Bilateral in 20% of cases
• 90% of cases in children and young adults have indirect inguinal hernias. As age of patient
increases, so does incidence of acquired (direct) hernias.
• Risk factors: chronically increased intra-abdominal pressure (such as caused by obesity,
pregnancy, and ascites); reduced muscle tone and deterioration of connective tissue (due to aging,
systemic disease, malnutrition, or smoking).
• Pediatrics:
Approximately 3% to 5% of full-term infants and up to 30% of preterm infants will have an
inguinal hernia.
Presents within first 6 mths with an asymptomatic groin mass or more acutely with abdominal
pain and vomiting due to incarceration.
More common in boys, premature infants and on the right.
Bilateral disease incidence between 5% and 30%.
An incarcerated inguinal hernia is the commonest cause of intestinal obstruction from the 1st
week to the 5th month of life

This ILM will focus on indirect and direct inguinal hernias.

Inguinal Canal Anatomy

• Canal has the following boundaries
Anterior – aponeurosis of external oblique
Posterior – conjoint tendon, combined tendon of internal oblique and transversus abdominis
Roof – arching fibers of internal oblique and transversus abdominis
Floor – inguinal ligament
Medially – pubic symphisis
Laterally – anterior superior iliac spine
Superficial ring – lies superior to the pubic tubercle
• Deep ring – lies superior to midpoint of inguinal ligament. This point is midway between pubic
tubercle and ipsilateral anterior superior iliac spine.

From Madden JL: Abdominal Wall Hernias: An Atlas of Anatomy and Repair. Philadelphia, WB Saunders, 1989.
 Hasselbach’s Triangle defined by
Medially – lateral border of rectus abdominis
Laterally – inferior epigastric vessels
• Base – inguinal ligament

Inguinal Canal Contents

• Men – Spermatic cord structures (vas deferens, testicular artery, testicular vein, ilioinguinal
nerve, genital branch of genitofemoral nerve, lymphatics and sympathetic plexus)
• Women - Round ligament of the uterus, ilioinguinal nerve, genital branch of genitofemoral nerve,
lymphatics and sympathetic plexus
• Canal courses from lateral to medial, deep to superficial, and cephalad to caudad

Indirect Hernia:
The hernia develops at the internal ring, which is the site where the spermatic cord in males or the
round ligament in females exits the abdomen. The origin is lateral to the inferior epigastric
artery, in contrast to direct hernias which arise medially to the inferior epigastric vessels.
• Contents: Sac of peritoneum coming through internal ring, antero-medial to the spermatic cord
(or round ligament) through which omentum or bowel can enter.
• Course: Sac passes outside Hasselbach’s Triangle, herniates via inguinal canal through both
rings into scrotum. Herniates lateral to inferior epigastric artery. May stay in canal, exit ring, and
even enter scrotum.
• Pathophysiology: Usually congenital (though may not become apparent until later in life). During
embryologic development, the spermatic cord and testis in men (or the round ligament in women)
migrate from the retroperitoneum through the anterior abdominal wall to the inguinal canal along
with a projection of peritoneum (processus vaginalis). The internal ring normally closes following the
migration of the testicle into the canal and then into the scrotum. Failure to close provides the
necessary defect (an area of potential weakness) through which an indirect inguinal hernia may
form. The processus vaginalis may persist in up to 20% of adults, further predisposing to hernia
formation. Prematurity and low birth weight are risk factors.

• Risk: Higher risk of incarceration/strangulation if hernia large and extends into scrotum.
• Epidemiology: Often children and young males
• Presentation: Soft swelling in area of internal ring; pain on straining; hernia comes down canal
and touches fingertip on examination.
Direct Hernia
• Contents: Retroperitoneal fat; less commonly, peritoneal sac containing bowel
• Course: Hernia sac passes within Hasselbach’s Triangle; breaches posterior inguinal wall (bulges
“directly” through abdominal wall); passes medial to inferior epigastric artery; Goes through
external inguinal ring only.
• Pathophysiology: Acquired defect in transversus abdominis muscle; bulging as a result of
weakness of the posterior floor of the inguinal canal, anywhere from the internal ring to the pubic
bone. Straining to urinate or defecate, coughing, and heavy lifting have been implicated as causative
factors, leading to trauma and weakening of the inguinal floor.
• Risk: Usually at low (but not zero) risk for incarceration or strangulation.
• Epidemiology: less common than indirect inguinal; males > females; more common in those > 40.
• Presentation: Bulge in area of Hesselbach triangle; usually painless; easily reduced; hernia bulges
anteriorly, pushes against side of finger on examination.

Symptoms of direct and indirect hernias

• Bulge that enlarges when stand or strain, but can be asymptomatic
• Pain or dull sensation in groin
• Patients can present with complication (obstruction or strangulation-->10-20% of pts with
inguinal hernia present with strangulation)
• Extreme pain related to a hernia in the absence of incarceration and intestinal vascular
compromise is unusual and should raise the suspicion of an alternative cause of the pain.

Indirect inguinal Hernia Direct Inguinal Hernia

Complications
• Bowel incarceration
Irreducible, but without signs of obstruction or strangulation
Common symptoms include vague discomfort or intestinal issues; possibly pain, edema
extending to the scrotum, nausea, vomiting and low-grade fever
 If the inguinal mass can be palpated separately from the testes, then it is possible to
diagnose an inguinal hernia clinically.
Causes: adhesions, chronicity, neck that is narrow but wide enough not to strangulate
• Small Bowel obstruction
Nausea, vomiting, abdominal distension, obstipation, and abdominal pain
Prominent hernia might be apparent but can be difficult to detect in the obese patient or if
the hernia is femoral.
Reduction only attempted under adequate sedation and analgesia taking care not to put too
much pressure lest you cause an intestinal rupture
Usually urgent surgical repair
• Strangulation
Compromised vascular supply with gangrenous bowel
Surgical emergency
Presentation: irreducible hernia, inflammation (red, painful, tenderness) signs of obstruction
and dehydration...sepsis/toxicity
50% indirect, 3-10% direct,
• These rates remind us of the anatomy (the indirect come through narrow neck; the direct come
through wide neck).

Treatment
• Incidence of discomfort and complications increase with time
• 66% painful at first presentation-->90% painful for those who have had hernia for ten years
• Likelihood of irreducibility 6.5% at 1 yr, 30% at 30yrs
• Whether asymptomatic hernias should be surgically repaired is still under debate
• Repaired by traditional tissue-based or by mesh procedures and by either open or laparoscopic
approaches.
• Recurrence: risk factors for tissue deterioration, such as malnutrition, liver or renal failure,
steroid therapy, and malignancies.

3 Questions: (1) Is the mass truly a hernia? (2) Is the hernia reducible or incarcerated? (3) Is
the vascular supply to the bowel strangulated?

Quiz yourself
1) What abdominal wall layers must be incised at the pubic hairline (near the midline) in order to
access the abdominal cavity?
A midline incision would pass through skin, superficial fascia (outer fatty and inner membranous
layers), linea alba, transversalis fascia, extraperitoneal connective tissue, median umbilical
ligament, and parietal peritoneum.
2) What caused the bulge in Mr. Strain? What body layers would surround it as it proceeded into
the scrotum and what abdominal layers are they derived from?
• Bulge most likely caused by a loop of small intestine that traversed the inguinal canal
The body layers surrounding the intestinal bulge in the scrotum are: skin, dartos muscle,
membranous layer of the superficial fascia, external spermatic fascia (from the external oblique
aponeurosis), the cremasteric fascia (from the internal oblique aponeurosis), and the internal
spermatic fascia (from the transversalis fascia)
References:
Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., Copyright © 2002 Elsevier
Ferri: Ferri's Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th Ed.
Madden JL: Abdominal Wall Hernias: An Atlas of Anatomy and Repair. Philadelphia, WB Saunders, 1989.)
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc
Roberts: Clinical Procedures in Emergency Medicine, 4th ed., Copyright © 2004 Elsevier
Perrott CA. Inguinal hernias: room for a better understanding. - Am J Emerg Med - 01-JAN-2004; 22(1): 48-
50.
Townsend: Sabiston Textbook of Surgery, 16th ed., Copyright © 2001 W. B. Saunders Company