1. Examination of
Hernia
DR MIN OO
Surgery

2. Outline
• Definition
• Types
• Predisposing factors
• Basic features of a hernia
• Inguinal hernia
• Applied anatomy
• Examination of inguinal hernia
• Differences b/t direct and indirect inguinal hernia
• Some definitions
• Video click for inguinal hernia examination
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3. Learning out come
• To understand the basic principle for examination of hernia.
• To know the various types of herniae.
• Able to understand the applied anatomy for the inguinal region.
• Able to demonstrate the examination of inguinal hernia.
• Comprehend the differences between direct and indirect inguinal
hernia.
• To appreciate the some confused definitions.
• To be able to develop the skill for the examination of a herniae
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4. What is hernia?
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5. Hernia – protrusion of a viscous or part of
viscous through an abnormal opening in the
walls of its containing activity.
25th edition,Bailey`s & Love`s Short practice of surgery
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6. WHY HERNIA
OCCUR?
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7. Predisposing factors ???
Obesity
Straining Smoking
Abdominal
Coughing Causes distension
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8. Composition of hernia
Sac Covering Contents
• Derived • Omentum- omentocele
from the • Intestine- enterocoele
• Sac is a
layers of
diverticulum of
abd wall • Portion of circumference of
peritoneum
through intestine- Richter’s Hernia
which the • Portion of bladder (or a
• Consist of sac passes diverticulum)
mouth,neck, • Ovary with or w/o
body and corresponding Fallopian
fundus tube
• Meckel’s diverticulum-
Littre’s hernia
• Fluid
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9. Classification
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10. Irrreducible Hernia-
Reducible Hernia- contents cannot be
contents can be returned to the
returned to abdomen abdomen but there is
no other complication
Obstructed Hernia-
irreducible hernia Strangulated Hernia-
containing intestine blood supply is
that is obstructed with obstructed
good blood supply
Inflammed Hernia-
contents of the sac
become inflammed
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11. Basic features of hernia???
• Occur at weak point (Congenital or acquired)
• Reducible on lying down or with direct pressure
• Have an expansile cough impulse
(Visible & palpable)
Note: last 2 signs may be absent if constricted at
the neck
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12. Causes of abdominal Herniae
Anatomical weakness Acquired weakness
• Structures passing through • Trauma
• High intra-abdominal
the abdominal wall pressure
• Muscle fail to develop • Coughing
• Straining
• Scar tissue
• Abdominal distension
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13. Various types of Herniae?(common)
• Inguinal
• Umblical
• Incisional
• Femoral
• Epigastric
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14. Other rare herniae
• Spigelian
• Obturator
• Lumbar
• Gluteal
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15. Inguinal
Hernia
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16. Surface anatomy ?????
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17. 7/31/2012 17

18. Relation to the surrounding
structures
1.Anterior wall
Medially-external obliqueaponeurosis
Lateral- internal oblique muscle
2.Posterior wall
Medially – strong conjoint tendon
Lateral- fascia transversalis
3.Floor
Medial- Lacunar ligament
Lateral- inguinal ligament
4.Roof
Arching of fibers of int oblique and
transverse muscles.
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20. 7/31/2012 20

21. Examination of the hernia
• Ask permission
• Exposure
• Position
• Third party
• Privacy
• Manner
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22. Ask the patient to stand up
• Lying position …..why not?
Not possible to see the true size.
proper examination even not detect at all.
• If suspect since early,start with standing position
• If found during routine abdominal exam, complete
abd exam first and ask the patient to stand up to
examine properly.
NOTE: examine both inguinal regions
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23. Look at the swelling from the front
• Exact size and shape
• Visible expansile cough impulse
• Distinguish from femoral hernia
• Extend of lump…down into the scrotum ??
• Other scrotal swelling ….
• Any other swelling on the “normal side”
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24. Feel from the front
• Exam the scrotum and content
• First whether inguino-scrotal or true scrotal by
getting above the upper edge ( get above )
• Don’t exam the external ring or canal as it is
painful
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25. Feel from the side
• Having exam the scrotal content & can’t get above the lump –
assuming the inguinal hernia – proceed to examination of the
lump…….??? Inguinal Hernia examination
• Stand at the side of the patient –same side of hernia
• Place on hand at the back of to support the patient
• Examinating hand and fingers parallel to the inguinal ligament.
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26. Expansile cough impulse
• Firmly compress the lump with fingers
• Ask the patient to turn head toward to opposite side &
to cough
• If Tense and expansile = cough impulse (+)
Note:
• Localized swelling in the spermatic cord and undescended testis
come out during cough but not bigger nor tense .
• (+) is diagnostic for hernia
• (-) can not exclude diagnosis (e.g adhesion …)
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27. Is the swelling is reducible?
• Position????
• Can control at internal ring =indirect
• Can not control = direct
Note:
• Reduction point to pubic tubercle
• above and medial … inguinal
• Below and lateral …….femoral
Only for reducible one
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28. Remove the finger and watch the
reappearance
• Direction and the way reappearance help to deduct the
origin of hernia
• Obliquely downward = indirect
• Directly project forward = direct
NOTE:
Difficult in obese patient
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29. Percuss and auscultate
• Intestine = resonant and audible bowel sound
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30. Feel the other side
• Move the other side and exam the inguinal region
• Commonly bilateral particularly in direct inguinal hernia
• Ask the patient to cough to make obvious small bulge
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31. Examine the abdomen
• Any possible increased intra-abdominal
pressure
e.g ..????
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32. Cardiovascular & respiratory assessment
• Fitness
• Any chronic respiratory problem..
• Increased intraabdominal pressure
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33. Differences b/t
direct and indirect inguinal hernia
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34. Indirect inguinal hernia Direct inguinal hernia
Any age but common in young Elderly
Via deep inguinal ring and long the Via transversalis fascia (hasselbach’s
inguinal canal triangle)
Patent or reopen processus vaginalis Weak abdominal wall/muscle
Unilateral in 2/3 case (right side more Bilateral in > ½ case
common)
Enter scrotum (complete) Does not enter scrotum (incomplete)
Reduced by patient/doctor (manually) Reduced on lying down (automatically)
Narrow neck- more liable to strangulate Broad neck
Zieman technique- impulse on index Impulse on middle finger
finger
Deep ring occlusion test- control Bulge out
Little finger invagination test- impulse on Impulse on pulp
finger tip
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35. Clinical features
Indirect inguinal hernia
Direct inguinal hernia
- sudden pain at the groin
- seen protruding directly forward
- swelling in inguinal canal which
- usually readily reducible
may extend into scrotum
- gradual onset
- become visible when patient
- Severe pain is rare If there is no
stand or cough
complication such as incarceration or
- dragging/ discomfort
strangulation
- passes above and medial to
pubic tubercle
- palpable cough impulse
- audible bowel sound +/-
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36. D/Dx of inguinal hernia???
• Femoral hernia
• Vaginal hydrocele
• Hydrocele of cord or canal of nuck
• Undescended testis
• Lipoma of cord
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37. Some definition ?????
• Strangulated hernia ?
• Richter`s hernia?
• Maydl`s hernia?
• Sliding hernia?
• Incarceration ?
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38. Video for inguinal hernia examination
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39. THANK YOU
HAVE A NICE DAY
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