Inguinal and femoral hernia: A hernia is a protusion of a viscus or a part of viscus through and abnormal opening in the walls of its containing cavity. Details of inguinal hernia and few slides on other types of hernia.

1. Inguinal
and
Femoral hernia
Prepared by:
Anish Dhakal
(Aryan)

2. Hernia
A hernia is a protusion of a viscus or a part
of viscus through and abnormal opening in
the walls of its containing cavity

3. Etiology
 Weakness due to structures entering and leaving the
abdomen
 Developmental failures
 Genetic weakness of collagen
 Sharp and blunt trauma
 Ageing & pregnancy
 Primary neurological and muscle diseases
 Excessive intra-abdominal pressure

4. Composition of Hernia
 The Sac :
 Diverticulum of peritoneum
 Has mouth, neck, body and fundus
 The Covering:
 Layers of abdominal wall through which sac passes
 Content:
 Omentum- Omentocele (Epiplocele)
 Intestine- Enterocele
 Urinary bladder or part of the posterior wall of sac- Cystocele
 Ovary with or without fallopian tube
 Meckel’s diverticulum- Littre’s hernia
 A portion of circumference of bowel- Richter’s hernia
 Fluid

5. Classification I
 Reducible
 Irreducible
 Obstructed
 Strangulated
 Inflamed

6. Classification II
 Congenital : Preformed sac defect
 Acquired : secondary to any causes which raise the
intra abdominal pressure

7. Classification III
According to the content
• Omentocele
• Enterocele
• Cystocele
• Littre’s hernia
• Richter’s hernia
• Sliding hernia

8. Classification IV
Based on sites
 Inguinal hernia
 Femoral hernia
 Obturator hernia
 Diaphragmatic hernia
 Lumbar hernia
 Umbilical hernia
 Epigastric hernia

9. Inguinal Hernia

10. Anatomy
 Inguinal region extends between the ASIS to pubic
tubercle
 It’s a region where structures enter and exit the
abdominal cavity
 Most common site

11. Inguinal Canal

13. Contents of inguinal canal
Male Female
Spermatic cord
Testicular Artery, veins &
lymphatic
Vas deferens
Illioinguinal nerve
Iliohypogastric nerve
Genital branch of
genitofemoral nerve
Round ligament of uterus
Illioinguinal nerve
Iliohypogastric nerve
Genital branch of genital
femoral nerve

14. Deep Inguinal Ring
 Is an oval opening in the fascia transversalis
 Lies about ½ inch (1.3cm) above the inguinal
ligament midway between the anterosuperior iliac
spine and the symphysis pubis
 Margins of the ring give attachment to the internal
spermatic fascia

15. Superficial Inguinal Ring
 Is triangular in shape
 Lies in the aponeurosis of the external oblique muscle
 Lies immediately above and medial to the pubic tubercle
 Its margins give attachment to the external spermatic
fascia

16. Classification of Inguinal hernia

17.  According to extent:
 Incomplete:
 Bubonocele- sac within
inguinal canal
 Funicular- sac crosses
superficial inguinal ring,
but does not reach the
bottom of scrotum
 Complete:
 Sac descends to the
bottom of the scrotum

18. Clinical features
 Incidence:
 Male: 25% ; Female: 2%
 Male: Female: 20:1
• Dragging pain and swelling in groin
 Better seen while coughing and standing and felt
together with an expansile impulse
 Usually reducible but can go irreducibility,
inflammation, obstruction, strangulation

19. Internal ring occlusion test:
 Lie the patient
 Reduce the content
 Occlude the internal ring using thumb
 Ask patient to cough
 Direct hernia: swelling medial to thumb
 Indirect hernia: swelling doesn’t appear
• Swelling confirmed on standing position if
swelling appears on releasing thumb and
during coughing

20. Ring invagination test
 Reduce the hernia
 Invaginate little finger from bottom of scrotum,
gradually push up and rotate to enter the superficial
ring
 Ask patient to cough
 Impulse is felt at the tip of the invaginated finger

21. Zieman’s test
 Place index finger on deep inguinal ring and
middle finger on superficial inguinal ring and
ring finger above saphenous opening
 Ask patient to cough
 Indirect hernia: impulse felt on index finger
 Direct hernia: no impulse

23.  Valsalva manuever or head/leg raising test:
• To check the tone of abdominal muscle
wall
 Systemic examination:
• To find out precipitating factors like chronic
bronchitis, ascitis
 Urethral examination:
• To look for urethral strictures, BPH
 Rectal examination

24. Investigations
 No diagnostic test required
 USG
 Contrast radiology herniogram
 Tests relevant for precipitating cause

25. Treatment
 No surgery in case of early, asymptomatic,
direct hernia in elderly
 Surgery:
 Herniotomy
 Herniorraphy
 Hernioplasty

26. Herniotomy
 Removing and closing the sac
Herniorrhaphy
 In adult
 Herniotomy+ strengthening of weakened posterior wall
(shouldice repair or lichtenstein repair)
Hernioplasty
 Herniotomy+ strengthening of posterior wall by putting a
synthetic mesh

27. Laparoscopic repair
1.Totally extra peritoneal approach(TEP)
2.Transabdominal preperitoneal approach(TAPP)
 Aim is to reduce the hernia sac within the
abdomen then place 10*15 cm mesh just deep to
abdominal wall extending across midline into
retropubic space and 5 cm lateral to deep inguinal
ring

28. Open plug /complex mesh repair
 Introduce a finger through deep inguinal ring
 Open preperitoneal space deep to inguinal canal
 Mesh is inserted (two layered)
 Inner – transversalis fascia and outer to it
superficial layer

29. Complications of inguinal hernia
surgery
 Early
• Bleeding (damage to
inferior epigastric or iliac
vessel)
• Urinary retention
• Femoral nerve blockade
(anaesthesia)
• Late
• Seroma formation
and wound infection
over next week
• Hernia recurrence
• Chronic pain
• Testicular artery
damage leading to
testicular infarction
(rare)

30. Femoral Hernia

34. Pathology
 Enters through femoral canal and becomes superficial
through saphenous opening.
 Because of its irregular pathway and narrow neck, it is
more prone for obstruction and strangulation.
 During surgery, precaution should be taken about the
femoral vein and pubic branch of obturator artery (or
accessory obturator artery) which often may get injured
leading to torrential haemorrhage.

35. Clinical features
 Age: rare before puberty
 Sex: common in females (2:1), common in
multiparous.
 20% bilateral however Common on right side
 Swelling in the groin below and lateral to the pubic
tubercle.
 Swelling:
 Impulse on coughing
 Reducible
 Gurgling sound during reduction
 Dragging pain

36. Cont…..
 obstruction and strangulation occurs which is more
common, then features of intestinal obstruction:
painful, tender, inflamed, irreducible swelling
without any impulse.
 They also present with abdominal distension,
vomiting and features of toxicity.
 Often femoral hernia can be associated with
inguinal hernia also.
 40% of femoral hernias present as emergency
hernia with obstruction/strangulation.
 Gaur’s sign: In femoral hernia, distension of
superficial epigastric and/or circumflex iliac veins
occurs due to the pressure by the hernial sac.

37. Diagnosis and Investigations
 Good history and examination
 Below and lateral to the pubic tubercle and lies in
upper leg than in lower abdomen
 May be confused with lymph node
 No investigations required
 USG, CT, plain X-Ray abdomen if features
of bowel obstruction

38. Differential diagnosis
 Inguinal hernia
 Lipoma
 Psoas abscess/ bursa
 Femoral artery aneurysm
 Enlarged femoral lymph nodes

39. Treatment
Surgery:
1. Lockwood-low operation:
Here sac is approached below the inguinal ligament
through groin crease incision (or over the swelling)
so that fundus of sac is dissected by direct vision
and repair is done from below
Here inguinal ligament is sutured to Cooper’s
ligament.

40. 2. Mc’ Evedy-
high operation: an incision is made over the femoral
canal extending vertically above the inguinal
ligament.
-sac is dissected from below, neck from above and
repair is done from above.
- It is done in strangulated femoral hernia.
- 3. Lotheissen’s operation:
It is through inguinal canal approach. Transversalis
fascia is opened and neck of the sac is identified in
femoral ring. Sac is dissected from above, neck is
ligated and repair is done.
Complication: bleeding, hematoma, abscess formation

41. 4. AK Henry’s approach: Repair of bilateral femoral
hernia through lower abdominal incision.
5. Laparoscopic mesh repair
a. Totally extra peritoneal approach(TEP)
b. Transabdominal preperitoneal approach(TAPP)

42. Inguinal hernia Femoral hernia
Relation to
pubic tubercle
Above and medial below and lateral
Three finger test Impulse on index or
middle finger
Impulse on ring
finger
Common in male female
Strangulation Less common More common
Incidence 10 times more
common than femoral
Difference between femoral and inguinal hernia

43. Ventral hernia
 Hernia of anterior abdominal wall.
 Except femoral and abdominal wall.
 Ventral hernia
1. Umbilical
2. Epigastric
3. Incisional
4. Parastomal
5. Spigelian
6. Lumbar
7. Traumatic

44. Umbilical hernia(children)
 Common condition occurring in up to 10% of infants.
 High incidence in premature babies.
 Symptomless at the beginning but gradually in
ceases

45. Umbilical hernia(adults)
 More common in female
 Condition that cause thinning of linea alba.
 Pregnancy, obesity, liver disease
 Defect in linea alba is immediately adjacent to
umbilicus (indistinguishable at surgery) but it is
termed as para-umbilical hernia.

46. Epigastric hernia
 Arise through linea alba anywhere between xiphoid
process and umbilicus.
 Elliptical
 Multiple hernia may be present
 Treatment
1. Very small: spontaneously disappear
2. Moderate: not dangerous
3. Surgery: symptomatic

47. Lumbar hernia
 Mostly through inferior lumbar triangle of petit.
 Rare but is mimicked but incisional hernias arising
through flank incisions.
 Surgery recommended
1. Open
2. Laparoscopic(TAPP is popular)

48. Rare hernias
 Perineal hernia
 Obturator hernia
 Gluteal and sciatic hernia

49. References
1. Norman S. Williams et al, Bailey & love’s Short Practice
of Surgery, 26th edition
2. Das S., A manual of clinical Surgery, 11th Edition
3. Keith L. Moore, Clinically oriented anatomy, 7th edition

50. THANK
YOU