Inguinal Hernia

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Boundaries of the inguinal canal—

Anterior—skin, superficial fascia, external oblique aponeurosis and lateral 1/3rd by the fleshy fibres of internal oblique.

Posterior—extraperitoneal fat with parietal peritoneum, fascia transversalis and medial 1/3rd by the conjoined tendon (interlacing fibres of internal oblique and transversus abdominis).

Roof—conjoined muscle fibres of internal oblique and transversus abdominis.

Floor—upper surface of the inguinal ligament, medial end of lacunar ligament.

 

Boundaries of inguinal triangle—

Medial—lateral border of rectus abdominis

Lateral—inferior epigastric vessels

Apex—meeting point of above two

Base—inguinal ligament

 

Superficial inguinal ring—1.25 cm above and lateral to the pubic tubercle

Deep inguinal ring—1.25 cm above and medial to the mid point of inguinal ligament

Length of the inguinal canal—3.25cm

 

Types of indirect inguinal hernia—

1.  Incomplete—

·     Bubonocele—limited within the inguinal canal

·     Funicular—limited just above the epididymis

2.  Complete—traverses to the bottom of the scrotum

 

*** indirect hernia always descends downwards towards the bottom of the scrotum but direct hernia forms bulging in the inguinal region.

*** indirect hernia is more prone to obstruction and strangulation and direct hernia is less prone because direct hernia has no neck as it comes through the posterior wall.

 

 

Examination—

Inspection—swelling which becomes prominent by strain like cough.

 

Palpation—

Reducibility test—usually done in lying position. The thigh of the affected side should be flexed, adducted and internally rotated. Finger guard of the inguinal canal by thumb and index finger and then the scrotum is gently squeezed.

 

Get above the swelling test—done in standing position, sit by the lateral side of the patient. At the root of the scrotum place the thumb in front and the index finger behind and then try to reach above the swelling. In case of inguinal hernia one cannot get above the swelling whereas in pure scrotal swelling one will get only spermatic cord and the structures in it.

 

Invagination test—after reduction of the hernia in lying position. Index finger is used but the little finger can be used to minimize hurting the patient. At first push from the bottom of the scrotum to palpate the pubis tubercle and then rotate the finger and push upto the superficial inguinal ring. The pulp should feel the ring. Patient is asked to cough, a palpable impulse will confirm the diagnosis. If the impulse is felt on the pulp then direct and if felt on the tip then indirect hernia.

 

Three finger test / Zieman’s technique—Index finger on deep inguinal ring, middle finger on superficial inguinal ring and ring finger on the saphenous opening. The patient is asked to cough, if felt on the deep inguinal ring then indirect hernia, if superficial inguinal ring then direct hernia and if at the saphenous opening then its femoral hernia.

 

Ring occlusion test—in lying position reduce the hernia and occlusion of the deep inguinal ring by thumb. Then holding the thumb in position ask the patient to stand and then cough. If no bulging then indirect and if bulging then direct hernia.

 

Treatment—no medical treatment, only surgical treatment.

Indirect hernia—herniotomy and herniorrhapy

Direct hernia—herniorrhapy

*** in children <5 yrs—herniotomy

*** in recurrent, incisional, wider hernial orifice—hernioplasty (Prolene/Decron mash)

 

*** Prolene—Poly Propylene Ethylene

*** if surgery not done then—irreducible/obstructed/strangulated hernia

*** describe the hernia—

1.  Site (inguinal)

2.  Right/Left

3.  Reducible/Irreducible

4.  Complete/Incomplete

5.  Direct/Indirect