Inguinal Hernia
Mohamad Medawar MED3
Case Presentation
• 44 year-old male patient with history of DM and HTN presenting
with a mass in the left inguinal area for the last 7 months and a mild
pain that increases when lifting heavy objects
• PSH: Appendectomy (40 years)
• Home Medication: Glucophage; Bisoprolol; Brintellix
• Social history: smoker; no alcohol
• Allergies: No allergies
• Family history: CAD; Diabetes
Case Presentation
• System Review:
Head, Eye and Neck No vertigo; No dizziness
Cardiovascular No palpitations; No chest pain; Hypertension
Respiratory No dyspnea
GI No constipation No diarrhea; No dysuria
Endocrine Diabetes
Hematology/oncology No anemia; No history of cancer
Muscular/Neurology No weakness
Physical Examination:
Height: 179cm; Weight: 95Kg
Abdomen was soft, nontender, non distended with positive bowel sounds.
Swelling in the left inguinal area
Case Presentation
Vital Signs: BP (mmHg): 118/75; Pulse: 69 bpm; Temp: 36.5 °C
Lab results: Within Normal range Imaging: Normal CXR
Neutrophils 58.7
WBC 7.70
Lymph 33.1
Hg 15.9
MCV 88.7
Platelets 275
PT 15.7
PTT 40.5
Glucose 112
Case Presentation
• Differential Diagnosis: Left Inguinal Hernia
• Treatment: Left Sided Hernioplasty
Hernias in general
• Hernia (L. rupture): A general term referring to a
protrusion of a tissue through the wall of the cavity in
which it is normally contained
• Most hernias occur in the abdomen especially in the
groin
• Groin is divided by the inguinal ligament into inguinal
and femoral regions
• 96% Inguinal- 9:1 M:F (75% of all abdominal wall
hernias)
• 4% Femoral- 10:1 F:M
• Lifetime risk is approximately 25% in males and <5% in
females for developing groin hernia
Hernias in general
• Causes and prevalence: Any condition that increases the
intra-abdominal pressure may contribute to the
formation or worsening of a hernia:
- Straining.
- Lifting of heavy weight.
- Chronic cough (tuberculosis, chronic bronchitis,
bronchial asthma, emphysema).
- Chronic constipation (habitual, rectal stricture).
- Obesity.
- Pregnancy and pelvic anatomy (especially in
femoral hernia in females).
- Smoking.
- Ascites.
Appendectomy through McBurney's incision may
injure the Ilioinguinal nerve causing right sided
direct inguinal hernia.
• Failure of obliteration of the processus
vaginalis Congenital indirect inguinal
hernia
• Familial collagen disorder- Prune Belly
syndrome.
• Acquired herniation is also probably due
to collagen deficiency called as
Metastatic emphysema of Read.
PARTS OF HERNIA
• Hernia comprises of: Sac; Covering; Content.
• Sac is a diverticulum of peritoneum with mouth, neck, body
and fundus.
-Neck is narrow in indirect sac but wide in direct sac.
-Body of the sac is thin in children and in indirect sac, but is thick in
direct and long-standing hernia.
• Coverings of the sac are the layers of the abdominal wall
through which the sac passes.
• Contents of Sac:
-Omentum Omentocele
-Intestine Enterocele
-Meckle’s diverticulum Littre’s hernia
-Appendix Amyand’s hernia
-Urinary bladder cystocele
Classification of Hernia
Clinical Classification:
1. Reducible Hernia
2. Irreducible Hernia
3. Obstructed Hernia
4. Inflamed Hernia
5. Strangulated Hernia
6. Occult (Inguinal) Hernia
Inguinal canal:
CLASSIFICATION OF INGUINAL HERNIA
• Pantaloon Hernia
Newer Classifications of Inguinal Hernia
Indirect Inguinal Hernia
• Bubonocele VS Funicular VS Complete (Scrotal)
• 20:1 : Male:Female
• Expansile Impulse
• Contents are either small bowel, large bowel,
omentum or combination of all these. In females,
sometimes ovary and tubes may be the content.
• It is usually reducible, but can go for irreducibility,
inflammation, obstruction, strangulation.
Presenting Features • Clinical Examination:
• Chief complaints
Asymptomatic lump
Pain esp. with strangulation and
inflammation
Gastro-Intestinal Complaints
Neurovascular Symptoms
• Past medical history:
Chronic cough
Constipation
Dysuria
• Past surgical History:
Appendectomy
Hernia Repair
Abdominal surgery
Investigations:
Physical Examination
Ultrasonography
CT / MRI
Physical Examination:
• Internal Ring Occlusion Test: • Zieman’s Test:
Reduce the hernia Index Finger deep inguinal ring (indirect
Occlude the deep ring using the thumb hernia)
Ask patient to cough: Middle finger superficial inguinal ring
(direct hernia)
If NO BULGING DIRECT HERNIA
Ring finger saphenous opening (femoral
If BULGING INDIRECT HERNIA
hernia)
• Ring invagination test: • Valsalva manoeuvre:
Reduce the hernia Increase intra-abdominal pressure
Index finger is pushed up from the bottom of Makes hernia more apparent clinically
the scrotum into the superficial inguinal ring
Ask patient to cough • Inguinal hernia in females:
A palpable impulse will confirm the hernia Increased thickness of labium majus on
Felt on the PULP DIRECT HERNIA palpation, when compared to contralateral
Felt on the TIP INDIRECT HERNIA side.
• Per rectal examination
Treatment
Treatment:
• Conservative treatment: • Surgical Approach to Hernia:
Watchful waiting Preoperative Care
Analgesics (pain) Anesthesia
Truss (swelling)
Taxis
Surgical Approach to Hernia
Surgical Steps:
Skin Incision above and parallel to inguinal
ligament
Incision of superficial fascia
Ligation of superficial epigastric vessels
Incision of External oblique aponeurosis
Identify inguinal ligament inferiorly
Identify and Isolate spermatic cord
Dissection of cremasteric muscle
Identify and open the hernia sac
Resposition contents into the abdominal wall
Twist sac and excise it (herniotomy)
Surgical Steps:
• Starting medially, anchor the mesh along the inferior
border of the inguinal ligament up to the deep inguinal
ring.
• Ensure that medially the mesh covers the pubic bone by
at least 2 cm because this is where most recurrences are
seen.
• Creating a new deep inguinal ring At the deep inguinal
ring place the superior tail of mesh over the inferior tail.
Suture both tails together and then anchor both tails on
the inguinal ligament.
• Anchor the superior part of the mesh on the internal
oblique
Laparoscopic Mesh Hernioplasty
Complications
• If there is no complications, most patients are discharged on the same day.
• Complications can be intra-operative, post-operative and delayed.
