The document discusses the anatomy and types of inguinal hernias. It describes the superficial and deep inguinal rings, differences in infants and adults, and contents that pass through the inguinal canal in males and females. It details characteristics of indirect, direct, sliding, and femoral hernias. Risk factors, signs, and surgical treatment are outlined. Strangulated hernias are also summarized, including contents, risk factors, and management approach.

1. Dr. Ashok Jaisingani

2.  Superficial Inguinal Ring: It is triangular
aperture in the aponeurosis of the external
oblique muscle and lie 1.25 cm above the pubic
tubercle. Normally the ring will not admit the tip of
little finger.
 Deep Inguinal Ring: It is U shape condensation
of transversalis fascia and it lies 1.25 cm above
inguinal (Poupart’s) ligament.
 The transversalis fascia is the fascial envelope of
abdomen and competency of deep inguinal ring
depends on the integrity of this fascia.

3.  Infants: In infants the superficial and deep ring
is almost superimposed and the obliquity of the
canal is slight.
 Adult: In adult the inguinal canal is 3.75 cm is
long is directed downward and medially from the
deep to superficial inguinal ring.
 In male inguinal canal transmit the spermatic
cord, ilioinguinal nerve & genital branch of
genitofemoral nerve.
 In female round ligament replace the spermatic
cord.

4.  Indirect Inguinal hernia is most common hernia of all
especially in young.
 Direct inguinal hernia become more common in the elderly.
 An indirect hernia travels down the canal on the outer
(Lateral & anterior) side of spermatic cord.
 A direct inguinal hernia comes out directly forward through
posterior wall of inguinal canal.
 The neck of indirect inguinal hernia lateral to inferior
epigastric vessels
 The neck of direct inguinal hernia usually emerge medial to
the inferior epigastric vessels except in saddle – bag or
pantaloon type (have both lateral & medial component)

5.  An inguinal hernia can be differentiate from the
femoral by ascertaining the relation of the neck of
the sac to the medial end of the inguinal ligament
& pubic tubercle.
 Inguinal Hernia: The neck lie above and medial
to the medial end of inguinal ligament & pubic
tubercle.
 Femoral Hernia: The neck lie below and lateral
to the medial end of the inguinal ligament & pubic
tubercle.

6.  Indirect inguinal hernia is most common in young
 In first decade of life inguinal hernia is more
common on right side in male, this is associated
with later descent of right testis & higher
incidences of failure of closure of procesus
vaginalis.
 In adult male 65% of inguinal hernias are indirect
and 55% are right – sided
 The hernia is bilateral 12% of the cases

7.  There are three types of indirect inguinal hernia;
 1- Bubonocele: (hernia is limited to inguinal canal)
 2- Funicular: (The processus vaginalis closed just
above the epididymis), the content of sac can be
left separately from the testis (lie below the
hernia)
 3- Complete (scrotal): Rarely present at birth
commonly encounter in infancy. The testis appear
to lie within the lower part of hernia.

8.  The patient is instructed to look at the ceiling and
cough, if the hernia will comes down, the
examiner look and feel for impulse and address
following question.
 Is the hernia right, left or bilateral?
 Is it an inguinal or femoral hernia?
 Is it a direct or indirect inguinal hernia?
 Is it reducible or irreducible hernia?
 Is the inguinal hernia is complete or incomplete?
 Looks for contents.

9.  Indirect inguinal hernia is 20 times more common in males than
females.
 The patient complain the pain in groin or pain refer to testis
when perform the work or strenuous exercise.
 On coughing a small transitient bulging is seen and feel together
with expansile impulse.
 When the sac is limited to inguinal canal, the bulge may be
better seen by observing the inguinal region from side or looking
down to abdominal wall.
 An indirect inguinal hernia on coughing comes down and persist
until it is reduced
 In large hernias there is sensation of the dragging & weight on
mesentery, may produce epigastric pain.
 The indirect inguinal hernia is “translucent” in infancy and early
childhood but never in adult hood

10.  Vaginal Hydrocele
 Encysted hydrocele of cord
 Spermatocele
 Femoral hernia
 Incomplete descended testis in inguinal canal
 Lipoma of the cord

11.  Hydrocele of the canal of Nuck
 Femoral Hernia

12.  Surgery is the treatment of the choice
 Surgery is either open or laparoscopic
 Truss is used when the operation is
contraindicated or when operation is refused.

13.  It is consist of
1- Excision of hernial sac
2- Repair of transversalis fascia and internal ring
3- Further reinforcement of posterior wall of
inguinal canal.

14.  In adult male 35% of inguinal hernias are direct
 At presentation 12% of patients will have
contralateral hernia, and there is four fold increase
in risk of contra-lateral hernia.
 A direct inguinal hernia is always acquired, the sac
passes through a weakness or defect of
transversalis fascia in posterior wall of inguinal
canal.
 Women practically never develop direct inguinal
hernia (Brown).

15.  Smoking
 Occupation that involve straining and heavy lifting
 Damage to illioinguinal nerve (Previous
appendicectomy) is another cause

16.  Direct hernia do not often attain a large size or
descend into scrotum
 In contrast to indirect inguinal hernia, direct
inguinal hernia lies behind the spermatic cord
 The sac is often smaller than mass, the protruding
mass consist of the extra-peritoneal fat.
 As the neck of sac is wide, the direct inguinal
hernias do not strangulate or strangulate rarely.

17.  This is narrow necked hernia with prevesical fat
and portion of bladder that occur through a small
oval defect in the medial part of conjoined tendon
just above the pubic tubercle.
 It occurs principally in elderly
 Occasionally it become strangulated
 Operation should always be advised until there is
definite contraindication.

18.  This type of hernia consist of two sac that straddle
the inferior epigastric artery,
 One sac being medial and other one lateral to this
vessel.
 This condition is not rare & is cause of recurrence

19.  Strangulation of inguinal hernia occurs at any time
during life, occurs in both sex equally.
 Indirect inguinal hernia strangulate more
commonly, but not so often direct variety because
of wide neck of sac.
 More often the strangulation occurs in pts who
have worn truss for long time & those with
partially reducible or irreducible hernias.

20.  The Neck Of Sac
 The External Inguinal Ring In Children
 Adhesion Within Sac

21.  Usually the small intestine is involved in
strangulation with next most common that
involved in strangulation is omentum.
 It is rare the large intestine to become
strangulated, even when the hernia is of sliding
type.

22.  The incidences of strangulation during infancy is
4% (Gross).
 The ratio of girls to boy is 5:1
 More frequently the hernia is irreducible but not
strangulated.
 Most cases of strangulated inguinal hernias occurs
in females infants and contents will be ovary or
ovary plus fallopian tube.

23.  Resuscitation with adequate fluids
 Empty stomach with nasogastric tube
 Give antibiotic to contain infection
 Catheterize to monitor hemodynamic state
 Operation:
 Inguinal herniotomy for strangulation

24.  These are indicated only in infants, the child is
given analgesics & placed in gallow’s traction.
 In 75% of the cases the reduction is effected and
there appear to be no danger of gangrenous
intestine
 Forcible reduction must be avoided & should not
be attempted.

25.  It is rare type of the hernia.
 The strangulated loop of W within abdomen, so
local tenderness over the hernia is not marked.
 At operation two – comparatively normal looking
loop of intestine are present in the sac.
 The strangulated loop will become apparent if
traction is exerted on the middle of the loops
occupying the sac.

26.  It result from slipping of posterior parietal
peritoneum on the underlying retroperitoneal
structure.
 The posterior wall of the sac formed by sigmoid
colon, mesentery on left, caecum on right & some
time by either side portion of bladder.
 Mostly sac consist of caecum, appendix or the
portion of the colon.
 A small bowl sliding hernia occurs approx. 1 in
2000 cases
 The sac-less hernia occurs 1 in 8000 cases

27.  A sliding hernia occurs almost exclusively in men
 Five out of six sliding hernias are situated on the
left sides
 Bilateral sliding hernias are rare
 The patient is nearly over the 40 year of age
 It should be suspected in very large globular
inguinal hernia descending well into the scrotum.
 Occasionally the large intestine strangulated in
sliding hernia, more often non – strangulated
large intestine large intestine is present behind the
sac