HERNIA CASE

PRESENTATION

Dr TARAKA KRISHNA
9494843132
tarakb4u@gmail.com
Chief Complaints
Swelling in the groin
Pain over the swelling
Present illness
Swelling:

Duration
mode of onset
reducible /partially reducible or irreducible
Pain:
Site of pain—whether it is in the groin or in the scrotum
duration
severity
type of pain
aggravating or relieving factors.
History relevant to precipitating factors
Chronic cough
tuberculosis,
bronchial asthma or other respiratory diseases
constipation,
dysuria/urgency/hesitancy/altered stream/night
frequency/retention of urine/burning urine/haematuria
History suggestive of complications:
Irreducibility

severe pain in the groin over the swelling

colicky abdominal pain
abdominal distension
vomiting
constipation
Past History

Past history of hernia surgery—same side/opposite

side.
Type of surgery whether mesh used or repair done.
History of appendicectomy done earlier
Past history suggestive of irreducibility/obstruction
Personal History
History of smoking
History of pan chewing/alcohol intake
appetite and altered weight
Inspection
Inspection is done always first in standing straight up
without bending
later in lying down position.
Inspection in standing position

Side of the swelling.

Extent of the swelling.
Incomplete indirect inguinal hernia and usually direct
inguinal hernias are located in inguinal region.
 Complete indirect inguinal hernia is inguinoscrotal—
extending down into the bottom of the scrotum
Swelling extends from the proximal part of the inguinal
canal towards the scrotum below.
Both transverse and vertical dimensions of the size should
be mentioned.
Shape of the swelling is pyriform in indirect inguinal
hernia
Globular/ hemispherical in direct inguinal hernia or
femoral hernia.
Expansile impulse on coughing over the swelling is
diagnostic.
It is better seen than felt.
Surface—Smooth/uneven;
Margin—well-defined/illdefined
Visible peristalsis
Scars
Dilated veins/discolouration/redness over the swelling
Whether testis is seen separately from the swelling or
covered by the swelling all over should be noted.
Palpation
Temperature
Tenderness over the swelling (in
strangulated/inflamed hernia).
Get above the swelling or not—one can get above
purely scrotal swelling but not in inguinoscrotal
swelling.
Consistency
soft and elastic in enterocele;
doughy in omentocele (epiplocele)
Location of the swelling—
swelling is above and medial to pubic tubercle
in inguinal hernia
below and lateral to pubic tubercle in femoral
hernia
Reducibility of the swelling is checked
 Whether it reduces spontaneously while lying
down (usually direct hernia).
Patient himself reduces the content.
In enterocele it is difficult to reduce the first part
but last part gets reduced easily.
In omentocele it is difficult to reduce the last part
but first part gets reduced easily.
Manipulation to get reduced - Taxis
Taxis is gradual
Manipulation by flexion, adduction and rotation
of hip joint. This maneuver relaxes the superficial
ring and oblique abdominal muscles.
Expansile impulse on cough - by placing finger on
superficial ring or by holding the root of the scrotum
between index and thumb, patient is asked to cough to
feel expansile impulse on coughing.
Fingers may get separated allowing contents to force
down.
Impulse will be absent in strangulated hernia,
incarcerated hernia, in presence of adhesions blocking
the entrance of sac.
Zieman’s test is done to find out over which finger
cough impulse is felt and so which type of hernia it
could be— whether femoral/direct inguinal or indirect
inguinal.
Deep ring occlusion test:
When deep ring is occluded after reducing the
contents,
 if impulse on coughing is absent - indirect inguinal
hernia;
if impulse on coughing present - direct inguinal hernia
Finger invagination test:

Size of the superficial ring is noted

site of the impulse felt is observed whether it is in the
tip of the finger or on the pulp.
Palpation of testis, epididymis and spermatic cord.

Opposite inguinal region, opposite testis, epididymis

and spermatic cord should be examined.

Presence or absence of impulse on coughing on

opposite side should be mentioned.
Percussion
Without reducing contents of the swelling,
percussio is done over the surface.

• If it is resonant, it is enterocele.
• If it is dull on percussion then it is omentocele.
Auscultation
Bowel sounds may be heard over the swelling if it is
enterocele.
Per Abdomen Examination
Abdominal muscle tone should be checked by shoulder
head raising test, leg raising test and Valsalva maneuver.
Malgaigne bulging and should be palpated to check
whether the tone is adequate (firm) or inadequate.
Any scar over the abdomen
ascites or mass per abdomen should be mentioned
Why this is hernia?
The points in favor of hernia are:
1. Inguinoscrotal swelling
2. Visible and palpable impulse on coughing [an impulse
is often better seen than felt].
3. Cannot get above the swelling [inguinoscrotal]
4. Reducibility [absent in case of complication]
5. Ring occlusion test
a. Positive in case of indirect hernia [swelling will not come
out]
b. Negative in case of direct hernia [swelling will come out].
What is the definition of hernia?
Hernia is defined as an abnormal protrusion of a
viscous or a part of a viscous through an opening,
artificial or natural with a sac, covering it.
What is the test to differentiate
between direct and indirect inguinal
hernia?
Deep ring occlusion test is the test of choice to
differentiate these two.
What is the name of the triangle in which
you get the direct hernia?
The direct hernia comes out through Hesselbach’s
triangle.

• medially by the lateral border of rectus abdominis

• laterally by the inferior epigastric artery
• below by the inguinal ligament.
What are the differential diagnoses of
inguinal hernia?
a. Femoral hernia
b. Vaginal hydrocele
c. Undescended testis in superficial inguinal pouch
d. Hydrocele of the cord
e. Lipoma of the cord
f. Infantile hydrocele
g. Ectopic testis
h. Lipoma of the cord
i. Hydrocele of canal of Nuck
j. Psoas abscess
k. Psoas bursae
l. Sapheno-varix
m. Enlarged lymph nodes
n. Femoral aneurysm
What is external inguinal ring?
It is an opening in the external oblique aponeurosis
This is formed by the two crurae of the external
oblique aponeurosis
It lies just above and medial to the pubic tubercle.
What is internal ring?
It is an opening in the fascia transversalis
This is a ‘U’ shaped condensation of the fascia
transversalis
It is situated ½ inch (1.25 cm) above the midinguinal
point [between the pubic symphysis and the anterior
superior iliac spine]
The inferior epigastric artery runs medially.
What is mid point of the inguinal
ligament?
It is situated between the pubic tubercle and the
anterior superior iliac spine
It is 1–1.5 cm lateral to the mid inguinal point.
What is conjoined tendon?
fusion of fibers of the internal oblique aponeurosis
and aponeurosis of the transversus abdominis muscle.

In reality conjoined tendon is present only in 5% of

individuals and therefore it is considered as a myth
How expansile impulse on coughing is
clinically demonstrated?
Expansile impulse on coughing is seen on inspection
patient is asked to cough.
Expansile impulse on coughing is also felt by placing
the thumb in front, middle and index fingers behind
the root of the scrotum and asking the patient to
cough.
What is the meaning of ‘get above the
swelling’?
Root of the scrotum is held between the thumb in front,
index and middle fingers behind.
In purely scrotal swelling like vaginal hydrocele, fingers
and thumb can be approximated well without any
additional structures other than cord in between (one
can get above the swelling).
In case of inguinoscrotal swelling thumb and fingers do
not meet each other properly because of the descent of
hernial contents down (one cannot get above the
swelling). It occurs in funicular and complete type of
inguinal hernia but not in bubonocele
How is finger invagination test done?
Using the little finger, scrotal skin is invaginated from
below upwards near upper part of the testis.
Finger is reached towards the superficial inguinal
ring/external ring.
Normally external ring does not admit the tip of the little
finger.
Finger is rotated inwards so that nail is towards the cord
side and pulp is towards the ring.
Patient is asked to cough.
If the impulse is felt on the tip of the finger, then it is
indirect inguinal hernia.
If impulse is felt on the pulp then it is direct inguinal
hernia.
External ring is patulous - assessed by invagination
test.
In direct hernia finger goes directly; in indirect hernia
finger goes upwards and outwards.
How is Zieman’s test done?
The hernial contents are reduced.
Index finger is placed over the deep ring.
Middle finger is placed over the superficial ring and
ring finger over the saphenous opening.
Patient is asked to cough
If impulse touches

Index finger — indirect inguinal hernia.

Middle finger — direct inguinal hernia.
Ring finger — femoral hernia.
What are the complications of hernia?

Irreducibility
Obstruction
Strangulation
Incarceration
Inflammation.
What are the surgical procedures available?

a. Herniotomy
b. Herniorrhaphy
c. Hernioplasty.
What is the current gold standard
surgery for hernia repair.?
The gold standard current hernia surgery is the
Lichtenstein Tension-free Hernioplasty.
 Polypropylene mesh is placed anterior to the posterior
wall after herniotomy
What are the methods of
laparoscopic hernia repair?
TEP and TAPP
What are the vessels likely to be
injured in hernia surgery?
1. Pubic branch of the obturator artery
2. Aberrant obturator artery originating from the deep
inferior epigastric artery—‘Artery of death’
3. Inferior deep epigastric artery
4. Deep circumflex iliac vessel
5. Cremasteric artery
6. External iliac vessel.
What are the complications of hernia
surgery?
i. Hematoma
ii. Seroma
iii. Wound infection
- Superficial incisional surgical site infection
 - Deep incisional surgical site infection

iv. Infection of mesh

v. Scrotal edema
vi. Postherniorrhaphy hydrocele
vii. Recurrent hernia
viii. Ischemic orchitis
ix. Testicular atrophy
x. Chronic residual neuralgia (sensory nerve):
• Ilioinguinal neuralgia
• Genitofemoral neuralgia
xi. Obstruction of vas deferens
xii. Dysejaculation
What is Bassini’s herniorrhaphy?
This is the oldest technique of hernia repair where
after herniotomy the conjoint tendon is approximated
to the inguinal ligament using No.1 size interrupted
polypropylene sutures (synthetic nonabsorbable).
What is Shouldice’s repair?
This is a four layer repair using non-absorbable
monofilament (polypropelene) suture material.
The basic principle - division of transversalis fascia
obliquely, suturing of the lower leaf of transversalis fascia
to the under surface of the upper leaf (first layer) followed
by the suturing of the lower border of transversalis fascia to
the inguinal ligament (second layer).
This is called imbrication of a double layer of transversalis
fascia to the inguinal ligament.
This is followed by a double layer of conjoint tendon—
internal oblique muscle suturing to the inguinal
ligament (third and fourth layers).
Most common type of hernia in females is:
(AIIMS Feb 97, DPG 2005, JIPMER GIS 2011)
a. Direct inguinal hernia b. Indirect inguinal hernia
c. Femoral hernia d. Umbilical hernia
Funicular hernia is type of: (DNB 2007)
a. Direct inguinal hernia b. Indirect inguinal hernia
c. Femoral Hernia d. Umbilical hernia
Method of reduction of inguinal hernia:
a. Kugel maneuvve
b. Taxis
c. Macvay procedure
d. Stopa’s technique
Which of the following is content of Littre’s hernia?
a. Urinary bladder (DNB 2012, MHPGMET 2005)
b. Meckel’s diverticulum
c. Circumference of intestinal wall
d. Appendix
The sac contains only a portion of the
circumference of the intestine: (UPPG 2007, 2005)
a. Richter’s hernia b. Littre’s hernia
c. Spigelian hernia d. Lumbar hernia
Type IIIA in Nyhus classification of hernia: (DNB
2011)
a. Direct inguinal hernia b. Indirect inguinal hernia
c. Femoral hernia d. Umbilical hernia
THANK YOU