Hernias Definition, Clinical and anatomical classification, surgical anatomy of the inguinal canal and related structures, Inguinal hernias and their types; the difference between direct and indirect inguinal hernias.

1. HERNIAS:
AN OVERVIEW
Definition
Types
Surgical Anatomy
No disease of the human body, belonging to the province of surgeon, requires in its treatment,
a better combination of accurate anatomical knowledge with surgical skills than hernia in all its variants

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DEFINITION:
• An abnormal protrusion of a viscus or a
part of viscus through a weakness in the
wall of its containing cavity, but takes
with it all the linings of cavity.
• Parts:
• Sac
• Mouth, Neck, body, Fundus
• Coverings of the sac
• Contents of the sac
• Omentum, intestines, portion
of bladder, ovary, fallopian
tube, Meckel’s diverticulum,
only fluid as part of ascities.
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TYPES:
• External Hernias:
• Inguinal
• Femoral
• Umbilical
• Paraumbilical
• Epigastric
• Incisional
• Obturator
• Lumbar
• Gluteal sciatic
• Spigelian (at the lateral border
of rectus abdominis)
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Anatomical Classification:

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TYPES:
• Internal Hernias:
• Paraduodenal
• Foramen of winslow
• Pericaecal
• Transmesenteric
• Intersigmoid
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Anatomical Classification: (cont.)

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TYPES:
• Occult
• Reducible
• Irreducible
• Incarcerated
• Obstructed
• Strangulated
• Inflamed
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Clinical Classification:

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SURGICAL ANATOMY:
• Inguinal triangle
• Superficial inguinal ring
• Deep inguinal ring
• Inguinal canal
• Spermatic cord
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INGUINAL TRIANGLE:
• Also called Hasselbach’s triangle
• Direct inguinal hernia protrudes
through it
• Boundaries:
• Medially: Lateral border of rectus
sheath
• Superolaterally: Inferior epigastric
vessels
• Inferiorly: Inguinal ligament
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SUPERFICIAL INGUINAL RING:
• Triangular opening
• In the aponeurosis of external oblique
muscle
• Lies 1.25 cm above and medial to the
pubic tubercle
• Bounded by superomedial and
inferolateral crura, with intercrural
fibers bridging between the borders
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DEEP INGUINAL RING:
• Oval shaped opening
• Condensation of the transversalis fascia
• Lies 1.25 cm above the inguinal ligament
• Midway between pubic symphysis and
anterior superior iliac spine
• Inferior epigastric vessels lie posterior and
medial to deep inguinal ring
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INGUINAL CANAL:
• 3.75 cm long
• Direction of canal in adults and in infants
• Contents:
• In males: Spermatic cord, ilioinguinal
nerve and the genital branch of
genitofemoral nerve
• In females: Round ligament of uterus
replaces the spermatic cord
• Surface Marking:
• A horizontal line stretching from
anterior superior iliac spine to lateral
margin of rectus abdominis
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BOUNDARIES:
• Anterior:
• External oblique aponeurosis,
conjoint tendon (laterally)
• Inferior:
• Inguinal ligament
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BOUNDARIES: (CONT.)
• Posterior:
• Fascia transversalis, conjoint
tendon
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BOUNDARIES: (CONT.)
• Superior:
• Conjoint muscle
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SCHEMATIC REPRESENTATION:
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SPERMATIC CORD:
• Three arteries:
• Testicular artery, cremasteric artery,
artery to vas deferens
• Three nerves:
• Ilioinguinal nerve, cremasteric branch
of genitofemoral nerve, T10
sympathetic nerve
• Three other structures:
• Vas deferens, pampiniform venous
plexus, draining lymph nodes
• Three coverings:
• Internal spermatic fascia, cremasteric
fascia, external spermatic fascia
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COMPARISON
Indirect Inguinal Hernia
• Loops of bowel pass through deep ring,
inguinal canal and superficial ring to reach
the scrotum
• Results from persistent patency of processus
vaginalis
• Hernial neck lies lateral to inferior epigastric
vessels
• Hernial sac lies within the spermatic cord (on
the outer side)
• More chances of strangulation as neck is
narrow
• More common, especially in children and
young adults
Direct Inguinal Hernia
• Bulges through the inguinal triangle into the
inguinal canal, then through superficial
inguinal ring to scrotum
• Main cause is weakening of abdominal
muscles
• Hernial sac lies medial to inferior epigastric
vessels
• Hernial sac runs parallel to the spermatic cord
• Less chances of strangulation as neck is broad
• Less common
• More common in old age
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TYPES OF INDIRECT INGUINAL HERNIA:
• Bubonocele:
• Hernia is limited to inguinal canal
• Fuicular:
• Processus vaginalis is closed just
above the epididymis. Contents of
the sac can be felt separately from
the testes
• Complete/scrotal:
• Hernia reaches the bottom of the
scrotum
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SPECIAL VARIETIES:
• Richter’s Hernia: only a part of
intestine’s anti mesenteric border is
herniated.
• Pantaloon/Saddle Hernia: Both direct
and indirect hernias are present,
straddled by inferior epigastric vessels.
• Littre’s Hernia: Has Meckles’s
diverticulum.
• Sliding Hernia: Extraperitoneal bowel
forms the wall of the sac.
• Amyand Hernia: Has appendix as
content of the sac.
• Maydl’s Hernia: W shaped, has two
loops of bowel.
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