INGUINAL HERNIA

Issah J. kiswagala

(M.B.B.S)

HERNIA

• A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity.
• The word hernia is a Latin term that means rupture of a portion of a structure

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ALL HERNIAS CONSISTS OF 3 PARTS

• The sac
• This is the diverticulum of peritoneum consisting of a mouth, neck and the fundus
• Coverings
• Derived from the layers of the abdominal wall through which the sac passes
• Contents
• Omentum (omentocoele)
• Intestine (enterocoele)
• Part of the urinary bladder ( cystocoele)
• Ovaries
• Meckel’s diverticulum (Littre’s hernia)
• Part of the circumference of the intestine (Richter’s hernia)
• Fluids

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CLASSIFICATION

AETIOLOGICAL CLASSIFICATION

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• Congenital hernias
• Acquired hernias

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ANATOMICAL CLASSIFICATION

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• According to the site of the hernia
• Inguinal hernia
• Femoral hernia
• Umbilical hernia
• Epigastric hernia
• Incisional hernia

ANATOMICAL CLASSIFICATION Cont..

• According to the contents of the hernia
• Enterocoele (intestines)
• Omentocoele (omentum)
• Cystocoele (urinary bladder)
• Littre’s hernia (Meckel’s diverticulum)
• Richter’s hernia (part of the circumference of the bowel)

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CLINICAL CLASSIFICATION �

• Reducible hernia
• Contents can be easily returned into the abdominal cavity leaving the hernial sac in its position
• Irreducible hernia
• Contents cannot be returned to the abdomen

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• Obstructed hernia
• Irreducible hernia + intestinal obstruction
• No interference with blood supply to the intestine
• Strangulated hernia
• Irreducible hernia + interference with blood supply± intestinal obstruction
• Inflamed hernia
• Differs from strangulated hernia not tense and not associated with I.O

INGUINAL HERNIA

• Is the protrusions of abdominal cavity contents through the inguinal canal

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SURGICAL ANATOMY

• The inguinal region (groin) is the lower part of the anterior abdominal wall extending between the ASIS and pubic tubercle.(ASIS-Anterior Superior Iliac Spine)
• The inguinal region is the weak part of the abdominal wall by the presence of the:-
• Superficial inguinal ring
• Deep inguinal ring
• Inguinal canal
• Hesselbach’s triangle

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• Superficial inguinal ring (SIR)
• Triangular opening in the aponeurosis of the external oblique muscle
• Lies 1.25cm above and lateral to the pubic tubercle
• Deep inguinal ring (DIR)
• U-shaped condensation of the transversalis fascia
• Lies 1.25cm above the mid-inguinal point
• Inguinal canal
• Position: extends downwards and medially from the DIR to the SIR
• It is 3.75 cm long

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• The Hesselbach triangle
• Refers to the margins of the floor of the inguinal canal
• The inferior epigastric vessels serve as its superolateral border, the rectus sheath as medial border, and the inguinal ligament as the inferior border
• Direct hernias occur within the Hesselbach triangle, whereas indirect inguinal hernias arise lateral to the triangle

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• Boundaries of Inguinal Canal:

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• Anteriorly: External oblique aponeurosis

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• Posteriorly: Fascia transversalis +conjoint tendon + inferior epigastric vessels

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• Superiorly: conjoint muscles (internal oblique + transversalis )

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• Inferiorly: inguinal ligament

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CONTENTS OF INGUINAL CANAL

• 3 coverings
• Internal spermatic fascia (derived from transversalis fascia)
• Cremasteric fascia (derived from internal oblique)
• External spermatic fascia (derived from external oblique aponeurosis)
• 3 nerves
• Ilioinguinal nerve
• Genital branch of Genitofemoral nerve
• Sympathetic fibres from T10-11 spinal segments
• 3 coverings
• Internal spermatic fascia (derived from transversalis fascia)
• Cremasteric fascia (derived from internal oblique)
• External spermatic fascia (derived from external oblique aponeurosis)

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• 3 nerves
• Ilioinguinal nerve
• Genital branch of Genitofemoral nerve
• Sympathetic fibres from T10-11 spinal segments
• 3 arteries
• Testicular artery
• Artery of the vas
• Cremasteric artery
• 3 veins
• Pampiniform plexus of veins
• Cremasteric vein
• Vein of the vas
• 3 others
• Vas deferens
• Lymphatic vessels of the testis
• A patent processus vaginalis in patients with indirect hernia

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EPIDEMIOLOGY

• Incidence - Worldwide, inguinal Hernias account for up to 75% of all anterior abdominal hernias. 2/3 of these are indirect, and the remaining 1/3 are direct inguinal hernias
• Morbidity/mortality - Worldwide inguinal hernia is the most common cause of intestinal obstruction
• Age - Generally, the prevalence of inguinal hernias increases with age. Indirect hernia is more common in children and young adult while direct hernia is common in elderly individuals
• Sex - In men, indirect hernias predominate over direct hernias at a ratio of 2:1. Direct hernias are very uncommon in women

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AETIOLOGY

1. Congenital causes
• Developed from preformed hernial sac as a result of persistent processus vaginalis
• All indirect inguinal hernia belongs to this type
2. Acquired causes
• Intra-abdominal pressure
• Chronic cough
• Straining
• Weakness of abdominal wall due:-
• Acquired deficiency of collagens
• Damage to the ilio-ingiunal nerve
• Recurrent inguinal hernia

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CLASSIFICATION

• According to its site of exit
• Indirect
• Comes through deep inguinal ring lateral to the inferior epigastric artery
• Direct
• Comes out through the Hesselbach’s triangle
• The neck of the sac lies medial to the inferior epigastric artery
• According to the extent of the hernia
• Bubonocele inguinal hernia
• Hernia does not come out the superficial inguinal ring
• Funicular inguinal hernia
• Comes out through the SIR but does not reach the bottom of the scrotum
• Complete inguinal hernia
• Reaches the bottom of the scrotum

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DIFFERENCES BETWEEN INDIRECT AND DIRECT HERNIA

CLINICAL PRESENTATION

• History
• Physical Examination

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HISTORY

• Patient characteristics
• Age
• Indirect inguinal hernia is common in young individual while direct inguinal hernia is common in the older
• Occupation
• Strenuous work is often responsible for development of hernia

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• Main symptoms
• Inguinal or inguinal swelling; note:-
• How long has the swelling been there?
• How did it start?
• Where did it 1^St appear?
• What were the size & extent when it was first seen?
• Congenital type: reaches the bottom of the scrotum at its first appearance
• Acquired type: small to start and gradually descend to reach the bottom of the scrotum
• Does it disappear automatically on lying down?

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• Features of intestinal obstruction
• Colicky abdominal pain
• Absolute constipation
• Vomiting
• Abdominal distension
• Other complaints
• Chronic cough
• History of straining e.g. chronic constipation, lifting heavy objects, obstructive uropathy etc.
• Previous H/o hernial repair or appendicectomy
• H/o strenuous work is responsible for development of hernia

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PHYSICAL EXAMINATION

• General examination
• Local examination
• Systemic examination

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GENERAL EXAMINATION

• Commonly normal in uncomplicated hernia but a patient can present
• In pain
• Dehydrated
• Shock
• Etc.

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LOCAL EXAMINATION

• Position and extent
• If the swelling reaches the scrotum or labia majora it is an obviously inguinal hernia
• When confined to the groin, the hernia needs to be differentiated from femoral hernia
• Two anatomical landmarks to be considered: pubic tubercle +inguinal ligament
• Inguinal hernia lies above the inguinal ligament and medial to pubic tubercle
• Femoral hernia lies below the inguinal ligament and lateral to the pubic tubercle
• To get above the swelling
• To differentiate scrotal swelling from inguino-scrotal swelling
• The root of the scrotum is held between the thumb in front and other fingers behind in an attempt to reach above the swelling
• One cannot get above the swelling in case of inguinal hernia, whereas in case of pure scrotal swelling e.g. Hydrocoele one can get above the swelling

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• Consistency
• Omentocoele (doughy and granular)
• Enterocoele (elastic)
• Strangulated hernia (tense and tender)
• Impulse on coughing
• When a finger is placed over the SIR or when the root of the scrotum is held between the index finger and the thumb and the patient asked to cough and expansile impulse on coughing can be felt as the hernial contents will be forced out through the SIR in case of reducible hernia
• Impulse on coughing is negative in case of:-
• Irreducible hernia
• Obstructed hernia
• Strangulated hernia

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• Reducibility
• The hernial contents is squeezed in the abdomen by holding the fundus of the sac gently using one hand while the other hand is guiding the contents into the superficial inguinal ring
• Invagination test
• After reduction of the hernia one can perform this test to know the gap in the superficial inguinal ring, A little or the index finger is pushed up gradually from the bottom of scrotum to enter the superficial inguinal ring
• Normal ring is a triangular slit which admits only the tip of a finger then patient is asked to cough.
• When the finger enters the ring, does it go directly backwards (direct hernia) or upwards, backwards and outwards (indirect hernia). The finger is again rotated so that the pulp of the finger looks backwards. The patient is again asked to cough. If the impulse is felt on the pulp of the finger the hernia is a direct one and if the impulse is felt on the tip it is an oblique hernia.

• Ring occlusion test
• The hernia must be reduced first
• This is a confirmatory test to differentiate an indirect inguinal hernia from a direct inguinal hernia.
• A thumb is placed on the deep inguinal ring i.e. 1.3cm above the mid-inguinal point
• The patient is asked to cough
• A direct hernia will show a budge medial to the occluding finger but an indirect hernia (deep inguinal ring) will not find access, so no budge
• In case of femoral hernia if pressure is exerted over the femoral canal the hernia will not be able to come out. This is a confirmatory test for femoral hernia.

• Zieman’s technique
• the index finger is place on the deep inguinal ring (to detect bulge of the indirect inguinal hernia when the patient coughs), the middle finger is placed superficial inguinal ring and the ring finger is placed on the saphenous opening (to detect bulge of the femoral hernia of the expansile impulse when a patient coughs). The patient is now asked to cough diagnose the type of hernia the patient is suffering from.
• Remember this technique (Zieman’s technique) can only be applied when there is no obvious swelling or after the hernia has been completely reduced.
• When impulse is felt on the index finger the case is one of indirect hernia, when impulse is felt on the middle finger the case is one of direct hernia and when it is felt on the ring finger the case is one of femoral hernia.

SYSTEMIC EXAMINATION

• Abdominal examination
• CVS
• RS
• CNS

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TREATMENT

• Conservative treatment
• Surgical (operation) treatment

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CONSERVATIVE TREATMENT

Truss

• A truss does not cure a hernia, it is used to prevent the hernia to come out of the superficial inguinal ring
• The requirements are:-
• The hernia should be easily reducible
• The patient should be reasonably intelligent

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TRUSS

• Indications:-
• Very old patients suffering from diseases like chronic bronchitis, obstructive uropathy etc
• Patients who refuses surgery
• In children

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OPERATIVE TREATMENT

• Open hernial repair
• Herniotomy
• Commonly done in children < 10 years
• No repair of the posterior wall of the inguinal canal

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• Herniorrhaphy
• Herniotomy + repair of the posterior wall

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POSTOPERATIVE COMPLICATIONS

• Hematoma formation
• Injury to adjacent structures
• Major vessel injury
• Bowel injury
• Bladder injury
• Wound infection
• Urinary retention
• Recurrence

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• Hydrocoele
• Nerve transaction
• Nerve entrapment

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