Hernia (Inguinal and femoral hernia)

Q1: Anatomy and function of the inguinal canal:

Length of inguinal canal: 4-6 cm
Function: transmits the spermatic cord in males and the round ligament of the uterus in
females
Origin and end: the inguinal canal lies above the inguinal ligament and it starts at the deep
inguinal ring and ends in the external inguinal ring

Deep inguinal ring =

internal inguinal ring

superficial inguinal ring =

External inguinal ring

Q2: Boundaries of inguinal canal: Catchy point:

Floor, roof, anterior wall, posterior wall The spermatic cord starts at the
deep inguinal ring, it contains
Floor: inguinal ligament the Vas deferens
Anteriorly: aponeurosis of external oblique muscle
Posteriorly: Transversalis fascia/muscle
Roof: Internal oblique muscle + transversus abdominis muscle + Conjoint tendon

Q3: indirect vs direct inguinal hernia (see the pic above):

Catchy point:
Indirect inguinal hernia passes through the Internal and external ring
Hernia is a protrusion
Direct inguinal hernia directly passes through the external/superficial ring of the peritoneal sac
through the
abdominal wall OR
Catchy point:
any abnormal
Inguinal hernia is much more common among males protrusion through an
opening
Femoral hernia is more common among females

The most common hernia in females  indirect inguinal hernia

The most common hernia in males  indirect inguinal hernia
Q4: Relationship of the indirect and direct inguinal hernia to the inferior
epigastric vessels:
The relationship between the hernia and the epigastric vessels allow for intraoperative
differentiation between direct and indirect inguinal hernia

 Medial to the inferior epigastric vessels  direct inguinal hernia

 Lateral to the inferior epigastric vessels  indirect inguinal hernia, this is why the
indirect inguinal hernia passes through the internal and external ring

Q5: Hasselbach triangle:

The site of the Direct inguinal hernia
Boundaries:
Inferiorly  inguinal ligament
Medially  Rectus abdominis muscle
Laterally  inferior epigastric vessels
Floor  Internal oblique and transversus abdominis muscles Catchy point:

Q6: The most common type of hernia among males and females is: Inguinal hernia Male
to female ratio: 25:1
Indirect inguinal hernia

Q7: Patent processus vaginalis can cause:

 Indirect inguinal hernia in infants
Or
 Communicating Hydrocele
Transillumination test will differentiate the hernia from hydrocele. Hydrocele will light up
when transillumination test is applied while hernias will NOT light up

Q8: How to differentiate between Femoral hernia vs inguinal hernia:

In relation to the pubic tubercle

 Above and medial to pubic tubercle  inguinal hernia (could be direct or indirect
inguinal hernia)
 Below and lateral to the pubic tubercle  femoral hernia

Catchy point:

The nerve that runs through the inguinal canal along

with the spermatic cord is: Ilioinguinal nerve

The inguinal region is examined with the patient in

standing position
Q9: How to differentiate between direct and indirect inguinal hernia on
clinical examination?
While the patient is standing, reduce the hernia back into the abdominal wall and put your
finger on the internal inguinal ring and ask the patient to cough. If there is bulging through
the external inguinal ring after coughing, this is a direct inguinal hernia. Why? because your
finger is on the internal ring so that the indirect hernia cannot pass through. Thus, any
bulging during coughing while you are occluding the internal ring means this is a direct
hernia

The internal ring location:

Just above the midpoint of inguinal ligament and lateral to the epigastric vessels

Q10: Mid-point of inguinal ligament vs mid-inguinal point:

 Mid-point of inguinal ligament  half-way between the Anterior superior iliac spine
(ASIS) and pubic tubercle
 Mid-inguinal point  half-way between the ASIS and pubic symphysis

Here you find Catchy point:

the deep
inguinal ring
Femoral hernia is more likely to present
with complications (strangulation and
incarceration) than inguinal hernia

Above the midpoint of

Here you find inguinal ligament = DIR
the femoral
artery Above the mid-inguinal point
= Femoral artery
Q11: Femoral triangle vs femoral sheath:
 Femoral triangle contains  femoral nerve, femoral artery, and femoral vein
 Femoral sheath contains  Femoral artery, vein, and femoral canal but NOT the
femoral nerve
Q12: Important structures in the femoral region from lateral to medial:
: you go from lateral to medial to touch your NAVEL (Umbilicus)
N: Femoral nerve
A: Femoral Artery
V: Femoral Vein
E: Empty space
L: Lymphatics and Lymph node Catchy point:
Q13: Inguinal hernia: Smoking is a risk factor
for inguinal hernia
 Direct
or
 indirect
Anything that increases the intra-abdominal pressure will be a risk factor for
inguinal hernia  obesity, pregnancy, chronic cough (COPD), and ascites

Q14: Direct inguinal hernia:

 Wide neck  low incidence of strangulation and incarceration
 Comes from the Hasselbach triangle
 Goes directly through the external inguinal ring
 Practically, never enters the scrotum
 Almost always in males
 Seen most commonly in elderly males
 Smoking is a well-known risk factor  smoking weakens the connective tissue 
herniation
 Risk factors include increased intraabdominal pressure + old age + male gender +
smoking
 Intraoperatively, direct hernia lies medial to the inferior epigastric vessel

Q15: indirect inguinal hernia:

 Higher risk of strangulation when compared to direct hernia
 Lateral to hasselbach triangle
 Enters the internal ring and goes through the external ring  can enter the scrotum
when it is complete indirect inguinal hernia
 Occurs in males and females in all age groups
 Can occur in infants due to patency of the processus vaginalis (congenital)
 Found bilaterally in 30% of patients
 Most common hernia in males and females. 25 times more common among males
 Risk factors include intraabdominal pressure + male gender + smoking
Q16: Differential diagnosis of inguino-scrotal mass: Catchy point:
 Inguinal hernia In the first 10 years of life, the
 Lipoma of the spermatic cord right-sided indirect inguinal
 Lymphadenopathy hernia is more common than
 Testicular torsion the left side because the right
 Femoral artery aneurysm  mainly inguinal swelling testis tends to descends late.
 Psoas abscess  mainly inguinal swelling
 Hydrocele  mainly scrotal swelling
 Varicocele  Mainly scrotal swelling

Q17: Femoral hernia:

 More common among females
 Narrow neck  High-incidence of strangulation and incarceration
 Right-sided femoral hernia is more common than the left. Why? because the
sigmoid colon covers the left femoral canal
 Uncommon
 DDX  same as inguino-scrotal swelling
 Treatment  mcVay (cooper’s ligament repair), mesh plug repair

Q18: What is present inside the hernia sac in a male patient with inguinal
hernia?
Small bowel, but it can be large bowel instead

Q19: What is most commonly present inside the hernia sac in a female
patient with inguinal hernia?
Adnexa (Ovary + fallopian tube), but it can be small bowel instead.

Q20: Hernia complications (including inguinal and femoral hernia):

 Incarceration  Irreducible  cannot be moved back into the abdomen
 Strangulation and ischemia  strangulation means decreased perfusion due to
compression of the artery that supplies the herniated portion
 Small bowel obstruction

Q21: Clinical presentation of hernia complications:

 Incarceration  irreducible (could be acute or chronic. Acute = emergency repair)
 Strangulation and ischemia  Pain, fever, Marked tenderness with overlying
erythema, nausea & vomiting, and leukocytosis
 Small bowel obstruction  Nausea, vomiting, abdominal distention, constipation or
obstipation (no passage of stool or flatus)
Q22: Treatment for complicated inguinal hernia: Catchy point:

 Incarcerated: Hernioplasty (Mesh repair) Femoral hernia is nothing but an indirect

hernia that passes through the femoral
 Sterile strangulation: Hernioplasty (mesh repair) canal instead of going through the
 Infected strangulation: Herniorrhaphy (Suture repair) internal and external rings
 Emergent herniotomy in children

Q23: Treatment of inguinal hernia (elective): Emergency = mesh/Hernioplasty (unless

infected)
 Herniotomy in children and young patients
Infected strangulation = Suture
 Herniorrhaphy + hernioplasty in adults
repair/herniorrhaphy
Herniotomy  excision of the sac
Herniorrhaphy  Suture repair  excision of the sac + closure of the defect by suturing
Hernioplasty  Mesh repair

Q24: Approach to recurrent groin hernia (inguinal + femoral):

 Switch the choice between the previous surgery and the current surgery
 Do OPEN if the first surgery was laparoscopic
 Do laparoscopic if the first was OPEN

Q25: Clinical examination of inguino-scrotal swelling:

 Vitals  fever, tachypnea, and tachycardia would suggest strangulation. Tachycardia
may suggest hypovolemia due to vomiting secondary to bowel obstruction.
Tachycardia may also occur secondary to fever alone
 General inspection
 Abdominal Examination  inspection, auscultation, palpation and percussion
 Examination of the inguino-scrotal swelling:
-Inspection: inguino-scrotal swelling, any redness or discharge or scars?
-Palpation: reducible or NOT
-Scrotal neck test: can you get above it or not? In inguinal hernia, you cannot get
above it because it is an inguino-scrotal swelling
-Auscultation: Bowel sounds  Absent bowel sounds with overlying erythema would
suggest
-Transillumination test: Negative (hernia) or positive (hydrocele)
Q26: Indications to perform laparoscopic repair in inguinal hernia:

 Bilateral
 Recurrent
 The patient needs to resume activity as soon as possible
Q27: Abdominal wall layers from external to internal:
 Skin
 Subcutaneous fat – Camper’s fascia
 Scarpa’s fascia
 External oblique muscle
 Internal oblique muscle
 Transversus abdominis muscle
 Transversalis fascia
 Extraperitoneal fat
 Peritoneum
Catchy point:
Q28: Hydrocele vs Inguinoscrotal hernia: Complications of laparoscopic
 Transillumination test: Paraumbilical hernia repair:
Seroma (common)
-Positive in hydrocele
Hematoma
-Negative in hernia
 Can you get above it? Both are fluctuant and non-tender +
-Yes in hydrocele occur around 1 week post-op
-No in hernia
 Cough impulse: Catchy point:
-Negative in hydrocele
Seroma is self-limited, does
-Positive in hernia
NOT require treatment. (it is
a serous fluid)
Q30: What to tell the patient post-hernia repair?
 Pregnancy is allowed after 1 year
 Abdominal binder is useless
 Lifting heavy objects is after 2 weeks if the patient received mesh repair
 Lifting heavy objects is after 2 months if the patient did NOT receive mesh repair
 Lifting heavy objects is after 6 months after treating recurrent hernia

Q31: Hernia management in a nutshell:

 1st time + unilateral: Open surgery (1= One)
 1st time + bilateral: Laparoscopic
 Recurrent: Switch (if you started open, do laparoscopic now and vice versa)
 Hernioplasty (mesh): Any Non-infected emergency case (acute incarceration or
sterile strangulation)
 Herniorrhaphy (suture repair): infected strangulation (because if you apply a mesh,
it will act as a focus of infection and the patient may go into sepsis  it is better to
do SUTURE repair). Mesh = foreign body = risk of infection = do NOT apply it for
infected cases
 Herniotomy (excision of the sac): Done for KIDS
 Who gets elective hernia repair?
-Chronic incarceration
-Reducible hernia
 Who gets emergency hernia repair?
-Complicated hernia  strangulated, obstructed, and acute incarceration
(irreducible)
 Who gets hernioplasty (Mesh repair)?
-All patients except the infected strangulation (which gets suture repair)
 Adult + Unilateral groin hernia:
-Open surgery (Unilateral + for the first time  open surgery)
 Adult + Bilateral groin hernia:
-Laparoscopic (Bilateral + for the first time  laparoscopic)
 Kids with groin hernia?
-Always herniotomy
 Paraumbilical hernia:
-Seen in adults
-Always acquired
-High risk of incarceration
-Elective repair (if NOT complicated  acute incarceration/strangulation)
-Treatment: Suture (< 2 cm), mesh (> 2 cm)
 Umbilical hernia:
-Seen in infants
-Always congenital
-Low risk of incarceration
-Treatment: Repair at 5 years of age (before this age, allow for spontaneous closure
 reassure the family and observe
 Incisional hernia management:
-Because of its fragility, it is always treated with a MESH (always)
 Infected mesh management:
-Remove the infected mesh (remove the focus of infection always) + antibiotics
 What is the golden rule in hernia repair?
-Always control/treat the risk factor (Ex: Chronic cough with inguinal hernia or
ascites with paraumbilical hernia) before managing the elective cases (NOT
emergency)

Done by Dr Ali Almajid

YouTube: Medicine with Alis