Inguinal and femoral hernia:
A hernia is a protusion of a viscus or a part of viscus through and abnormal opening in the walls of its containing cavity. Details of inguinal hernia and few slides on other types of hernia.
2. Hernia
A hernia is a protusion of a viscus or a part
of viscus through and abnormal opening in
the walls of its containing cavity
3. Etiology
Weakness due to structures entering and leaving the
abdomen
Developmental failures
Genetic weakness of collagen
Sharp and blunt trauma
Ageing & pregnancy
Primary neurological and muscle diseases
Excessive intra-abdominal pressure
4. Composition of Hernia
The Sac :
Diverticulum of peritoneum
Has mouth, neck, body and fundus
The Covering:
Layers of abdominal wall through which sac passes
Content:
Omentum- Omentocele (Epiplocele)
Intestine- Enterocele
Urinary bladder or part of the posterior wall of sac- Cystocele
Ovary with or without fallopian tube
Meckel’s diverticulum- Littre’s hernia
A portion of circumference of bowel- Richter’s hernia
Fluid
10. Anatomy
Inguinal region extends between the ASIS to pubic
tubercle
It’s a region where structures enter and exit the
abdominal cavity
Most common site
13. Contents of inguinal canal
Male Female
Spermatic cord
Testicular Artery, veins &
lymphatic
Vas deferens
Illioinguinal nerve
Iliohypogastric nerve
Genital branch of
genitofemoral nerve
Round ligament of uterus
Illioinguinal nerve
Iliohypogastric nerve
Genital branch of genital
femoral nerve
14. Deep Inguinal Ring
Is an oval opening in the fascia transversalis
Lies about ½ inch (1.3cm) above the inguinal
ligament midway between the anterosuperior iliac
spine and the symphysis pubis
Margins of the ring give attachment to the internal
spermatic fascia
15. Superficial Inguinal Ring
Is triangular in shape
Lies in the aponeurosis of the external oblique muscle
Lies immediately above and medial to the pubic tubercle
Its margins give attachment to the external spermatic
fascia
17. According to extent:
Incomplete:
Bubonocele- sac within
inguinal canal
Funicular- sac crosses
superficial inguinal ring,
but does not reach the
bottom of scrotum
Complete:
Sac descends to the
bottom of the scrotum
18. Clinical features
Incidence:
Male: 25% ; Female: 2%
Male: Female: 20:1
• Dragging pain and swelling in groin
Better seen while coughing and standing and felt
together with an expansile impulse
Usually reducible but can go irreducibility,
inflammation, obstruction, strangulation
19. Internal ring occlusion test:
Lie the patient
Reduce the content
Occlude the internal ring using thumb
Ask patient to cough
Direct hernia: swelling medial to thumb
Indirect hernia: swelling doesn’t appear
• Swelling confirmed on standing position if
swelling appears on releasing thumb and
during coughing
20. Ring invagination test
Reduce the hernia
Invaginate little finger from bottom of scrotum,
gradually push up and rotate to enter the superficial
ring
Ask patient to cough
Impulse is felt at the tip of the invaginated finger
21. Zieman’s test
Place index finger on deep inguinal ring and
middle finger on superficial inguinal ring and
ring finger above saphenous opening
Ask patient to cough
Indirect hernia: impulse felt on index finger
Direct hernia: no impulse
22.
23. Valsalva manuever or head/leg raising test:
• To check the tone of abdominal muscle
wall
Systemic examination:
• To find out precipitating factors like chronic
bronchitis, ascitis
Urethral examination:
• To look for urethral strictures, BPH
Rectal examination
24. Investigations
No diagnostic test required
USG
Contrast radiology herniogram
Tests relevant for precipitating cause
25. Treatment
No surgery in case of early, asymptomatic,
direct hernia in elderly
Surgery:
Herniotomy
Herniorraphy
Hernioplasty
26. Herniotomy
Removing and closing the sac
Herniorrhaphy
In adult
Herniotomy+ strengthening of weakened posterior wall
(shouldice repair or lichtenstein repair)
Hernioplasty
Herniotomy+ strengthening of posterior wall by putting a
synthetic mesh
27. Laparoscopic repair
1.Totally extra peritoneal approach(TEP)
2.Transabdominal preperitoneal approach(TAPP)
Aim is to reduce the hernia sac within the
abdomen then place 10*15 cm mesh just deep to
abdominal wall extending across midline into
retropubic space and 5 cm lateral to deep inguinal
ring
28. Open plug /complex mesh repair
Introduce a finger through deep inguinal ring
Open preperitoneal space deep to inguinal canal
Mesh is inserted (two layered)
Inner – transversalis fascia and outer to it
superficial layer
29. Complications of inguinal hernia
surgery
Early
• Bleeding (damage to
inferior epigastric or iliac
vessel)
• Urinary retention
• Femoral nerve blockade
(anaesthesia)
• Late
• Seroma formation
and wound infection
over next week
• Hernia recurrence
• Chronic pain
• Testicular artery
damage leading to
testicular infarction
(rare)
34. Pathology
Enters through femoral canal and becomes superficial
through saphenous opening.
Because of its irregular pathway and narrow neck, it is
more prone for obstruction and strangulation.
During surgery, precaution should be taken about the
femoral vein and pubic branch of obturator artery (or
accessory obturator artery) which often may get injured
leading to torrential haemorrhage.
35. Clinical features
Age: rare before puberty
Sex: common in females (2:1), common in
multiparous.
20% bilateral however Common on right side
Swelling in the groin below and lateral to the pubic
tubercle.
Swelling:
Impulse on coughing
Reducible
Gurgling sound during reduction
Dragging pain
36. Cont…..
obstruction and strangulation occurs which is more
common, then features of intestinal obstruction:
painful, tender, inflamed, irreducible swelling
without any impulse.
They also present with abdominal distension,
vomiting and features of toxicity.
Often femoral hernia can be associated with
inguinal hernia also.
40% of femoral hernias present as emergency
hernia with obstruction/strangulation.
Gaur’s sign: In femoral hernia, distension of
superficial epigastric and/or circumflex iliac veins
occurs due to the pressure by the hernial sac.
37. Diagnosis and Investigations
Good history and examination
Below and lateral to the pubic tubercle and lies in
upper leg than in lower abdomen
May be confused with lymph node
No investigations required
USG, CT, plain X-Ray abdomen if features
of bowel obstruction
39. Treatment
Surgery:
1. Lockwood-low operation:
Here sac is approached below the inguinal ligament
through groin crease incision (or over the swelling)
so that fundus of sac is dissected by direct vision
and repair is done from below
Here inguinal ligament is sutured to Cooper’s
ligament.
40. 2. Mc’ Evedy-
high operation: an incision is made over the femoral
canal extending vertically above the inguinal
ligament.
-sac is dissected from below, neck from above and
repair is done from above.
- It is done in strangulated femoral hernia.
- 3. Lotheissen’s operation:
It is through inguinal canal approach. Transversalis
fascia is opened and neck of the sac is identified in
femoral ring. Sac is dissected from above, neck is
ligated and repair is done.
Complication: bleeding, hematoma, abscess formation
41. 4. AK Henry’s approach: Repair of bilateral femoral
hernia through lower abdominal incision.
5. Laparoscopic mesh repair
a. Totally extra peritoneal approach(TEP)
b. Transabdominal preperitoneal approach(TAPP)
42. Inguinal hernia Femoral hernia
Relation to
pubic tubercle
Above and medial below and lateral
Three finger test Impulse on index or
middle finger
Impulse on ring
finger
Common in male female
Strangulation Less common More common
Incidence 10 times more
common than femoral
Difference between femoral and inguinal hernia
44. Umbilical hernia(children)
Common condition occurring in up to 10% of infants.
High incidence in premature babies.
Symptomless at the beginning but gradually in
ceases
45. Umbilical hernia(adults)
More common in female
Condition that cause thinning of linea alba.
Pregnancy, obesity, liver disease
Defect in linea alba is immediately adjacent to
umbilicus (indistinguishable at surgery) but it is
termed as para-umbilical hernia.
46. Epigastric hernia
Arise through linea alba anywhere between xiphoid
process and umbilicus.
Elliptical
Multiple hernia may be present
Treatment
1. Very small: spontaneously disappear
2. Moderate: not dangerous
3. Surgery: symptomatic
47. Lumbar hernia
Mostly through inferior lumbar triangle of petit.
Rare but is mimicked but incisional hernias arising
through flank incisions.
Surgery recommended
1. Open
2. Laparoscopic(TAPP is popular)
49. References
1. Norman S. Williams et al, Bailey & love’s Short Practice
of Surgery, 26th edition
2. Das S., A manual of clinical Surgery, 11th Edition
3. Keith L. Moore, Clinically oriented anatomy, 7th edition
Extends from the deep inguinal ring downward and medially to the superficial inguinal ring
Lies parallel to and immediately above the inguinal ligament
Present in both sexes
It allows structures to pass to and from the testis to the abdomen in males
In females it permits the passage of the round ligament of the uterus from the uterus to the labium majus
Transmits ilioinguinal nerve in both sexes
An oblique passage
- 4cm in length
- Directed inferomedially
2 Openings:
• Deep inguinal ring
• Superficial inguinal ring
Anterior Wall of Inguinal Canal : Is formed along its entire length by aponeurosis of the external oblique muscle
It is reinforced in its lateral third by the origin of the internal oblique from the inguinal ligament
This wall is strongest where it lies opposite the weakest part of posterior wall, that is deep inguinal ring
Posterior Wall of Inguinal Canal:Is formed along its entire length by the fascia transversalis
It is reinforced in its medial third by conjoint tendon, the common tendon of insertion of internal oblique and transversus, attached to the pubic crest and pectineal line
This wall is strongest where it lies opposite the weakest part of the anterior wall, that is superficial inguinal ring
Inferior Wall of Inguinal Canal:Is formed by the rolled-under inferior edge of the aponeurosis of the external oblique muscle called inguinal ligament and at its medial end, the lacunar ligament
Superior Wall of Inguinal Canal: Is formed by the arching lowest fibers of the internal oblique and transversus abdominis muscles
Direct hernia: impulse on the pulp of the finger
Indirect hernia: impulse on the tip of the finger
Herniogram: contrast injected into peritoneal cavity followed by screening which shows presence of sac or asymetric bulging in ingiunal anatomy.
Srb ma detail padhera aaunu
Smallest of 3 compartment of femoral sheath
Conical and short 1.25 cm
Extend from femoral ring to saphenous opening
Boundary of femoral ring:
laterally: septum betn femoral canal and femoral vein
Medially: lacunar ligament
Anteriorly: inguinal ligament
Posteriorly: superior ramus of pubic bone covered by pectineus muscle and fascia
Meaning padhera aaune
Suitable when there is no risk of bowel resection
Conservative treatment for age of less than 2 years when hernia is symptomless.
95% resolves spontaneously
If persists beyond the age of 2, needs surgical repair.