1. science
2. medicine
3. surgery

Shohreh Toutounchi
Reference: Schwartz Principles of Surgery 2010
Internship: 1391
Anatomy
 The inguinal canal is 4-6 cm long.
 The inguinal canal starts in the abdomen from the point that the
spermatic cord crosses the internal/deep inguinal ring in the
transversalis fascia (in women the Round ligament).
 This canal finally ends in the external/surface inguinal ring at the
level of the abdominal muscles where the spermatic cord passes from
the aponeurosis of the external oblique muscle.
Epidemiology
 About 75% of all hernias happen in the inguinal region.
 90% of them are in men and 10% in women.
 70% of femoral hernia repairs occur in women (although the
prevalence of inguinal hernia in women is 5 times that of femoral
hernia.
 The most common inguinal hernia in women and in men is the
indirect inguinal hernia.
 The prevalence of hernia in men has two peak ages:
Under one and above 40.
Epidemiology
 About 1/3 of the patients who present with hernia, also develop a contralateral
hernia.
 Hernia in the right side is more common.
 In the laparascopic repair of the hernia, the diagnosis of contralateral hernia
can be made.
 Femoral hernia in the elderly and in those who had a previous hernia repair is
more common.
 The prevalence of inguinal hernia increases with age (especially in men).
 Inguinal hernia in adults is mainly from an acquired weakness in the abdominal
wall (the most important one is a defect in the abdominal muscle).
Etiology

Inguinal hernia has two etiologies:
A) Congenital
B) Acquired
A) Congenital Hernia:
i.
Congenital hernia consists most of the cases of pediatric hernias
ii.
In the descent of the testes from the abdomen to the scrotom in the third trimester, a part of the
perituneum descends with it which is called the process vaginalis.
i.
In the weeks 36-40 of gestation this process vaginalis closes.
i.
Lack of closure of process vaginalis results in a patent process vaginalis which is a reason for the high
prevalence of inguinal hernia in the preterm neonates.
i.
A lot of the process vaginalises close in a few months after birth and its patency does not necessarily
mean that a hernia will be formed.
Etiology
B) Acquired Hernia:
It seems that most cases of hernia come from an acquired defect in the abdominal wall and
the reason for its formation is multifactorial:
1- Strenuous physical activity can be a factor but it is not known whether the hernia is just
from physical activity or in the setting of a patent process vaginalis.
2- A positive family history which can increase its incidence 8 times.
3- COPD increases the direct hernia risk.
4- Collagen deficiency associated diseases like collagen type I deficiency relative to type
III.
5- An association exists between aneurisms and hernias.
Being overweight is to some extent protective (maybe it is from the more difficult diagnosis
of hernia)
Symptoms
 The symptoms are variable from a hernia with no symptoms to one
with stangulation.
 Asymptomatic hernia is either found in physical exam, or the
patient himself realizes the bulging, or it is found during
laparascopy.
 Symptomatic patients mostly present with inquinal pain.
 Sometimes patients present with symptoms outside the inguinal
region such as a change in bowel habits, and/or urinary
symptoms (in the form of sliding hernia).
Symptoms
 With pressure on the nearby nerves, hernia can cause different symptoms
such as a general feeling of pressure, localized pain, and referred pain.
 The feeling of pressure and weight on the inguinal region especially after a
daily activity is common.
 Important Point: A sharp pain indicates nerve entrapment and does
not have anything to do with physical activity.
 Important Point: Neurogenic pains may refer to the scrotom or inside
the thigh.
 Important Point: A change in bowel habits or in the urinary
symptoms can indicate involvement of the bladder inside the hernial sac.
Symptoms
 Important Point: Pain in the inguinal region without bulging is usually
not due to a hernia.
 Important Point: The duration and the way the symptoms progress is
important
 Usually the patient can reduce the hernia but the bigger the hernia, the
less likely it is to reduce.
 The possibility of the incarceration of the hernia at the beginning of the
progress of hernia, for example during the first year , is more likely.
 The possibility of incarceration is neonates is more likely than in adults.
Physical Exam
 The history is usually indicative of hernia but the physical exam is
also an important part of the evaluation.
 The examination in obese patients is difficult.
 It is best that the patient is examined in an upright position so that
the inguinal region and the scrotum is completely exposed.
Physical Exam
 A) First we look to see the bulging. If we do not have a bulging, we place a
finger inside the scrotum and raise it toward the external ring, and ask
the patient to cough or do the Valsalva maneuver until the hernial
contents fall.
The valsalva maneuver causes an unusual bulging and it is possible to
realize if this bulging can be reduced or not.
 B) We examine the contralateral side and compare the two sides to each
other.
The extent of bulging on the two sides can be a criteria for the diagnosis
of hernia on one or both sides.
Physical Exam
 The differentiation between a direct and an indirect inguinal hernia
in the physical exam:
There are different techniques for differentiating a direct from an
indirect hernia in physical exam.
- If the finger is inside the inguinal canal and the patient exerts
pressure or coughs and the hernia comes in contact with the tip of the
finger it is a direct hernia.
- If with closure of the internal ring with the finger while the
patient strains (coughs) the hernial sac does not bulge out the hernia
is an indirect one, and if the hernial sac bulges the hernia is a direct
one.
Physical Exam
Important Point: the examination of the femoral hernia is difficult.
This hernia presents under the inguinal ligament and the presence
of too much or too little fat in the inguinal region can cause an error in
the diagnosis. (Femoral Psuedohernia)
Therefore even the presence of a smallest bulging under the inguinal
ligament has to raise the suspicion for a femoral hernia.
Differential Diagnosis
1-Malignancy: Lypoma, metastasis, testicular tumory
2-Testeicular primary conditions : Varicocele, Epididimitis, Testicular
torsion, Hydrocele, Ectopic testes, undescended testes
3- Aneurism or pseudoaneurism of the femoral artery
4- Lymphadenopathy
5- Sebacious cyst
6- Hydroadenitis
7- Nuck canal cyst (in women)
8- Varices
9-Psoas Abcess
10- Hematoma
11- Ascites
Diagnosis
 The diagnosis is based on history, physical exam and sometimes
imaging.
Imaging in hernia:
 In some conditions physical exam cannot diagnose the hernia:
1- Overwieght individuals
2- Recurrent hernia
3- Hernias that are not found in the physical exam
In these conditions imaging is important
Diagnosis
 The most common radiologic conditions include sonography, CT,
MRI, and each has its own pros. and cons.
1-Sonography: It is inexpensive and does not have radiation.
Important Point: In underweight individuals the movement of the
posterior wall and spermatic cord toward the anterior wall of the
abdomen can have false positive results (the false positive results of
the sonography is more than in the phyisical exam and MRI)
Diagnosis
2- CT scan: Although it gives more information but the routine use of it
is not recommended.
Important Point: In one determined evaluation among the imaging
techniques, MRI was more truthful, and an accurate physical exam
was more truthful than sonography.
Treatment
 The final treatment of inguinal hernia is surgery.
 Now using a mesh herniorhaphy, hernia repair takes place.
 Mesh herniorhaphy is the golden standard because less tension is produced
and there is less recurrency.
 Because of the very good results of mesh the initial tissue repair is not used any
more.
 Important Point: Laparascopic surgery is used in bilateral and recurrent
conditions or when another surgery like prostate surgery has to take place at the
same time.
 Important Point: The laparascopic procedure is not different from the open
surgery method in the recurrency rate. It has less post-op complications and a
sooner return to work. Intestinal obstruction and ileus is seen more often after
a laparascopic procedure.
Treatment
 Contraindications of laparascopy:
1- A previous surgery in the area (a surgery that the surgeon entered the
abdomen such as prostatectomy)
2-Primary medical condition
Important Point: In recurrent cases, dissection in the scar tissue
should not be made (due to inability in exactly differentiating the
anatomic parts.
Important point: In the treatment of hernia surgery is necessary, since
with a conservative method, the wall defect is not removed but has the
tendency to enlarge and cause incarceration.
Treatment
 Indications of conservative surgery:
1-Bad coexisting medical condition
2-A small asymptomatic hernia
3-An elderly person who is asymptomatic
Important Point: Conservative treatment is not used in femoral hernia.
Anesthesia Method
 Anterior surgery can be done with, local, regional, or general anesthesia.
 Laparascopic surgery has to be done with general anesthesia.
 Local anesthesia: Lidocaine, Marcaine with or without epinephrine.
 Important Point: The use of epinephrine in people with coronary
problems is contraindicated.
 Important Point: Before incision or prep inguinal nerve has to be
blocked.
 Epidural anesthesia is also a proper method.
Emergency Surgery
 Incarceration, Sliding, Strangulation
Emergencies.
 Incarcerated Hernia: Hernia that cannot be reduced for a long time.
Three reasons for incarceration
1- Enlargement of the contents of the hernia
2- Adhesion of sac contents to the canal wall
3- Narrow neck of the sac
Important Point: Indication for urgent surgery is when the intestines are under pressure
and the patient has symptoms of bowel obstruction either in incarceration or in a sliding
hernia.
Emergency Surgery
Treatment:
1-Simple Reduction
2-Taxis
3-Surgery
 Sliding Hernia: In this condition one side of the intestinal wall
is trapped but the lumen is not closed. However with the progress of
edema, the lumen closes and sometimes in this kind of hernia, the
bladder is entrapped.
Emergency Surgery
 Strangulated Hernia:
NO TAXIS
1-Fever
2-Leukocytosis
3- Hemodynamic instability
4- Tender and warm hernia contents
5- Erythema in hernial sac
Important Point: Before surgery
Antibiotics, and NG Tube
Serum and electrolytes, IV
Recurrence
 Depends on:
1-Patient condition: Nutrient deficiency, Immune deficiency, Diabetes,
Steroid use, Smoking
2-Surgical Technique: Inexperienced surgeon, Not fixing the mesh, a
Small mesh
3-Tissue: Infection, Tension, Ischemia
To reduce recurrence
use a mesh
Diagnosis of Recurrence
 Bulging
 Important Point: Can have no bulging or mass and still suspect
recurrence
Sonography, CT, or MRI
 DDX of hernia recurrence:
1-Cord lipoma
2-Seroma
3-Weakness of external oblique muscle
4-Cough
Complications of Hernia Surgery
1-Pain
2-Spermatic Cord Damage and Ischemic Orchitis
3-Vas deferans cut
4-Wound infection
5-Seroma
6-Urinary Retention
Sportsman’s Hernia
 Occult hernia, pubic pain in sportsmen, sportsmen’s
hernia
Due to repetitive movement in lower extremity such as skiing, hockey, or
American football, usually hernia is not found in physical exam other than the time
of surgery.
 Symptoms: Acute or chronic pain that gets worse with movement, coughing or
sneezing and can reduce the sportsman’s function. In the physical exam no
bulging or evidence of hernia is seen and pain and tenderness in the inguinal canal
and the external ring is present.
 Diagnosis: Best choice is MRI.
 Treatment: Conservative, if after 6-8 weeks fails
inguinal canal repair.
surgery
Pediatric Hernia
 Prevalence in children
0.8-44 % and in 10% bilateral.
 Prevalence of hernia is higher in, premature and LBW and on the right side.
 Hernia is more likely indirect in children.
 Diagnosis: Made by observation and during crying.
 DDx: UDT, Testicular Tumor, Hydrocele, Varicocele
 Treatment: to some extent emergency even if with no symptoms.
In premature neonates inguinal hernia repair
before hospital discharge.
 Surgery
Herniotomy (Cut in the inguinal area)
 Important Point: Method of exploring the opposite side is somewhat controversial. Now
laparascopy is mostly used. But sonography has also been used.