INDIRECT INGUINAL HERNIA

An indirect inguinal hernia is an inguinal hernia that results from the failure of embryonic closure of the deep inguinal ring after
the testicle has passed through it. Like other inguinal hernias, it protrudes through the superficial inguinal ring. It is the most common
cause of groin hernia.

PATHOPHYSIOLOGY

In men, indirect hernias follow the same route as the descending testes, which migrate from the abdomen into the scrotum during
the development of the urinary and reproductive organs. The larger size of their inguinal canal, which transmitted the testicle and
accommodates the structures of the spermatic cord, might be one reason why men are 25 times more likely to have an inguinal hernia
than women. Although several mechanisms such as strength of the posterior wall of the inguinal canal and shutter mechanisms
compensating for raised intra-abdominal pressure prevent hernia formation in normal individuals, the exact importance of each factor
is still under debate

CAUSES

A hernia occurs when intra-abdominal contents, commonly including preperitoneal fatty tissues, the peritoneum itself, and eventually
omentum and intestines, traverse the ring to enter the inguinal canal. As time passes, the hernia contents may enlarge, extend the
length of the canal, and even exit the canal through the external inguinal ring, an opening in the external oblique fascia, into the
scrotum.

Failure of the processus vaginalis to close properly is very common in infants and will usually leave only a small hole through which
abdominal fluid can pass from the abdomen into the scrotum. This is termed a communicating hydrocele and must be differentiated
from a non-communicating hydrocele.

In a communicating hydrocele, the fluid collection will change in size from time to time as fluid may drain back and forth between
abdominal cavity and scrotum and on examination there will be no way to "get over" the hydrocele when palpating. This is in contrast
to a non-communicating hydrocele, which is a distinct entity that occurs when there is excess fluid formation within the scrotum for
any number of reasons.

IN FEMALES

In the female, groin hernias are only 4% as common as in males. Indirect inguinal hernia is still the most common groin hernia for
females. If a woman has an indirect inguinal hernia, her internal inguinal ring is patent, which is abnormal for females. The protrusion
of peritoneum is not called "processus vaginalis" in women, as this structure is related to the migration of the testicle to the scrotum. It
is simply a hernia sac. The eventual destination of the hernia contents for a woman is the labium majoris on the same side, and hernias
can enlarge one labium dramatically if they are allowed to progress.

TREATMENT

During herniorraphy, the surgeon recognizes the "indirect" hernia by noting that the hernia sac begins lateral to the inferior epigastric
artery and vein, indicating that it arose at the top of the inguinal canal.