By Dr Rubzzz

Inguinal Canal
3.75cm long directed downwards and medially
from the deep to superficial inguinal ring.Just
above the medial half of inguinal ligament.
The inguinal canal can be thought of as a
tunnel that travels from an "entrance", which is
lateral and deep, to an "exit", which is medial
and superficial. It, like a tunnel, also has a
roof, a floor, and two walls.
Or
pathway for the spermatic cord in males +
ilioinguinal Nerve or round ligament of the
uterus + ilioinguinal nerve in females

Entrance- deep inguinal ring in the transversalis fascia

(U-shape). Lies 1.25cm above the inguinal ligament.
Exit- superficial inguinal ring ,slitlike opening in the
external oblique aponeurosis.Lies 1.25cm above the
pubic tubercle
Roof -fibers of internal abdominal oblique ,transversus
abdominis muscles and medial crus of external oblique
muscle
Floor inguinal ligament throughout, with lacunar
ligament (Gimbernat's ligament) added medially and
iliopubic tract
Anterior wall- external abdominal oblique aponeurosis
throughout, with internal abdominal oblique aponeurosis
added laterally and superficial inguinal ring
Posterior wall - mostly transversalis fascia, with conjoint
tendon (falx inguinalis/Henle's ligament) which is the
joining of internal abdominal oblique and transversus
abdominis aponeuroses, medially.and deep inguinal ring

Inguinal
Triangle (of
Hesselbach)
Medially: lateral
edge of rectus
abdominis (linea
semilunaris)
2. Laterally: inferior
epigastric artery
3. Inferiorly: inguinal
ligament
(Pouparts
ligament)
1.

the weak fascia, where direct hernias occur, is located in

the inferior portion of this triangle
Indirect Hernias protrude lateral to Hesselbach's Triangle.

Blood supply
and Nerve
innervation

1.

2.

Artery Inferior Epigastric (lie posteriorly

and medially to deep inguinal ring)
Vein Inferior Epigastric
Nerve Ilioinguinal and Iliogastric
During an open hernia repair, careful
dissection of the ilioinguinal nerve is
important for two reasons.
Because of the nerve distributions cited
above, injury during incision or closure
can result in pain following the L1
dermatome (including the scrotum or
labium majorum).
Because the ilioinguinal nerve has motor
distributions to the internal oblique
(which are inserted into the lateral
border of the conjoint tendon), division
of the nerve paralyzes these muscle
fibers, weakening the conjoint tendon,
which can precipitate a direct inguinal
hernia.

Spermatic cord

The classic description of the contents

of spermatic cord in the male are:
3 arteries: artery to vas deferens (or
ductus deferens), testicular
artery,cremasteric artery;
3 fascial layers: external spermatic,
cresmasteric and internal spermatic
fascia;
3 other structures: pampiniform plexua,
vas deferens(ductus deferens),
testicular lymphatics;
3 nerves: genital branch of the
genitofemoral nerve (L1/2), autonomic
and visceral afferent fibres, ilioinguinal
nerve (
The ilioinguinal nerve passes through
the superficial ring to descend into the
scrotum, but does not formally run
through the canal.

Inguinal hernia

Affect 9% of men and 1% of female but it is more common

in female compare to femoral hernia - (Browses introduction to the symptoms and
sign of surgical disease 4th edition)

Classification

1.
2.

3.

Direct ,Indirect
Congenital , Acquired (by causes).
Complete , Incomplete, Bubonocele (type of indirect inguinal hernia)
Enterocle, Epiplocele/ Omentocele, Cystocle (content of hernia)
Special type :
Pantaloon hernia ( Direct and indirect in the same groin) two sacs
by the inferior epigastric artery
Sliding hernia Extraperitoneal bowel (cecum/terminall ileum on the
Rt and sigmoid colon on the Lt) which slides down into the inguinal
canal, pulling a sac of peritonuem on its surface
Maydls hernia two loops of bowel in the sac with the strangulation of
the loop of bowel in the abdomen which connects them.
Clinically : Reducible, Irreducible, Obstructed/Incarcerated,
Strangulated, Inflamed

Etiology
Wall defect weakness of the anterior wall
Ex:Omphocele and Gastroschisis
Embriogenic defect
EX: Patent Processus Vaginalis and Patent canal of
Nuck in Female
Increased intraabdominal pressure
Pregnancy
Heavy lifting
Excessive weight
Straining during bowel movement or urination
Chronic coughing or sneezing
Smoking
Damage to ilioinguinal nerve due to previous
appendectomy

Inguinal Hernia

Direct IH

Enter the inguinal canal

through the medial half of
its weak posterior wall
(through Hesselbachs
triangle) to the inferior
epigastric artery and then
protruded out from the
superficial inguinal ring
separate from the
spermatic cord.

Indirect IH

Comes out of the abdomen

cavity through out the deep
inguinal ring,travel along the
inguinal canal and then
protruded out from the
superficial inguinal ring
descends along the spermatic
cord in males or the round
ligament in females.
Congenital; through patent
processus vaginalis
Acquired: passes through
deep inguinal ring initially, i.e
lateral to the inferior epigastric
artery and exits through the
superficial ring.

It is not always possible to distinguish clinically between a direct and indirect inguinal
hernia

Direct Inguinal Hernia

Indirect Inguinal Hernia

In older men. These hernias never occur in females.All Acquired

Common in young men. Congenital and acquired

Lies posteriomedial to the spermatid cord

Lies anterolateral to the spermatid cord

Wider Neck and lies medial to inferior epigastric artery.Uncommon

to reach down into the scrotum, and its generally smaller. Common
to bulge forward. They are often bilateral in the older person.

Narrow Neck and lies lateral to inferior epigastric artery

Bulge from the Hesselbach triangle

Descend through deep inguinal hernia

Cough impulse :usually not increased in size

Cough impulse: increased in size

Weakness anterior wall. Mostly do not descend the scrotum

Patent Processus vaginalis. The persistence of the processus

vaginalis sac at birth associated with and following the descent of
the testis

Easy to reduce

Difficult to reduce

Less chance of strangulation

Generally indirect herniae should be surgically repaired because

they become larger, cause symptoms and may obstruct and
strangulate. Especially in children

Congenital Inguinal
Hernia

Processus vaginalis is an embrogenic

developmental outpouching of the peritoneum
Gubernaculum -are embryonic structures
which begin as undifferentiated mesenchyme
attaching to the caudal end of the gonads
(testes in males and ovaries in females).

 An obvious bulge at the internal or

external ring or within the scrotum. The
parents typically provide the history of a
visible swelling or bulge, commonly
intermittent, in the inguinoscrotal region
in boys and inguinolabial region in girls.
The image shows depicts a 4-month-old
baby boy with a large right-sided indirect
inguinal hernia.
The swelling may or may not be associated with any pain or discomfort. The
parents may perceive the bulge as being painful when, in truth, it causes no
discomfort to the patient.
The bulge commonly occurs after crying or straining and often resolves during the
night while the baby is sleeping.
Indirect hernias are more common on the right side because of delayed descent of
the right testicle. Hernias are present on the right side in 60% of patients, on the left
in 30%, and bilaterally in 10% of patients.
If the patient or the family provides a history of a painful bulge in the inguinal region,
one must suspect the presence of an incarcerated inguinal hernia. Patients with an
incarcerated hernia generally present with a tender firm mass in the inguinal canal
or scrotum. The child may be fussy, unwilling to feed, and inconsolably crying. The
skin overlying the bulge may be edematous, erythematous, and discolored.

Sign and symptoms

an inguinal hernia either may not cause any symptoms or may

cause only a feeling of heaviness or pressure in the groin.
Symptoms are most likely to appear after standing for long
periods, or when you engage in activities that increase pressure
inside the abdomen, such as heavy lifting, persistent coughing
or straining while urinating or moving the bowels.
As the hernia grows, it eventually causes an abnormal bulge
under the skin near the groin. This bulge may become
increasingly more uncomfortable or tender to the touch.
In strangulated type: severe pain will occur so must do give
immediate treament. Cx: Necrosis due to blood supply cut.
In obstructed type: cardinal symptoms of intestinal obstruction
(colicky pain in abdomen, vomiting, abdominal distension and
absolute constipation)

Examination

Position:Ask Pt to stand .Dr sit

Size/shape : Indirect (pyriform with a stalk at the external inguinal ring.Usually
extend down to scrotum)
Direct (spherical and little tendency to enter into scrotum)
Position of penis: Large hernia push the penis to other side
Skin colour :Normal,Red(inflammed or strangulated). Longer term of truss
usage discolouration and streaks of hyperpigmentation due to deposition of
hemosiderin). Scar in previous operation.
Temperature : Normal or warm (strangulated/Inflamed)
Composition: Gut (soft,resonant,bowel sound and fluctuant), Bowel
( resonant,hard ,tense and fluctuant), Small intestine ( Visible peritalsis, large
scrotal hernia), Omentum ( firm like rubber, non fluctuant and dull to
percussion)
Tenderness : Manual pressure is uncomfortable but not painful. Pain
(strangulated, Inflamed)
Reducibility: No painful but sometime with excessive pressure can cause pain.
Cough impulse: Most lumps in the groin moves up and down with coughing
but in hernia, it expand in all direction.

Gentle continuous pressure on the

hernial mass towards the inguinal ring
is generally effective (Trendelenburg)

Management

Plan for surgery after routine

investigation
Investigation
FBC TWC, HB
Blood sugar, urea and creatinine
Urine for routine examination
CXR PA view
ECG

Surgical
Indirect inguinal hernia
Inguinal herniotomy (disect out and opening the
hernial sac,reducing any content and then
transfixing the neck of the sac and removing the
remainder) +- with herniorrhaphy
Procedure:
1.Excision of the hernial sac
2.Repair of the strecthed internal inguinal ring and
the transversalis fascia
3.Reinforcement of posterior wall of inguinal canal

Direct Inguinal hernia

Shouldice (Canadian) repair
Utilizes a multi-layered imbricated repair of

the inguinal canal floor where ring and fascia

are incised and carefully separated from the
deep inferior epigastric vessels and
ectraperitoneal fat before an overlapping
repair (double breasting) of the lower flap
behind the upper flap

Lichtenstein (tension-free) Repair

One of the most commonly performed

procedures
The tails of mesh are overflapped and
crossed and single is placed to create a new
internal ring
A Marlex mesh patch is sutured over the
defect with a slit to allow passage of the
spermatic cord

Lichtenstein Repair

McVay (Coopers ligament) Repair

Is for the repair of large inguinal hernias, direct

inguinal hernias, recurrent hernias and femoral

hernias
The conjoined tendon is sutured to Coopers
ligament from the pubic cubicle laterally

Laparoscopic hernia repair

-Current techniques include
Transabdominal preperitoneal repair (TAPP)
Totally extraperitoneal approach (TEPA)
TAPP- pneumoperitoneum and places a synthetic

mes preperitoneally by dissecting the perionuem off

the hernial orifices and positioning the mesh
beneath the peritoneum before closing.
TEPA-completely periperitoneal. Used in any
inguinal hernia, unilateral, recurrent or bilateral
hernia, and femoral hernia

Strangulated Hernia EMERGENCY OP

Preop: resuscitate with adequate
fluid,empty the stomach with NG tube, Gv
antibiotic to contain infection and catherize
to monitor hemodynamic state
Inguinal herniotomy:incision on the
prominent part of swelling.

Femoral Hernias

More common in females than in males

Through a space bounded by the
ileopubic tract
Demonstrated by a mass below the
inguinal ligament

Femoral Canal
1.25cm in long and 1.25cm wide at its base,directed
upwards.Occupied most medial compartment of
femoral sheath and extends from femoral ring above
the saphenous opening.
Anterior Inguinal ligament
Posterior- iliopectineal ligament, pubic bone and
fascia over Pectineus Muscle
Medial Lacunar ligament and prolonged along the
iliopectineal ligament
Lateral thin septum separating it from the femoral
vein
Space Loose areolar tissue and lymph gland (Gland
of Cloquet)

Clinical features

Common in right side twice more than left

side.Occasionally Bilateral
Rare in children. Common in age 50.More
common in Female than man
Sign and symptoms similar to Inguinal hernia
Rarely large sac present
40% presented with strangulation
Richters Hernia intestinal obstruction
Thick walled with layer of fat and CT, cut cross
look like onion
Cannot control by truss
Urgent operation due to strangulation.

Surgical
Lockwood (low operation)
-sac dissect out below the inguinal ligament via groin
crease incision. Peel off all the anatomical layers that
cover the sac, deal with content. Then pull down the
neck of sac and ligate as high as possible and allow
to retract through femoral canal. Close the canal by
suturing to inguinal ligament to iliopectineal line.
McEvedy (high operation)
Lotheissen (inguinal operation)
- Open the inguinal canal by inguinal herniorrhaphy.
Tranversalis fascia is incised to medial side of
peigastric vessel and enlarged the opening. Open
peritoneum,withdraw sac from femoral canal.Deal
with the content. Suture the conjoined tendon to the
iliopectineal line to form a shutter

Umbilical hernia

Congenital (exomphalos)
1 in 6000 births due to failure of all or part of
midgut to return to the coelom during the early
fetal life
Age: Hernia wont be noticed till the umbilical is separated and
healed.Noticed after some months
Common in Afro- Carribean race
Symptoms: Swelling, others are rare. Sometime parental anxiety
or intestinal obstruction
Examination : hemispherical shape,overlie and easy to palpate
on the abdominal Size can be 0.5cm 10cm) Composition:
Soft, compresibble, and reducible.usually contained bowel and
resonant to percussion.Cough impulse invariable

Omphocele (contain organ outside the

abdomen) More common

Gastroschisis (umblical cord is not involved

and usually at right mid.)

In adult:
acquired ( due to defect to umbilical cicatrix)
True umbilical hernia
Secondary to intraabdominal pressure,
pregnancy and ascites
P/E: Distended abdomen

Management
Non-op
For premature infant with gigantic intact sac. Daily apply with desiccating
antiseptic solution.If successful,an eschar forms over the sac.Once the
granulisation tissue grow- ventral hernia can be repaired later age.

Skin flap closure

-sace is gently trimmed.The skin is freed from the fascial edges and
undermined laterally.Ligate the umbilical vessel for monitoring. Put skin
flap at midline with simple sutures and ventral hernia closed later

Primary closure
-sac dissect away from skin edge and fascia,evacuate the intestinal fully
from meconium,fluid and etc through NG tube.Strect abdominal wall
gradually to double the volume.Then replace the viscera and close the
fascia layer under moderate tension.

Herniorrhaphy after 2 years

Op
-small curved incision immediately below the umbilicus. The sin cicatrix is
dissected upwards and the neck of the sac isolated.Once the sac is
empty,either invert it into abdomen or ligate by transfixation and
excised.

Paraumbilical hernia

Common acquired umbilical hernia.

Common in mid age and old age.Common in women and men
especially in parous and obese women
Defect that is adjacent to the umbilical scar
Does not bulge into the centre of umblicus and not attach to the centre
of sac
Symptoms: Discomfort and swelling, pain worsen by prolong standing
and sternous exercise
Strangulated type contain extraperitoneal fat or omentum. Normally
bowel is not obstructed
P/E: bulge at beside umbilicus (pushed one side and stretched into a
cresent shape)maybe infected with foul smelling discharge ,collection of
dried- up sebacuoes secretion)
Smooth surface and edge is easy to define
Composition : firm, usually contain omentum .if contain bowel,(soft and
resonant). Reducible
Expansile cough impulse

Treatment
If untreated, hernia will increase in size and strangulation
can occur.
Indication: present symptoms and patient is not obese
Umbilical herniorrhaphy ( small ) primary herniorrhaphy
Transverse incision around the umbilicus and subcutaneous
tissue are dissected off the rectus sheath to expose the
neck of sac.Deal with content. Remove sac and close
peritoneum. Aponeurosis on both side of umbilical ring is
mobilised to allow an overlap.Interrupted matress
sutures are inserted into aponeurosis.
- If large- prosthetic buttressing of the abdominal wall.
(paraumbilical hernio plasty)

Incisional hernia

Age: all ages but common in adult.Mostly in obese pt.

Acquired scar in the abdominal wall caused by a previous
surgical operation (peritonitis) and injury
Pt remembered that it caused by the scar.usually occur in
first year of operation but maybe also in later age.
Might has hx of weakened the abdominal msuculature,
chronic cough,obesity or steroid therapy
Symptoms :lump and pain.Maybe intestinal obstruction
(distension, colic , vomit, constipation and severe pain in
the lump)
Irreducible , expansile cough impulse, local tissue thin
and weak

Treatment
If pt obese- weight reduction by dieting
before op.
Simple apposition
Complex apposition (various type of
layered closure)
Plastic fibre mesh or net closures
- Method of choice but in defect <4cm

References

Bailey & Loves 25th Edition

A manual On Clinical Surgery By S.Das
Browses Introduction To The Symptoms
And Sign of Surgical Disease 4th Edition
Dissector Answers by University of
Michigan Medical School
University of Connecticut Health Center
Bedside Clinics in Surgery by Makhan Lal
Saha
Melbourne Hernia Clinic