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Examination of Hernia
https://t.me/med1917
Expansile impulse on coughing
• Hernia
• Meningocele
• Laryngocele
• Empyema necessitans
• Intracranially extended dermoid
Boundaries and Anatomy of the
Inguinal Canal
In front: External oblique aponeurosis and conjoined
muscle laterally.
Behind: Inferior epigastric artery, fascia transversalis
and conjoined tendon medially.
Above: Conjoined muscle (Arched fibres of internal
oblique).
Below: Inguinal ligament.
411
symphysis pubis and the anterior superior iliac spine.
Inguinal canal – In infants both superficial and deep
rings are superimposed without any obliquity of the
inguinal canal. In adults it is 3.75 cm long, directed
downwards and medially from the deep to superficial
ring. In males inguinal canal transmits the spermatic
cord, ilioinguinal nerve and genital branch of the
genitofemoral nerve. In females, its content is the round
ligament. Inguinal canal in female is called as canal
of Nuck.
Inguinal defence mechanism: It is the natural
mechanism to maintain the strength of the inguinal
canal. It is by - Obliquity of the inguinal canal; arched
conjoined tendon; shutter mechanism of internal
oblique; ball valve mechanism of the cremaster; slit
valve mechanism of the intercrural fibres of the
superficial inguinal ring.
Superficial inguinal ring is a triangular opening in
the external oblique aponeurosis and is 1.25 cm above
the pubic tubercle. The ring is bounded by a
superomedial and inferolateral crus. Normally the ring
may just admit or may not admit the tip of little finger
(Fig. 17.18). Deep inguinal ring is a U–shaped
condensation of the transversalis fascia, lies 1.25 cm
above the inguinal ligament midway between the
Fig. 17.17: Inguinal hernia left sided in a female. Note
thick labium left side.
Types of Indirect Inguinal Hernia
It can be incomplete wherein sac does not reach to
the bottom of the scrotum. It can be complete wherein
sac descends completely up to the bottom of the
scrotum. Incomplete type can be bubonocele where
hernia limits to inguinal region without passing through
the superficial inguinal ring or can be funicular where
sac reaches up to the level of the upper part of the
testis into the scrotum across the external ring.
80% of inguinal hernia are indirect. Neck of the
sac is lateral to inferior epigastric artery. All hernia
(almost) in children and females are indirect type. After
occluding internal ring content will not descend. It
is commonly congenital occurring in a preformed (preexisting) processus vaginalis. Normally funicular part
of the processus vaginalis gets obliterated. In these
patients it remains patent forcing herniation suddenly
due to some precipitating causes. Commonly sac here
is complete. Acquired indirect sac also can occur (Figs
17.19 to 17.23).
Direct Hernia
It is 15% of all hernias; 50% are bilateral; 35% of
inguinal hernias; uncommon in females; always
acquired due to weak posterior wall of inguinal canal.
It occurs through Hesselbach’ s triangle. It is medial to
inferior epigastric artery; neck is wider; sac is often
thick; medial wall or content may be urinary bladder.
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Fig. 17.18: Anatomy of the inguinal canal. IL—Inguinal
Ligament. SIR—Superficial Inguinal Ring. DIR—Deep
Inguinal Ring. CT—Conjoined Tendon. ASIS—Anterior
Superior Iliac Spine. IEA—Inferior Epigastric Artery.
SRB’s Clinical Surgery
Fig. 17.20: Bubonocele.
Fig. 17.19: Types of indirect inguinal hernia.
(A) Bubonocele, (B) Funicular, (C) Complete.
It is usually reducible; becoming complete by descending into the bottom of the scrotum is rare but can occur.
Hesselbach’s triangle: It is bounded by inferior
epigastric artery laterally, lateral border of rectus
muscle medially and inguinal ligament below . Direct
hernia protrudes out through this triangle. It is divided
into medial and lateral by obliterated umbilical artery
(Figs 17.24A to 17.26).
Fig. 17.21: Incomplete inguinal hernia – funicular type. It
is probably irreducible in this patient.
Differences between enterocele and omentocele
(Figs 17.29 and 17.30)
Enterocele Omentocele (epiplocele)
First part is difficult to First part is easier to
reduce but last part is reduce but last part is
easier. There will be difficult. Has a doughy
gurgling sound on feeling
reduction
Resonant on percussion Dull on percussion
Peristalsis is seen No peristalsis seen
Bowel sounds may be Bowel sounds not heard
heard
Examination of Hernia
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Differences between indirect inguinal and direct inguinal hernias (Figs 17.27 and 17.28)
Indirect inguinal hernia Direct inguinal hernia
Can occur from childhood to adult Common in elderly
Occurs in a pre-existing sac Always acquired
Protrusion through the deep ring; herniation occurs later Herniation through posterior wall of the inguinal canal
Pyriform/oval in shape; descends obliquely and downwards Globular/round in shape; descends directly forwards
as a bulge
Can become complete by descending down into the scrotum Descent down into the scrotum is rare
Neck of the sac is narrow and lateral to inferior Neck of the sac is wide and medial to inferior epigastric
epigastric artery artery
Sac is anterolateral to the cord Sac is posterior to the cord
Ring occlusion test does not show any impulse after Test shows impulse even after occluding the
occluding the deep ring deep ring
Invagination test shows impulse on the Impulse is felt over the pulp of the little finger
tip of the little finger
Zieman’s test shows impulse on the index finger Test shows impulse on the middle finger
Commonly unilateral but can be bilateral Commonly bilateral
Obstruction/strangulation are common Rare but can occur
Sac should be opened during surgery Sac is not necessarily opened unless obstruction is
present
413
Fig. 17.22: Complete inguinal hernia is one where hernia
descends completely into the scrotum.
Differential Diagnoses for Groin
Swelling (Figs 17.31 and 17.32)
Indirect/direct inguinal hernia: Swelling is above and
medial to pubic tubercle; expansile impulse on
coughing; reducibility are the features.
Hydrocele—V aginal/encysted: One can get above the
swelling; absence of expansile impulse on coughing;
fluctuation is positive. Hydrocele of the canal of the
Nuck in females is transilluminant.
Femoral hernia: Swelling is below and lateral to pubic
tubercle with impulse on coughing.
Lipoma of the cord: Swelling in the inguinal canal
without any impulse on coughing. It is often observed
that hernia and lipoma of the cord can coexist and
is identified only on table during surgery.
Inguinal lymphadenopathy: Palpable inguinal nodes
may be of vertical or horizontal group in the inguinal
canal may be due to non-specific causes or filarial
lymphadenitis or secondaries in inguinal nodes primary
being in the limb or perineum or lymphoma.
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SRB’s Clinical Surgery
A
Fig. 17.23: Diagram of indirect inguinal hernial sac.
IL—Inguinal Ligament. SIR—Superficial Inguinal Ring. DIR—Deep Inguinal Ring. ASIS—Anterior Superior Iliac Spine.
IEA—Inferior Epigastric Artery.
Figs 17.24A and B: Direct hernia arises through
Hesselbach’s triangle. IL—Inguinal Ligament. SIR—
Superficial Inguinal Ring. DIR—Deep Inguinal Ring. ASIS—
Anterior Superior Iliac Spine. IEA—Inferior Epigastric Artery.
B
Fig. 17.25: Anatomy of Hesselbach’s triangle. ASIS—
Anterior Superior Iliac Spine. IEA—Inferior Epigastric Artery.
Fig. 17.26: Large bilateral direct hernias. Note, on right side
it has descended into the scrotum to become complete.
Usually direct hernia will not descend into the scrotum but long
standing direct hernia can descend down and become
complete.
Examination of Hernia
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Fig. 17.27: Diagrammatic representations of direct and
indirect sacs.
Fig. 17.28: Bilateral direct hernia. Note the medial location
of the hernia. Direct hernia occurs through Hesselbach’s
triangle.
Groin abscess: Fluctuant smooth, soft, tender, nonmobile swelling in the groin could be an abscess due
to lymph node suppuration. It is often difficult to
differentiate it from strangulated hernia.
Undescended testis: It presents as firm swelling in
the inguinal region; associated commonly with indirect
hernia. Testicular sensation may be elicited. Empty
scrotum is evident. It can be bilateral. Ectopic testis
is also often located in groin.
Fig. 17.29: Irreducible hernia with bowel as well as omentum
as contents. Note the change in color of the bowel.
Fig. 17.30: Hernial sac with small bowel (enterocele) as
content.
Infantile hydrocele: It presents as swelling in the
inguinal region as well as in the scrotum. Impulse on
coughing will be absent as it is not communicating
into the peritoneal cavity.
Parts of Hernia
It consists of neck, body and fundus. Neck is narrow
in indirect sac which is obliquely placed in the inguinal
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Fig. 17.31: Differential diagnosis for groin swellings.
canal (oblique hernia). Neck is wide in direct sac which
is placed posteriorly, medially and directly. Neck is
lateral to inferior epigastric artery in indirect sac;
medial to inferior epigastric artery in direct sac. Sac
is opened in the fundus in indirect sac. Sac is usually
not required to be opened in direct sac unless there
are adhesions (Fig. 17.33).
SRB’s Clinical Surgery
Groin Hernia
Groin hernia occurring through a myopectineal orifice.
It can be indirect inguinal hernia/direct inguinal hernia
or femoral hernia. A hernia is defined as an area of
weakness or disruption of the fibromuscular tissues
of the body wall. Hernia is also often defined as an
actual anatomical weakness or defect. 75% of abdominal wall hernias are groin hernias. 15% of males
and 5% of females will develop groin hernia. Presently
all hernias in groin are grouped as groin hernias.
Fruchaud’s Myopectineal Orifice
It is an osseo-myo-aponeurotic tunnel. It is bounded-
-medially by lateral border of rectus sheath; above
by the arched fibres of internal oblique and transverse
abdominis muscle; laterally by the iliopsoas muscle;
below by the pectin pubis and fascia covering it. It
is through this tunnel all groin hernias occur.
Newer Anatomical Considerations
Preperitoneal space is a potential space in front of
the peritoneum and behind the transversalis fascia and
Fig. 17.32: Bilateral inguinal hernia and right sided femoral
hernia. Femoral hernia is rare in males but can occur.
anterior rectus muscle. Below in front of the urinary
bladder it is called as space of Retzius (medially),
laterally it is called as space of Bogros. Median
umbilical fold is formed by urachus in the midline.
Medial umbilical ligament is formed by obliterated
umbilical arteries. Lateral umbilical fold by inferior
epigastric vessels. Three fossae are lying in relation
to these folds- supravesical and medial fossae are
medial to lateral umbilical fold which are sites of direct
hernia whereas lateral fossa is lateral to lateral
umbilical fold is site of indirect hernia (Fig. 17.34).
In 1956 Fruchaud described his myopectineal
orifice bounded medially by the lateral border of rectus
abdominis, laterally by iliopsoas, superiorly by
conjoined tendon and inferiorly by pectin pubis. This
area is the site of groin hernia which should be covered
by mesh of adequate size to strengthen the defect and
to prevent the recurrence. Iliopubic tract is analogue
of the inguinal ligament extends from Cooper’s
ligament to anterior superior iliac spine which divides
endoscopic view of pre-peritoneal space into superior
compartment (contains inferior epigastric artery,
Hesselbach’s triangle, cord structures and site of
indirect inguinal hernia) and inferior compartment
(contains femoral canal, iliac vessels, iliopsoas muscle,
genitofemoral nerve, lateral femoral cutaneous nerve).
External iliac vessels lie in a triangle formed by gonadal
vessels laterally , vas deferens medially and peritoneal
reflection inferiorly (triangle of doom).
Examination of Hernia
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Aberrant obturator artery which is an occasional
branch of inferior epigastric artery replacing its pubic
branch travels across Cooper’s ligament, which during
fixation of mesh can cause torrential haemorrhage—
circle of death. Triangle of pain is formed by gonadal
vessels medially, iliopubic tract laterally and peritoneal
reflection below. Genitofemoral nerve and lateral
cutaneous nerve of thigh traverse this triangle. Injury
to these nerves either by dissection or by tack (during
laparoscopic hernia r epair) cause postoperative pain.
Tacks/staplers should not be placed in this triangle.
Newer Classifications of Groin Hernias
Gilbert Classification (1987)
Type I: Hernia has got snug internal ring through
which a peritoneal sac passes out as indirect sac.
Type II: Hernia has a moderately enlarged internal
ring which admits one finger but lesser than two finger
breadth. Once reduced it protrudes during coughing
or straining.
Type III: Hernia has got large internal ring with
defect more than two finger breadth. Hernia descends
into the scrotum or with sliding hernia. Once reduced
it immediately protrudes out without any straining.
Type IV: It is direct hernia with large full blow
out of the posterior wall of the inguinal canal. The
internal ring is intact.
Type V: It is a direct hernia protruding out through
punched out hole/defect in the transversalis fascia.
The internal ring is intact.
Type VI: Pantaloon/double hernia.
Type VII: Femoral hernia.
Type VI and VII are Robbin’s modifications.
Nyhus Classification
Type I: Indirect hernia with normal deep ring.
Type II: Indirect hernia with dilated [patulous] deep
ring.
Type III: Posterior wall defect.
a. Direct hernia, sliding hernia.
b. Pantaloon hernia.
c. Femoral hernia.
Type IV: Recurrent hernia.
Bendavid Classification
Type I: Anterolateral defect (indirect).
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Type II: Anteromedial (direct).
Type III: Posteromedial (Femoral).
Type IV: Posterior-prevascular hernia.
Type V: Anteroposterior defect (Inguinofemoral
hernia).
Clinical Classification of Hernia
Reducible hernia: Here contents can be reduced to
abdominal cavity but sac is in position.
Irreducible hernia: Here contents cannot be reduced
to abdominal cavity. It is due to adhesion between
contents/adhesion between content and sac/adhesions
between surfaces of the sac; sliding hernia; large hernia
complete type; narrow neck of the sac acting as a
constricting band preventing reduction of the content.
.Obstructed hernia: Here irreducibility causes occlusion of the lumen of the intestine but bowel remains
viable.
Strangulated hernia: Here irreducibility , obstruction
and compromised blood supply of the bowel occurs.
Initially venous congestion occurs later arterial blood
supply is also compromised causing gangrene of the
bowel. Tender, tense, swelling with toxicity are the
features. Strangulation without obstruction occurs in
Richter’s hernia, omental strangulation.
Inflamed hernia: Here hernial contents being appendix/
Meckel’s diverticulum/fallopian tube are inflamed or
sac itself is inflamed. It is not tense. It is very rare.
Incarcerated hernia: Lumen of the portion of the
intestine usually colon existing in a hernial sac is
blocked with faeces. This scybalous content of the
bowel should be capable of being indented with the
finger like putty. Sac and contents are densely adherent
to each other. It is always irreducible often obstructed
but may not be strangulated.
Classification According to Contents
Omentocele—omemtum.
Enterocele—intestine.
Cystocele—urinary bladder.
Litter’s hernia—Meckel’s diverticulum.
Maydl’s hernia.
Sliding hernia.
Richter’s hernia—part of the bowel wall.
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Precipitating Causes for Inguinal Hernia
SRB’s Clinical Surgery
Smoking; obesity; respiratory causes like bronchial
asthma, tuberculosis, bronchitis; ascites; previous
surgery like appendicectomy (injury to ilioinguinal
nerve) which causes direct inguinal hernia;chronic
constipation due to anorectal strictures; rectal stricture
may be due to chronic proctitis (amoebic), tuberculosis
of anorectum, previous anorectal surgery, rectal
carcinoma or stricture due to lymphogranuloma
venereum; urinary problems like benign prostatic
hyperplasia (BPH), urethral stricture; straining;
multiple pregnancies.
Conservative treatment:
1. Taxis: : Patient lying in supine position, contents is
pushed with one hand directing with other hand, after
flexing hip and knee, and rotating hip internally. It is
not done in obstructed hernia, Maydl’s hernia, femoral
hernia and strangulated hernia.
2. TRUSS: Rat-tailed sprung truss is used. Measurement
is taken from the tip of greater trochanter to third piece
of sacrum. Complications are discomfort, ulceration,
strangulation, inflammation.
It may be used in old people who are not fit for
anaesthesia and surgery (Figs 17.35 and 17.36).
Conservative treatment should be avoided in hernia
as much as possible.
Fig. 17.34: Common and rare sites of hernia.
Recurrence rate after—
Bassini’s repair—10%
Shouldice repair—1%
Hernioplasty—1 to 3%
Other methods—1 to 5%
Fig. 17.33: Parts of hernia—neck, body and fundus.
Recurrent Hernia
Causes: Infection—most common—50%; haematoma
in the wound; early straining; retained indirect sac,
after repair of a direct sac (Pantaloon hernia); smoking,
constipation, obstructive uropathy , old age, nutritional
deficiencies; altered tension in repair site; altered
collagen synthesis.
Types of recurrent hernias: T rue or false recurrence—
based on type of recurrence—whether inguinal
recurrence after inguinal hernia repair (true)/femoral
hernia or obturator or other rare types after inguinal
hernia repair (false). But presently hernia is classified
grossly as groin hernias and so all recurrences are
true recurrences. Clinical features: Swelling, expansile
impulse on coughing, visible scar, reducibility (Fig.
17.37). Examination is like inguinal hernia. It is often
difficult to categorise it as direct or indirect as earlier
surgery has destroyed the true anatomy of the groin.
Often it is classified as medial recurrence or lateral
recurrence. Incidence of re-recurrent hernia after
hernioplasty is 1%.
Incisional Hernia
Incisional hernia is a hernia occurring through a weak
scar. Writing case sheets, taking detailed history is
similar to inguinal hernia.
Examination of Hernia
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Fig. 17.35: Hernia truss. Note the position where sac is
supported. It is not commonly used now as it may precipitate
strangulation.
Additional history to be collected in history of present
illness—Details of surgery patient has undergone
earlier. After how long incisional hernia has occurred?
History of wound infection, wound dehiscence,
whether surgery done was an emergency or elective,
and whether tension sutures was placed or not. History
of pain, irreducibility and details of precipitating factors has to be asked. Other precipitating factors similar
to inguinal hernia like smoking, urinary/respiratory/
abdominal symptoms should be asked (Fig. 17.38).
419
Local Examination (Abdomen)
Inspection
Scar, its extent and location, whether healed primarily
or secondarily , skin over the scar and swelling is noted.
Details of the swelling with expansile impulse on
coughing and examination both in lying down and
standing are done (Figs 17.39A and B).
A
Fig. 17.36: Left sided complete inguinal hernia in a patient
with Benign Prostatic Hyperplasia (BPH) who is on Foley’s
catheter. He needs Trans Urethral Resection of Prostate
(TURP) with hernioplasty.
B
Fig. 17.37: Recurrent hernia left sided.
Note the scar of earlier surgery.
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SRB’s Clinical Surgery
Palpation
Palpation is like for inguinal hernia. Size, extent,
impulse on coughing must be confirmed; scar and skin
should be palpated. The defect in the abdominal wall
must be assessed. It is done after reducing the hernial
content with patient in lying down position. Fingers
are placed horizontally over the hernial defect and
patient is asked to raise the head with arms folded
over the chest (to contract the abdominal wall muscles)
so that the defect is felt clearly. Its size, extent can
be assessed well. Assessment can also be done by
raising the legs instead of head (Figs 17.40 and 17.41).
Gap cannot be assessed in an irreducible hernia.
Fig. 17.38: Lower abdominal incisional hernia
adherent to skin.
Factors Responsible for Development of
Incisional Hernia
V ertical incision has got higher chances of incisional
hernia than horizontal incision; Layered closure of
the abdomen has got higher chance than single layer;
Continuous closure has got higher chances than
interrupted closure; Using of absorbable suture
material has got higher chances of hernia than use
of non-absorbable sutures; Emergency sur gical wound
has higher chances than elective surgical wound;
Laparotomy for peritonitis, acute abdomen, and trauma
Figs 17.39A and B: Large incisional hernia in standing
and lying down position.
can commonly cause incisional hernia; Drainage
through the main laparotomy wound may precipitate
formation of incisional hernia; Chronic cough, smoking, obstructive uropathy, constipation can precipitate
incisional hernia; Diabetes, old age, malnutrition,
malignancy, anaemia, hypoproteinaemia, jaundice,
ascites, liver disease, uraemia, steroid therapy , immunosuppressive diseases are other precipitating factors
(Fig. 17.42).
Fig. 17.40: Defect is assessed by placing fingers
horizontally in incisional hernia.
Type of defects in incisional hernia
Small defect
Large and wide defect
Very large defect
Massive/diffuse
Multiple defects
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