Inguinal hernia

Surgical Anatomy

Inguinal canal:

It is an oblique canal measuring about 3.75cm in length arising from deep inguinal ring (an oval opening ½ inch above the mid inguinal point) to superficial inguinal ring (triangular opening ½ inch above and medial to pubic tubercle.

Boundaries of inguinal canal:

Anterior:

·         External oblique muscle

·         Conjoined tendon

Posterior:

·         Fascia transversalis

·         Conjoined tendon

Inferior:

·         Inguinal ligament

Superior:

·         Internal oblique muscle

·         Transverses abdominis muscle

Spermatic cord (males):

In male the spermatic cord passes through the inguinal canal. The spermatic contents are:

         i.            Vas deference

       ii.            Artery of vas deference

      iii.            Testicular artery

     iv.            Testicular vein

       v.            Testicular lymph vessels

     vi.            Cremasteric artery

    vii.            Autonomic nerves

  viii.            Process vaginalis

     ix.            Genital branch of genitofemoral nerve

In females the inguinal canal contains the round ligament of uterus.

1.     Inguinal hernia:

A.     Indirect (oblique) inguinal hernia:

It is common in young. The hernia will protrude through the deep inguinal ring transverses the inguinal canal and becomes superficial through the superficial inguinal ring.

Types of indirect inguinal hernia:

a)      Bubonocele:

The hernia is limited to inguinal canal.

b)     Funicular:

The hernia is extended to the scrotum.

c)      Complete (scrotal):

Again the contents extend into the scrotum but they can’t be separated from the scrotal contents.

B.     Direct inguinal hernia:

It is more common in old. The hernia protrudes through the posterior abdominal wall (thru fascia transversalis).

Types of direct inguinal hernia:

a)      Incomplete:

The hernia extends to scrotum.

b)     Saddle:

There are two sacs because the inferior epigastric artery splits it, one sac become medial to the epigastric artery and one to the lateral.

Clinical features:

Ø  Lump (swelling) in inguinal region

Ø  Pain

Ø  If intestine is present in the hernia so gurgling sound will be produced

Ø  Constipation

Difference b/w direct and indirect inguinal hernia:

         i.            Direct inguinal hernia is common in elderly while indirect inguinal hernia is common in young age.

       ii.            Direct inguinal hernia is easily reducible while indirect inguinal hernia isn’t easily reducible.

      iii.            Chances of obstruction are more in indirect hernia as compared to direct hernia.

     iv.            Cough impulse is positive when deep inguinal ring is obliterated (pressed on thumb)

Diagnosis:

Clinical examination:

Management:

Non surgical:

Truss is advised which can’t cure the disease but prevent further progression.

Surgical:

         i.            In children Herniotomy is the standard procedure.

       ii.            In adults there are different procedures;

a.       Lytle procedure

b.      Darning repair

c.       Lichenstein

d.      Bassini repair

e.      Shouldice

Note: In surgery they reduce the contents. The remove the excess part of the sac, the facial and muscle layers are repaired.