This presentation is made by Dr Ashok Jaisingani

1. Dr. Ashok Jaisingani

2.  Superficial Inguinal Ring: It is triangular
aperture in the aponeurosis of the external
oblique muscle and lie 1.25 cm above the pubic
tubercle. Normally the ring will not admit the tip of
little finger.
 Deep Inguinal Ring: It is U shape condensation
of transversalis fascia and it lies 1.25 cm above
inguinal (Poupart’s) ligament.
 The transversalis fascia is the fascial envelope of
abdomen and competency of deep inguinal ring
depends on the integrity of this fascia.

3.  Infants: In infants the superficial and deep ring
is almost superimposed and the obliquity of the
canal is slight.
 Adult: In adult the inguinal canal is 3.75 cm is
long is directed downward and medially from the
deep to superficial inguinal ring.
 In male inguinal canal transmit the spermatic
cord, ilioinguinal nerve & genital branch of
genitofemoral nerve.
 In female round ligament replace the spermatic
cord.

4.  Indirect Inguinal hernia is most common hernia of all
especially in young.
 Direct inguinal hernia become more common in the elderly.
 An indirect hernia travels down the canal on the outer
(Lateral & anterior) side of spermatic cord.
 A direct inguinal hernia comes out directly forward through
posterior wall of inguinal canal.
 The neck of indirect inguinal hernia lateral to inferior
epigastric vessels
 The neck of direct inguinal hernia usually emerge medial to
the inferior epigastric vessels except in saddle – bag or
pantaloon type (have both lateral & medial component)

5.  An inguinal hernia can be differentiate from the
femoral by ascertaining the relation of the neck of
the sac to the medial end of the inguinal ligament
& pubic tubercle.
 Inguinal Hernia: The neck lie above and medial
to the medial end of inguinal ligament & pubic
tubercle.
 Femoral Hernia: The neck lie below and lateral
to the medial end of the inguinal ligament & pubic
tubercle.

6.  Indirect inguinal hernia is most common in young
 In first decade of life inguinal hernia is more
common on right side in male, this is associated
with later descent of right testis & higher
incidences of failure of closure of procesus
vaginalis.
 In adult male 65% of inguinal hernias are indirect
and 55% are right – sided
 The hernia is bilateral 12% of the cases

7.  There are three types of indirect inguinal hernia;
 1- Bubonocele: (hernia is limited to inguinal canal)
 2- Funicular: (The processus vaginalis closed just
above the epididymis), the content of sac can be
left separately from the testis (lie below the
hernia)
 3- Complete (scrotal): Rarely present at birth
commonly encounter in infancy. The testis appear
to lie within the lower part of hernia.

8.  The patient is instructed to look at the ceiling and
cough, if the hernia will comes down, the
examiner look and feel for impulse and address
following question.
 Is the hernia right, left or bilateral?
 Is it an inguinal or femoral hernia?
 Is it a direct or indirect inguinal hernia?
 Is it reducible or irreducible hernia?
 Is the inguinal hernia is complete or incomplete?
 Looks for contents.

9.  Indirect inguinal hernia is 20 times more common in males than
females.
 The patient complain the pain in groin or pain refer to testis
when perform the work or strenuous exercise.
 On coughing a small transitient bulging is seen and feel together
with expansile impulse.
 When the sac is limited to inguinal canal, the bulge may be
better seen by observing the inguinal region from side or looking
down to abdominal wall.
 An indirect inguinal hernia on coughing comes down and persist
until it is reduced
 In large hernias there is sensation of the dragging & weight on
mesentery, may produce epigastric pain.
 The indirect inguinal hernia is “translucent” in infancy and early
childhood but never in adult hood

10.  Vaginal Hydrocele
 Encysted hydrocele of cord
 Spermatocele
 Femoral hernia
 Incomplete descended testis in inguinal canal
 Lipoma of the cord

11.  Hydrocele of the canal of Nuck
 Femoral Hernia

12.  Surgery is the treatment of the choice
 Surgery is either open or laparoscopic
 Truss is used when the operation is
contraindicated or when operation is refused.

13.  It is consist of
1- Excision of hernial sac
2- Repair of transversalis fascia and internal ring
3- Further reinforcement of posterior wall of
inguinal canal.

14.  In adult male 35% of inguinal hernias are direct
 At presentation 12% of patients will have
contralateral hernia, and there is four fold increase
in risk of contra-lateral hernia.
 A direct inguinal hernia is always acquired, the sac
passes through a weakness or defect of
transversalis fascia in posterior wall of inguinal
canal.
 Women practically never develop direct inguinal
hernia (Brown).

15.  Smoking
 Occupation that involve straining and heavy lifting
 Damage to illioinguinal nerve (Previous
appendicectomy) is another cause

16.  Direct hernia do not often attain a large size or
descend into scrotum
 In contrast to indirect inguinal hernia, direct
inguinal hernia lies behind the spermatic cord
 The sac is often smaller than mass, the protruding
mass consist of the extra-peritoneal fat.
 As the neck of sac is wide, the direct inguinal
hernias do not strangulate or strangulate rarely.

17.  This is narrow necked hernia with prevesical fat
and portion of bladder that occur through a small
oval defect in the medial part of conjoined tendon
just above the pubic tubercle.
 It occurs principally in elderly
 Occasionally it become strangulated
 Operation should always be advised until there is
definite contraindication.

18.  This type of hernia consist of two sac that straddle
the inferior epigastric artery,
 One sac being medial and other one lateral to this
vessel.
 This condition is not rare & is cause of recurrence

19.  Strangulation of inguinal hernia occurs at any time
during life, occurs in both sex equally.
 Indirect inguinal hernia strangulate more
commonly, but not so often direct variety because
of wide neck of sac.
 More often the strangulation occurs in pts who
have worn truss for long time & those with
partially reducible or irreducible hernias.

20.  The Neck Of Sac
 The External Inguinal Ring In Children
 Adhesion Within Sac

21.  Usually the small intestine is involved in
strangulation with next most common that
involved in strangulation is omentum.
 It is rare the large intestine to become
strangulated, even when the hernia is of sliding
type.

22.  The incidences of strangulation during infancy is
4% (Gross).
 The ratio of girls to boy is 5:1
 More frequently the hernia is irreducible but not
strangulated.
 Most cases of strangulated inguinal hernias occurs
in females infants and contents will be ovary or
ovary plus fallopian tube.

23.  Resuscitation with adequate fluids
 Empty stomach with nasogastric tube
 Give antibiotic to contain infection
 Catheterize to monitor hemodynamic state
 Operation:
 Inguinal herniotomy for strangulation

24.  These are indicated only in infants, the child is
given analgesics & placed in gallow’s traction.
 In 75% of the cases the reduction is effected and
there appear to be no danger of gangrenous
intestine
 Forcible reduction must be avoided & should not
be attempted.

25.  It is rare type of the hernia.
 The strangulated loop of W within abdomen, so
local tenderness over the hernia is not marked.
 At operation two – comparatively normal looking
loop of intestine are present in the sac.
 The strangulated loop will become apparent if
traction is exerted on the middle of the loops
occupying the sac.

26.  It result from slipping of posterior parietal
peritoneum on the underlying retroperitoneal
structure.
 The posterior wall of the sac formed by sigmoid
colon, mesentery on left, caecum on right & some
time by either side portion of bladder.
 Mostly sac consist of caecum, appendix or the
portion of the colon.
 A small bowl sliding hernia occurs approx. 1 in
2000 cases
 The sac-less hernia occurs 1 in 8000 cases

27.  A sliding hernia occurs almost exclusively in men
 Five out of six sliding hernias are situated on the
left sides
 Bilateral sliding hernias are rare
 The patient is nearly over the 40 year of age
 It should be suspected in very large globular
inguinal hernia descending well into the scrotum.
 Occasionally the large intestine strangulated in
sliding hernia, more often non – strangulated
large intestine large intestine is present behind the
sac