INGUINAL HERNIA

Dr Phillipo L. Chalya M.D.(Dar); M.Med.Surg (Mak.)

Consultant Surgeon & Senior Lecturer
BMC/CUHAS-Bugando
 OUTLINE
 Definition  Clinical presentation
 Surgical anatomy  Diagnosis
 Epidemiology  Treatment
 Etiology  Complications
 Classification  Prevention
 Pathophysiology
 DEFINITION
 An inguinal hernia is
the protrusion of part
or whole of intra-
abdominal contents
through a weakness in
the inguinal region of
the abdominal wall 
 scrotum
SURGICAL ANATOMY
 Position
 The inguinal region
(groin) is the lower part
of the anterior
abdominal wall
extending between the
ASIS and pubic
tubercle
 Surgical importance
 Inguinal region is an important area
anatomically and clinically
 Anatomically
 because it is a region where structures exit and enter the
abdominal cavity
 Clinically
 because the pathways of exit and entrance are potential
sites of herniation
 What are the potential weak areas in the
inguinal region
 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
 Superficial inguinal ring
 Triangular opening in
the aponeurosis of the
external oblique muscle

 Lies immediately
(1.25cm) above and
medial to the pubic
tubercle
 Deep inguinal ring
 U-shaped condensation
of the transversalis
fascia
 Lies 1.25cm above the
mid-inguinal point
(ASIS  symphisis
pubis)
 Lateral to the inferior
epigastric vessels
 Inguinal canal
 Inguinal canal is a
tunnel in the lower
abdominal muscles
 Position
 It extends downwards and medially from the
deep inguinal ring to the superficial inguinal ring
 It is 3.75-4.0 cm long
 Boundaries
 Anteriorly
 External oblique aponeurosis
 Posteriorly
 Fascia transversalis+conjoint
tendon+ inferior epigastric
vessels
 Superiorly
 conjoint muscles (internal
oblique +transversalis )
 Inferiorly
 inguinal ligament
 Contents
 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
 Contents…….
 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
 Hesselbach’s triangle
 Boundaries
 Supero-lateral border
 Inferior epigastric vessels
 Medial border
 The lateral border of the
rectus sheath
 Inferior border
 Inguinal ligament
 Direct hernias occur within
the Hesselbach’s triangle,
whereas indirect inguinal
hernias arise lateral to the
triangle
 EPIDEMIOLOGY
 Incidence
 Morbidity/mortality
 Age
 Sex
 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
 Mortality/Morbidity
 Worldwide inguinal hernia is the most common cause of
intestinal obstruction
 It is associated with high morbidity and mortality
rates
 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
 Men are 25 times more likely to have a groin
hernia than women
 An indirect inguinal hernia is the most common
hernia, regardless of gender
 In men, indirect hernias predominate over direct
hernias at a ratio of 2:1
 Direct hernias are very uncommon in women
 ETIOLOGY
 Congenital causes
 Acquired causes
 Congenital causes
 Developed from preformed hernial sac as a result
of persistent processus vaginalis
 All indirect inguinal hernia belongs to this type
 Acquired causes
  intra-abdominal pressure
 Chronic cough
 Straining
 Obstructive uropathy
 Chronic constipation
 Lifting heavy objects
 Weakness of abdominal wall due:-
 Acquired deficiency of collagens
 Damage to the ilioingiunal nerve
 Recurrent inguinal hernia
 CLASSIFICATION
 Etiological classification
 Anatomical classification
 Clinical classification
 Etiological classification
 Congenital inguinal hernia
 It is due to persistence of processus vaginalis
 Developed from a pre-formed sac
 Reaches the scrotum very quickly
 All indirect inguinal hernia belongs to this type
 Acquired inguinal hernia
 Occurring later in life as a result of underlying
weakness of the abdominal muscles
 Most of direct inguinal hernias are of acquired type
 Anatomical classification
 According to its site of exit
 According to the extent of the hernia
 According to the contents
 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
 According to the contents
 Enterocoele (intestines)
 Omentocoele (omentum)
 Cystocoele (urinary bladder)
 Littre’s hernia (Meckel’s diverticulum)
 Richter’s hernia (part of the circumference of the
bowel)
 Clinical classification
 Reducible inguinal hernia
 irreducible inguinal hernia
 Obstructed inguinal hernia
 Strangulated inguinal hernia
 Inflamed inguinal hernia
 Reducible inguinal hernia
 Contents can be easily returned into the
abdominal cavity leaving the hernial sac in its
position
 Irreducible inguinal hernia
 Contents cannot be returned to the abdomen
 It is due to :-
 Adhesions of its contents to each other
 Adhesions of its contents with the sac
 Adhesions of one part of the sac to the other part
 Sliding hernia
 Very large scrotal hernia
 Obstructed inguinal hernia
 Irreducible hernia + intestinal obstruction
 No interference with blood supply to the
intestine
 Strangulated inguinal hernia
 Irreducible hernia + interference with blood
supply± intestinal obstruction
 Inflamed inguinal hernia
 Rare type
 Occurs when the contents of the hernia become
inflamed and present with constitutional
symptoms associated with inflammation e.g.
overlying skin become red, edematous,
tenderness
 Differs from strangulated hernia not tense and
not associated with intestinal obstruction
 PATHOPHYSIOLOGY
 A hernia consists of 3
parts:-
 The sac
 Coverings
 Contents
 The sac
 This is the diverticulum of peritoneum consisting
of a mouth, neck, the body and the fundus
 The mouth
 The neck
 The body
 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
 Mechanisms which prevent inguinal hernia
formation
 Obliquity of the inguinal canal opposes an intra-
abdominal pressure [IAP]
 Shutter mechanisms of the arched fibres of the conjoined
muscles opposes an  IAP as they contact
 Strong fibres of internal oblique in front of the deep
inguinal ring prevent herniation through it
 Strong conjoined tendon in front of Hesselbach’s triangle
prevents direct hernia
 Action of the cremaster muscle pulls up the spermatic
cord into the canal and plug it during  IAP
Pathophysiological consequences of hernia
 Reduced inguinal hernia

 Irreducible inguinal hernia

 Obstructed inguinal hernia

 Strangulated inguinal hernia
CLINICAL PRESENTATION
 History
 Physical Examination
 History
 Patient characteristics
 Main symptoms
 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
 Main symptoms
 Inguinal or inguinal swelling;
note:-
 How long has the swelling
been there?
 How did it start?
 Where did it 1st 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?
 Main symptoms……….
 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
 Physical Examination
 General examination
 Local examination
 Systemic examination
 General examination
 Commonly normal in uncomplicated hernia
 In pain
 Dehydrated
 Shock
 Etc
 Local examination
 Position and extent
 To get above the swelling
 Consistency
 Impulse on coughing
 Reducibility
 Invagination test
 Ring occlusion test
 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
 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 an 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
 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
 Ring occlusion test
 The hernia must be reduced first
 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 will not
find access, so no budge
 Systemic examination
 Abdominal examination
 CVS
 RS
 CNS
 TREATMENT
 Conservative treatment
 Surgical (operation) treatment
 Conservative treatment
 No treatment
 Truss
 No treatment
 This is indicated in a patient:-
 With severe general ill-health not suitable for
anaesthesia
 With chronic bronchitis not cured by medicinal
treatment
 With obstructive uropathy
 Who refuses surgery
 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
 Indications:-
 Very old patients suffering from diseases like chronic
bronchitis, obstructive uropathy etc
 Patients who refuses surgery
 In children
 Operative treatment
Preoperative care
Type of operations
Postoperative care
 Preoperative care
 Correct anemia
 Correct intercurent disease
 Admit a day before surgery or can be done as
an outpatients
 Anesthetic visit
 A written informed consent
 Type of operations
 Open hernial repair
 Laparoscopic hernial repair
 Open hernial repair
 Herniotomy
 Herniorrhaphy
 Herniotomy
 Commonly done in children < 10 years
 No repair of the posterior wall of the inguinal
canal
 Herniorrhaphy
 Herniotomy + repair of the posterior wall
 Technique include
 Modified Bassini repair
 Shouldice repair
 Lichtenstein mesh repair
 Desarda hernial repair
 Darning hernial repair
 Modified Bassini repair
 Suturing the conjoined
tendon to the inguinal
ligament
 Shouldice repair
 Multilayer imbricated repair
of the posterior wall of the
inguinal canal with a
continuous running suture
technique:
 1st suture line - transversus
abdominis aponeurotic arch to
the iliopubic tract
 2nd line - internal oblique and
transversus abdominis muscles
and aponeuroses (Conjoint) to
the inguinal ligament
 3rd line - Conjoint to Ext.
oblique
 4th line - Conjoint to Ext.
oblique
 1st posterior suture
 1st posterior suture –
Transversus abdominis to
Iliopubic tract
 2nd posterior suture
 2nd posterior suture
– Int. oblique and
transversus
abdominis to
inguinal ligament
 3rd posterior suture
 3rd posterior suture -
Conjoint to Ext.
oblique
 4th posterior suture
 4th posterior suture -
Conjoint to Ext.
oblique
Lichtenstein mesh repair
 Desarda hernial repair
The medial leaf of the external
oblique aponeurosis is
sutured to the Inguinal
ligament.
1) Medial leaf
2) Interrupted sutures taken to
suture the medial leaf to the
inguinal ligament
3) Pubic tubercle
4) Abdominal ring
5) Spermatic cord
6) inguinal ligament
Darning hernial repair
Postoperative complications
 Hematoma formation
 Injury to adjacent structures
 Major vessel injury
 Bowel injury
 Bladder injury
 Wound infection
 Urinary retention
 Recurrence
 Hydrocoele
 Nerve transaction
 Nerve entrapment