Indirect inguinal hernias are the most common type of groin hernia, accounting for 65% of cases. They occur when the hernia sac passes through the deep inguinal ring to the superficial ring. Direct inguinal hernias are less common, accounting for 10-15% of cases, and occur through Hesselbach's triangle due to weakness in the posterior wall of the inguinal canal. Femoral hernias are more common in females and occur when abdominal contents descend into the femoral canal below the inguinal ligament. Complications of hernias include strangulation, obstruction, and incarceration, while complications of hernia surgery include injury to surrounding nerves and vessels,

1. GROIN HERNIAS
Include-
Indirect inguinal hernia
Direct inguinal hernia
Femoral hernia
Dr. G S Randhawa
Associate professor of surgery
Punjab institute of medical scienc
es, Jalandhar,punjab,India.

2. INDIRECT INGUINAL HERNIA
 Definition- hernia, of which sac passes through
deep inguinal ring to superficial inguinal ring.
 Mostly preformed sac due to defect in development
of processes vaginalis.
 Most common type(65%)
 Common in younger age group.
 More common on right side in first decade of life.
Equal incidence in second decade.

4. INDIRECT...
 Bilateral in 30% of cases
 Neck is thin hence more prone to strangulation.
 Neck lies lateral to deep inferior epigastric vessels.
 In children sometimes sac is so narrow in the
middle that it admits only peritoneal fluid behaves
like hourglass.
 Often associated with undescended testis

6. INDIRECT ...
 Types –
 Bubonocele-when the hernia is limited to inguinal
canal.
 Funicular- processes closes just above the
epididymis. Hernia and testicle can be felt
separately.
 Complete(inguinoscrotal)- here testicle appears
lying in hernial sac. Occurs in completely open
processes.

8. INDIRECT...
 Clinical features-
 Prevalent 25% in males and 2% in females.
 Often present since birth
 Or appeared during adolescence
 Swelling increases in standing position while
reduces in lying down position.
 Impulse on coughing.
 Ring occlusion test positive.

9. INDIRECT....
 Differential diagnosis-
 Hydrocele
 Undescended testis
 Femoral hernia
 Lipoma of the cord
 Hydrocele of the canal of Nuck in females
 Inguinal lymphadenopathy
 Inguinal abscess

10. INDIRECT....
 Investigations-
 Routines
 X-ray chest
 u/s abdomen
 Tests relevant for precipitating causes like-chronic
cough,contipation,urinary obstruction, ascites, intra-
abdominal mass cyst etc.,
 Herniography(Gullmo)

11. INDIRECT....
 Treatment-
 In children- simple herniotomy
 In adults- herniotomy + reinforcement of posterior
wall by-
 Bassini’s repair.
 Lichtenstein tensionfree mesh repair
 Kugel’s repair(open or laparoscopic)
 Surgery can be done under local anaesthesia as
outpatient daycare procedure.

12. INDIRECT..TREATMENT
 Read-Rives repair-mesh sutured directly over
peritoneum after herniotomy and invasion of stump.
 Stoppa repair- mesh placed between peritoneum
and transversalis fascia.
 TEP
 TAPP

13. INDIRECT...
 Related/special conditions
 Hernia-en-glisade- non-mesentry content
 Richter’s hernia- partial strangulation of gut
 Littre’s hernia- meckel’s diverticulum as content
 Pantaloon hernia- two sacs saddled over inferior
epigastric vessels
 Maydl’s hernia- double loop(hernia-en-W)

14. CONSERVATIVE TREATMENT
 Truss

15. DIRECT HERNIA
 Hesselbach’s triangle

16. DIRECT ....
 10-15% hernias are direct.
 35% inguinal hernias are direct.
 50% direct h.are bilateral.
 Rare in females and children.
 Always acquired, due to weakness of posterior wall
of inguinal canal.
 Medial to inferior epigastric vessels; wide neck and
thick walled sac.

17. DIRECT.....
 Occurs through Hesselbach’s triangle.
 Medial or lateral according to the position of neck
vis a vis position of medial umbilical ligament
(obliterated umbilical artery)

19. DIRECT....
 Coverings- from inside out
 Extra-peritoneal tissue
 Fascia transversalis
 Conjoint tendon
 External spermatic fascia
 skin

20. DIRECT.....
 Predisposing factors-
 Chronic cough, smoking
 Straining at stool or urine
 Heavy weight lifting
 Appendicectomy (on right side)
 Malgaigne bulgings- soft supple bulges near
external ring on raising legs show weak
musculature of inguinal region.

22. DIRECT....
 Rarely descends into scrotum.
 When descends usually massive. Strangulation
may occur.
 Treatment-
 Mesh repair without herniotomy in most cases.
Herniotomy needed only when inguinoscrotal. Sac
dissected and invaginated and a prolene mesh
fixed over it. Bilateral problem can be dealt with
single suprapubic incision(pfennsteil’s)

23. COMPLICATIONS OF HERNIAS
 Most common esp. In indirect hernia is
strangulation
 Obstruction
 Incarcenation
 Intestinal obsruction

24. COMPLICATIONS OF SURGERY
 Injury to- ilioinguinal n.,spermatic artery leading to
testicular atrophy, vas deferens, inferior epigastric
vessels, femoral vessels, external illiac vessels (in
cases of endoscopic repair), urinary bladder esp. In
children.
 Haematoma formation
 Infection.
 Recurrence (10%) within 3yrs early;after 3yrs late.
 Chronic groin-pain syndrome.
 Infertility due to entrappement of vas in cases with
single functioning testicle.

25. FEMORAL HERNIA
 Surgical anatomy of femoral canal
 Medial most compartment of the femoral sheath
 Extends from femoral ring to saphenous ring
 Lower end covered with cribriform fascia
 Contents- fat,lymphatics and lymph node of Cloquet.
 1.25cm long and 1.25cm wide at the base which is
upper end.
 Boundries of femoral ring- anteriorly inguinal
ligament,posteriorly iliopecteneal ligament of
Cooper,pubic bone and fascia covering the pectineus
muscle.Medially free sharp border of lacunar ligament.
Laterally thin septum separating it from femoral vein.

27. SURGICAL ANATOMY OF FEMORAL CANAL

28. SURGICAL ANATOMY.....

29. FEMORAL...
 Surgical pathology
 Femoral canal>vercally descends upto saphenous
ring>escapes out in loose areolar tissue to expand
and assumes the shape of a retort.
 Due to arduos path and narrow neck more prone
to obsruction and strangulation
 During surgery utmost precaution should be taken
to prevent injury to femoral vein and pubic branch
of obturator artery. An alarming haemorrage takes
place otherwise.

30. FEMORAL HERNIA
 Clinical features
 Common in females 2:1
 Most patients multiparous females
 Rare before puberty, 20% bilateral; common on
right side
 Presents as a swelling below and lateral to the
pubic tubercle in contrast to inguinal hernia, which
is above and medial to pubic tubercle.
 Swelling, impulse on coughing, reducibility and
gurgling sound while being reduced.
 Dragging pain.

32. FEMORAL HERNIA

33. FEMORAL HERNIA

34. FEMORAL HERNIA
 Signs of obsruction/strangulation
 Pain, markedly tender.
 No impulse on coughing.
 Ireducible.
 Redness over swelling.
 Abdominal distension.
 Vomiting.
 Sighns of toxicity- fever, tachycardia,low
BP,dehydration, confusion etc.
 Often present along with inguinal hernia.
 40% present as intestinal obstruction.

35. FEMORAL HERNIA
 Differential diagnosis
 Inguinal hernia
 Enlarged cloquet’s lymph node
 Psoas abscess.
 Lipoma.
 Femoral artery aneurism.
 Distended psoas bursa.
 Saphena varix.
 Haematoma
 Haemangioma of adductor muscle

36. FEMORAL HERNIA
 Related conditions
 Hydrocele of femoral hernia
 Laugier’s femoral hernia- through a rent in
lacunar ligament
 Narath;s femoral hernia- hernia behind femoral
vessels in congenital dislocation of hip
 Cloquet’s hernia- when sac lies under pectineal
fascia.
 Sliding hernia –urinary bladder

37. FEMORAL HERNIA- TREATMENT
 Treament includes various surgical repair
techniques
 Lockwood low operation- approached from below.
Inguinal ligament sutured to Cooper’s
ligament(ideal and common)
 Mc’Evedy high operation- vertical incision across
inguinal ligament over swelling. Good exposure.
Ideal for strangulated hernia
 Lutheissen’s operation- conjoint tendon to
iliopectineal ligament
 AK Henery’s operation- repair of b/l hernia
through pfennsteil incision.
 Laparoscopic mesh repair-TEP/TAPP

38. FEMORAL HERNIA
 Complications-
 Of hernia- obsruction, strangulation, intestinal
obstruction.
 Of surgery- injury to femoral vein or artery, urinary
bladder, obturator artery
 Sequele-recurrence, ch groin-pain
syndrome,restricted hip flexion.

39. THANK ....YOU