Case: Mr. Strain, a 45-year-old man, who while trying to show his wife how strong he was, strained to pick up a particularly heavy coffee table. He suddenly felt a sharp pain in his right groin. Later, he noticed that a painful bulge had developed in his groin which disappeared when he was on his back. After several months, the pain and the bulge in his groin increased and he finally agreed to see a physician. On exam, you observe a swelling which begins about midway between the anterior superior iliac spine and the midline, progresses medially for about 4 cm, and then turns toward the scrotum.
Hernia: Protrusion of any viscus from its normal cavity through an abnormal opening. Hernias may be described as:
Reducible Contents easily put back
Irreducible Contents cannot be put back
Strangulated Contents are stuck, and there is constriction of the tissues at the neck of the hernia, leading to reduced venous drainage and arterial occlusion
hernias Description Strangulation Risk
IncisionalThrough an area weakened by prior surgery.Low
UmbilicalCongenital defect of the abdominal wall seen in infants Low
as a swelling at the umbilicus.
Paraumbilical Acquired defect above or below the umbilicus. High
Femoral Herniation through the femoral canal which appears belowHigh
and lateral to the pubic tubercle. More common in women than men.
InguinalTypically seen 'above and medial to the pubic tubercle'. Swelling is Depends
caused by weakness in the abdominal wall in the area of
•Male > Female by 9 to 1 ratio (indirect inguinal hernia most common for both sexes) •Lifetime incidence: 5-25% percent of males, 2% of females •Bimodal peaks before 1 year of age and then again after 40 •Groin hernias (femoral and inguinal) = 75% of abdominal wall hernias •Inguinal hernias account for 70-95% groin hernias; of these (2/3 of these indirect, see below) •Bilateral in 20% of cases
•90% of cases in children and young adults have indirect inguinal hernias. As age of patient increases, so does incidence of acquired (direct) hernias. •Risk factors: chronically increased intra-abdominal pressure (such as caused by obesity, pregnancy, and ascites); reduced muscle tone and deterioration of connective tissue (due to aging, systemic disease, malnutrition, or smoking). •Pediatrics:
Approximately 3% to 5% of full-term infants and up to 30% of preterm infants will have an inguinal hernia. Presents within first 6 mths with an asymptomatic groin mass or more acutely with abdominal pain and vomiting due to incarceration. More common in boys, premature infants and on the right.
Bilateral disease incidence between 5% and 30%.
An incarcerated inguinal hernia is the commonest cause of intestinal obstruction from the 1st week to the 5th month of life
This ILM will focus on indirect and direct inguinal hernias.
Inguinal Canal Anatomy
•Canal has the following boundaries
Anterior – aponeurosis of external oblique
Posterior – conjoint tendon, combined tendon of internal oblique and transversus abdominis Roof – arching fibers of internal oblique and transversus abdominis Floor – inguinal ligament
Medially – pubic symphisis
Laterally – anterior superior iliac spine
Superficial ring – lies superior to the pubic tubercle
Deep ring – lies superior to midpoint of inguinal ligament. This point is midway between pubic tubercle and ipsilateral anterior superior iliac spine.
From Madden JL: Abdominal Wall Hernias: An Atlas of Anatomy and Repair. Philadelphia, WB Saunders, 1989.
Hasselbach’s Triangle defined by
Medially – lateral border of rectus abdominis
Laterally – inferior epigastric vessels
Base – inguinal ligament
Inguinal Canal Contents
•Men – Spermatic cord structures (vas deferens, testicular...