hernia

1. Dr. Akhil Unnikrishnan
MS, DNB (Gen Surg)
Senior Resident

2.  Hernia – A protrusion of whole or a part of
the viscous through the wall that contains it
 Types – inguinal , femoral, umbilical ,
incisional, epigastric, obturator, lumbar,
gluteal ans spegialian hernia

3.  Comes out through the superficial inguinal
ring
 Two types- Indirect (oblique) & Direct
 Indirect IH comes out of abdominal cavity
through the deep inguinal ring, traverses
along the inguinal canal and becomes
superficial through the superficial ring

4.  Direct IH enters inguinal canal through the
medial half of its weak posterior wall
(Hesselbach’s triangle) and becomes
superficial through the superficial ring
 Femoral hernia becomes superficial through
the saphenous opening.

5.  Complete inguinal hernia- when contents
have reached the bottom of the scrotum
 Incomplete inguinal hernia- when the
contents have not reached the bottom of
scrotum

6. 1. Age
 Indirect IH – young individuals
 Direct IH – older people
2. Occupation
 Strenuous works

7. 1. Pain
2. Lump
3. Systemic symptoms
4. Other complaints

8.  Dragging and aching type of pain
 Worsens as the days pass
 Continues so long as the hernia is
progressing
 Ceases when it is fully formed
 Very painful and tender indicates
strangulation (pt may have abdominal pain
due to drag on mesentery or omentum)

9.  Swelling in the groin
1. How did it start?
2. Where did it first appear?
3. Size and its first appearance?
4. Disappears automatically on lying down?
◦ DIH- Disappears automatically
◦ IIH- has to be reduced

10.  If hernia is obstructing the lumen- symptoms
of intestinal obstruction occurs
 Pain abdomen, vomiting, distension ,
absolute constipation
 Faecal smelling vomitus is ominuos sign

11.  Persistant cough (chronic bronchitis)
 Constipation
 Frequency/ urgency of micturition (BPH)

12.  H/O operation (appendicectomy)
 h/o hernia surgery in the past (recurrent
hernia)

13.  Both the inguinal regions must be exposed
 From umbilicus to mid thigh
 Positions – standing & supine
 Patient should not bend forward while
standing

14. 1) Inspection
2) Palpation
3) Percussion
4) Auscultation

15. a) Swelling
b) Skin over the
swelling
c) Impulse on
coughing
d) Position of the penis
SWELLING
1. SIZE & SHAPE
• Indirect- pyriform
• Direct- spherical
• Femoral – spherical
2. POSITION & EXTENT
• Inginal H- extends
from above the ing
ligament
• Femoral H- extends
from below the ing
ligament
3. VISIBLE PERISTALSIS
• If covering is thin as in
recurrent hernia

16. a) Swelling
b) Skin over the
swelling
c) Impulse on
coughing
d) Position of the penis
SKIN OVER THE SWELLING
•Uncomplicated H-
normal skin
•Strangulated H- red skin
•Truss user-
discolouration and brown
pigmentation
•Wrinkled skin- atrophy
of sub cutaneous tissues

17. a) Swelling
b) Skin over the
swelling
c) Impulse on
coughing
d) Position of the penis
IMPULSE ON COUGHING
•Patient is asked to turn
his face away from the
clinician
•Look at the superficial
ring
•Swelling expands on
coughing if swelling
already present
•Momentary bulge if
swelling was not present

18. a) Swelling
b) Skin over the
swelling
c) Impulse on
coughing
d) Position of the penis
POSITION OF THE PENIS
• A large hernia will push
the penis to the other
side

19. 1) Position and extent
2) Getting above the swelling
3) Consistency
4) Relation of swelling to the testis and
spermatic cord
5) Cough impulse
6) Reducibility
7) Invagination test
8) Ring occlusion test

20.  Inguinal H should be differentiated from
Femoral H
 Inguinal H – above the inguinal ligament and
medial to pubic tubercle
 Femoral H- below the inguinal ligament and
lateral to pubic tubercle.
 In obese pts, pubic tubercle should reached by
following the tendon of adductor longus

21.  Differentiates between scrotal and inguino-
scrotal swelling
 Root of scrotum held between thumb in front
and other fingers from behind
 In inguinal H- cannot get above the swelling
 In scrotal swelling- nothing can be felt except
the structures within the spermatic cord.

22.  Doughy and granular- omentocoele or
elastocoele
 Elastic- enterocoele
 Tense and tender- strangulated hernia

23.  Inguinal hernia remains in front and sides of
the spermatic cord and testis
 If hernia is acquired or funicular type, hernia
stops just above the testis
 So testis can be felt apart from hernia

24.  Always in STANDING position
 In case if no swelling, finger placed on
superficial ring and pt is asked to cough
 The root of scrotum can also be held between
the index and thumb finger
 The contents of hernia will force out through
the superficial ring between the index finger
and thumb- EXPANSILE IMPULSE

25. 1. Strangulated hernia
2. Incarcerated hernia
3. When the sac neck is blocked by adhesions

26.  Place index finger – over deep ring
 Middle finger – over superficial ring
 Ring finger – over saphenous opening
 Applied only if no obvious swelling or after
hernia reduced completely
 Pt asked to hold the nose and blow or to
cough

27.  Impulse felt over index finger- Indirect IH
 Impulse over middle finger- Direct IH
 Impulse over the ring finger- Femoral H

28.  Position- supine
 Hernia reduces itself in some cases (direct H)
 In some cases, patient is asked to flex the
thigh on affected side and adduct & rotate it
internally.
 The fundus of sac is gently held with one hand
and even pressure is applied to squeeze the
contents towards abdomen and other hand will
guide the contents through the superficial
ring- “TAXIS”

29.  In Enterocoele, contents reduce with gurgling.
 In enterocoele, first part is difficult to reduce,
but last part slips in easily
 In an omentocoele, the first part goes easily
and last part is difficult to reduce.

30.  If a hernia is not able to be reduced, then it is
an irreducible hernia or an obstructed hernia
or strangulated hernia

31.  After reduction of hernia, this test is
performed.
 In recumbent position
 Little finger is used
 Invaginate the skin from the bottom of
scrotum and palpate the pubic tubercle
 Right hand should be used for right side and
left hand for left side

32.  Finger is then rotated and pushed upto the
superficial ring
 The nail will be against the spermatic cord
and pulp will feel the ring
 Normal ring- triangular and admits only one
finger tip

33.  When finger enters the ring- goes directly
backwards- Direct H
 When finger enters ring – goes upwards,
backwards and outwards- indirect H
 On coughing, impulse felt on pulp of finger,
Direct H
 If felt on the tip ,it is indirect H

34.  Standing position and hernia must be
reduced first
 CONFIRMATORY to differentiate between
Indirect and Direct.
 A thumb is pressed over the deep inguinal
ring and the patient is asked to cough.
 Deep ring- ½ inch above the mid point of
ASIS and pubic symphysis
 Indirect H- will not appear
 Direct H- bulge medial to the occluding
finger

35.  Small inguinal hernia is not visible due to
thick pad of fat
 To make it visible, child is asked jolt or jump
or make the child cry
 Palpate the spermatic cord and if the cord is
thicker, then it suggest of a hernia
 If this test fails, then perform GORNALL’S test

36.  The child is held from the back and lifted up
by the examiner
 Abdomen is pressed and it increases the intra
abdominal pressure.
 Thus the hernia will be visible

37.  Resonant note – intestine (enterocoele)
 Dull – omentum or extra peritoneal tissue
 Percussion helps in differentiating between
acute epididymitis , acute filarial funiculitis
and strangulated hernia
 Strangulated hernia – resonant, dull in others.

38.  Doesn’t give much diagnostic clue
 In enterocoele, peristaltic sounds