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Examination of Hernia
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Examination of
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17
Hernia is an important clinical topic for undergraduates
as well as postgraduate students in surgery . It is a long
case for undergraduate students and a short case for
postgraduate students in surgery . It is one of the commonest surgical entities that surgeons come across and
so detail knowledge of the subject is mandatory to both
undergraduates and postgraduates. W riting a case sheet
for hernia is important as a long case. Hernia means
- ‘to bud’ or ‘to protrude’ in Greek; ‘to rupture’ in Latin.
Hernia is protrusion of entire or part of the viscus
through the wall that contains it. Herniation can occur
from any cavities or through any defects, congenital
or acquired. Inguinal, femoral, umbilical, incisional
and epigastric are common hernias; obturator, gluteal,
lumbar or Spigelian are rare hernias. Inguinal hernia
is the commonest abdominal hernia. It occurs through
inguinal canal. Indirect hernia comes through deep
ring along the cord; direct from posterior wall of
inguinal canal. Usually indirect hernia is of congenital
origin, occurs in a preexisting processus vaginalis sac
but often revealed later by some precipitating factors
whereas direct hernia is always acquired due to weakening of posterior wall of the inguinal canal. Inguinal
hernia initially is incomplete but becomes complete
once it descends up to the bottom of the scrotum.
History taking begins with:
Name:
Age:
Sex:
Occupation:
Elderly people are more prone for hernia. Men with
strain full occupation like manual labourers, sportsmen,
weight lifters, etc. are more prone for hernia. Indirect
hernia occurs in young; direct hernia occurs in old.
Strenuous workers; gymnastics; sportsmen; weight
lifters may develop hernia due to straining.
Hernia
Chief Complaints
Swelling in the groin, right or left or both sided—
durations; or swelling in right/left/both inguinoscrotal
region for— durations.
Pain over the swelling for—durations.
History
History of Present Illness
Swelling: Duration of the swelling; mode of onset
of the swelling –spontaneous or on straining should
be asked. Site of first appearance of the swelling—
in the groin or in the scrotum should be asked. Inguinal
hernia begins in groin whereas hydrocele is purely
scrotal begins in scrotum. Femoral hernia begins below
the groin crease line. Progress and extent of the
swelling, whether it only limits to the groin or extends
down to the scrotum; or any changes in the size and
extent of the swelling on standing/walking/straining/
lying down should be asked. Whether swelling is
reducible on lying down/partially reducible or
irreducible on lying down or needs any manoeuvre
to reduce it should be also asked. History of gurgling
sound in the scrotum signifies enterocele. In irreducible
swelling one should be asked for the history of pain,
any abdominal distension/vomiting.
Pain: Site of pain—whether it is in the groin or in
the scrotum; duration of pain; severity of the pain;
type of pain—dull aching or severe pricking type;
aggravating or relieving factors should be asked. Pain
may be aggravated on straining/walking/weight lifting;
relieved on lying down. Patient with hernia often may
feel dragging or aching pain in the groin more after
straining prior to development of swelling in the groin.
Pain in an existing hernia may be due to drag on
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omentum, mesentery, adhesions, inflammation, obstruction or strangulation. Obstruction causes distension
and vomiting. Strangulation causes severe tenderness
and toxicity.
History relevant to precipitating factors: Chronic
cough, tuberculosis, bronchial asthma or other respiratory diseases; constipation, altered bowel habits,
tenesmus, bloody stool—in relation to anorectal stricture/carcinoma; dysuria/urgency/hesitancy/altered
stream/night frequency/retention of urine/burning
urine/haematuria—in relation to benign prostatic
hyperplasia/urethral stricture.
History suggestive of complications: Irreducibility,
severe pain in the groin over the swelling and also
colicky abdominal pain, abdominal distension, vomiting, and constipation should be asked.
Past History
Past history of hernia surgery—same side/opposite
side. Type of surgery whether mesh used or repair
done. History of appendicectomy done earlier
(ilioinguinal nerve may be injured causing direct
hernia) and if so details about the surgery (can cause
right sided direct hernia). Past history suggestive of
irreducibility/obstruction and treatment received for
that whether conservative/surgical should be asked.
Personal History
History of smoking—duration, number per day,
whether beedi or cigarette should be asked. History
of pan chewing/alcohol intake; appetite and altered
weight should be asked.
SRB’s Clinical Surgery
General Examination
Examination is done for general built and nutritional—
status, pallor, clubbing, cyanosis, jaundice, lymphadenopathy , and oedema feet. Pulse and blood pressure
is recorded.
Local Examination
Inguinoscrotal r egion should be examined in standing
position as swelling commonly reduces and disappears
in lying down position. Area from umbilicus to mid-
thigh region should be exposed after taking consent
for examination (Fig. 17.1).
Fig. 17.1: All hernias should be inspected
initially on standing.
Inspection
Inspection is done always first in standing straight
up without bending later in lying down position.
Inspection in standing position
Side of the swelling should be observed and mentioned.
Extent of the swelling is important. Incomplete indirect
inguinal hernia and usually direct inguinal hernias are
located in inguinal region. Complete indirect inguinal
hernia (rarely complete direct inguinal hernia) is
inguinoscrotal—extending down into the bottom of
the scrotum (Fig. 17.4). Swelling extends from the
proximal part of the inguinal canal towards the scrotum
below . Both transverse and vertical dimensions of the
size should be mentioned. Shape of the swelling is
pyriform in indirect inguinal hernia and globular/
hemispherical in direct inguinal hernia or femoral
hernia.
Expansile impulse on coughing over the swelling is
diagnostic. It is better seen than felt. While patient
is in standing position, and examiner sits beside the
Examination of Hernia
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A
Figs 17.2A and B: Expansile impulse on coughing is better
seen than felt. It should be inspected with patient standing
and examiner sitting beside the patient.
B
patient and is asked to turn his face to opposite side
(to prevent coughing towards examiner) and cough.
Expansile impulse is visible in the groin area; or an
already existing swelling will become much more
prominent as the intestines or omentum (contents) gets
driven into the hernial sac. Often swelling appears
only during the act of coughing and disappears later.
Absence of expansile impulse does not rule out the
possibility of hernia (Figs 17.2A and B).
Surface—Smooth/uneven; Margin—well-defined/illdefined; Visible peristalsis over the swelling should
be noted if present (should not be mistaken for dartos
muscle contraction). It means it could be enterocele.
Scar/dilated veins/discolouration/redness over the
swelling should be noted. On inspection, whether testis
is seen separately from the swelling or covered by
the swelling all over should be noted.
Skin over the swelling is usually normal. Scar of
recurrent hernia may be evident. Type of scar, linear
or wide; healed by primary or secondary intention
should be assessed. Infected wound causes wide deep
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puckered scar which may be the cause for recurrence.
Skin may be stretched. Atrophy of skin can occur.
In strangulated hernia skin may be oedematous and
red. W earing hernia truss may cause haemosiderin laid
brown pigmentation of skin. Occasionally strangulated
hernia may cause ulceration due to skin necrosis.
The features of hernia
• Expansile impulse on coughing
• Reducibility of the content on lying down or by direct
pressure.
Note: These two features may be absent once hernia
is strangulated.
Palpation
Temperature and tenderness over the swelling (in
strangulated/inflamed hernia) is noted.
Whether it is possible to get above the swelling
or not—one can get above purely scrotal swelling but
not in inguinoscrotal swelling. It is checked in standing
position.
Position and extent of the swelling; Size in vertical
and transverse directions; Margin well defined or ill
defined; Surface smooth/lobular/tense; Consistency—
soft and elastic in enterocele; doughy in omentocele
(epiplocele) should be noted.
Location of the swelling—swelling is above and medial
to pubic tubercle in inguinal hernia and below and
lateral to pubic tubercle in femoral hernia. Pubic
tubercle may be reached by following the tendon of
adductor longus. In obese patients often it may be
difficult to differentiate between inguinal and femoral
hernia. Occasionally femoral hernia may ascend
upwards from saphenous opening superficial to
inguinal ligament to present as swelling in inguinal
region which is invariably irreducible.
Reducibility of the swelling is checked by different
methods. Whether it reduces spontaneously while lying
down (usually direct hernia) and gets reduced
completely or partially should be checked. Patient
himself reduces the content easily if asked. In
enterocele it is difficult to reduce the first part but
last part gets reduced easily . In omentocele it is difficult
to reduce the last part but first part gets reduced easily.
Whether swelling needs any manipulation to get
reduced like taxis is to be noted. Taxis is gradual
reduction of contents of the scrotum by gentle
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Fig. 17.3: Inguinal hernia is reduced in lying down position;
done by elevating the scrotum and flexing and rotating the
hip—taxis.
SRB’s Clinical Surgery
manipulation by flexion, adduction and rotation of
hip joint. This maneuver relaxes the superficial ring
and oblique abdominal muscles (Fig. 17.3). Fundus
of the sac is held with one hand and contents are gently
squeezed towards the abdomen and other hand guides
the content across superficial inguinal ring.
Expansile impulse on coughing also should be
checked during palpation in standing position. After
complete reduction of the contents of the swelling,
either by placing finger on superficial ring or by holding
the root of the scrotum between index and thumb,
patient is asked to cough to feel expansile impulse
on coughing. Fingers may get separated allowing
contents to force down. Impulse will be absent in
strangulated hernia, incarcerated hernia, in presence
of adhesions blocking the entrance of sac.
Fig. 17.4: Giant hernia. Note that bottom of the hernia in
the scrotum is below the level of middle of the thigh (scrotal
abdomen). Note also the burial of penis. Such patient is
difficult to manage as often the contents cannot be reduced
completely into the abdomen cavity during surgery as
peritoneal cavity is reduced in size; if done forcibly it results
in abdominal compartment syndrome with IVC compression
and diaphragmatic elevation.
Zieman’ s test is done to find out over which finger cough
impulse is felt and so which type of hernia it could be—
whether femoral/direct inguinal or indirect inguinal.
Deep ring occlusion test: When deep ring is occluded
after reducing the contents, if impulse on coughing
is absent in standing position then it is indirect inguinal
hernia; if impulse on coughing is still present then
it is direct inguinal hernia.
Finger invagination test: Size of the superficial ring
is noted and site of the impulse felt is observed whether
it is in the tip of the finger or on the pulp.
Palpation of testis, epididymis and spermatic cord
should be done without fail. Relation of swelling to
testis also should be noted.
Opposite inguinal region, opposite testis, epididymis and spermatic cord should be examined. Presence
or absence of impulse on coughing on opposite side
should be mentioned.
Bulbar urethra is palpated by lifting the scrotum
and feeling in the midline (T o look for thickening and
button-like depression—a feature of stricture urethra)
(Fig. 17.5).
Examination of Hernia
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Fig. 17.5: Bulbar urethra should be palpated by raising the
scrotum in midline posteriorly. Any stricture urethra is
felt as thickening/button-like depression. Gonococcal
urethritis and trauma are the commonest causes of stricture
urethra. Bulbar urethra is the commonest site of stricture
urethra.
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Percussion
Without reducing contents of the swelling, percussion
is done over the surface. If it is resonant, it is enterocele.
If it is dull on percussion then it is omentocele.
Auscultation
Bowel sounds may be heard over the swelling if it
is enterocele.
Per Abdomen Examination
Abdominal muscle tone should be checked by shoulder
and head raising test, leg raising test and Valsalva
maneuver. It should be inspected for Malgaigne
bulging and should be palpated to check whether the
tone is adequate (firm) or inadequate (supple).
Any scar over the abdomen (appendicectomy scar
may cause right sided direct inguinal hernia); ascites
or mass per abdomen should be mentioned (Figs 17.6A
to C).
A
Figs 17.6A to C: Head and shoulder raising and Valsalva manoeuvre tests are needed to
B
C
check the tone of abdominal muscle in hernia.
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Digital Examination of the Rectum (P/R)
SRB’s Clinical Surgery
Rectal examination is done in all hernia cases to look
for prostate enlargement in elderly and rectal/anorectal
strictures. Causes of rectal stricture are – recurrent
proctitis, ulcerative colitis, carcinoma, previous anal
surgery, LGV induced proctitis, tuberculosis, etc . (Figs
17.7 and 17.8).
Fig. 17.7: Clinically per-rectal examination is a must in
hernia to look for prostate enlargement, and rectal stricture
which are precipitating factors.
Fig. 17.9: Respiratory system should be examined to find
out the precipitating causes for hernia like bronchitis,
tuberculosis or asthma.
Fig. 17.8: Inguinal hernia in a patient who is having benign
prostatic hyperplasia (BPH) with Foley’s urinary catheter
inserted. He is also having paraphimosis and so not able to
replace back the retracted prepuce after catheterisation.
Examination of Respiratory System
Respiratory system is examined for altered breath
sounds (rhonchi, bronchial breathing), effusion, etc.
to find out any precipitating causes like tuberculosis,
bronchitis, asthma, bronchiectasis (Fig. 17.9).
Other Systems
Cardiovascular system, nervous system including spine
and cranium are examined for any neurological problems before management of hernia.
Investigations
All case sheets for long case should mention the
investigations required for that particular case.
Relevant investigations required for inguinal hernia
are chest X-ray, haematocrit, blood sugar, serum
creatinine, ultrasound abdomen depending on the age/
suspected cause for the hernia. Chest X-ray is done
to look for bronchitis, tuberculosis, bronchiectasis.
US abdomen is done to look for benign prostatic
hyperplasia, residual urine, ascites, and mass lesion.
Note: Presentation of the case should be in order as
mentioned above. One cannot alter the order of
presentation like presenting percussion first and later
palpation or likewise in a haphazard manner. S tudents
should strictly follow the proper order of presentation
in clinical methods.
Why clinically it is called inguinal hernia?
Patient presents with a swelling in the groin, which
has gradually increased in size, often descends into
the scrotum and gets reduced on lying down. It increases
on straining, coughing or walking. Expansile impulse
on coughing is present and reduces on lying down
or by taxis.
Examination of Hernia
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Why it is indirect inguinal hernia?
It is pyriform in shape. It descends obliquely in the
groin. On occluding the internal ring in ring occlusion
test, swelling does not appear later on coughing. On
ring invagination test, impulse is felt at the tip of the
invaginating finger . Zieman’s test confirms the impulse
over the index finger.
If it is direct inguinal hernia what are the differentiating features?
Direct inguinal hernia is globular in shape. After
occluding the deep ring, swelling still appears on the
medial side of the inguinal region on coughing. Impulse
is felt on the pulp of the finger in invagination test
and over the middle finger in Zieman’s test.
How expansile impulse on coughing is clinically
demonstrated?
Expansile impulse on coughing is seen on inspection
when patient is asked to cough. Expansile impulse
on coughing is also felt by placing the thumb in front,
middle and index fingers behind the root of the scrotum
and asking the patient to cough.
407
A
When in a hernia impulse on coughing will not be
present?
Strangulated hernia will not show impulse on coughing.
What is the meaning of ‘get above the swelling’?
Root of the scrotum is held between the thumb in front,
index and middle fingers behind. In purely scrotal
swelling like vaginal hydrocele, fingers and thumb
can be approximated well without any additional
structures other than cord in between (one can get
above the swelling). In case of inguinoscrotal swelling
thumb and fingers do not meet each other properly
because of the descent of hernial contents down (one
cannot get above the swelling). It occurs in funicular
and complete type of inguinal hernia but not in
bubonocele (Figs 17.10A and B).
What is ring occlusion test?
It is the most important test in inguinal hernia. It is
performed in standing position. Deep/internal ring is
located 1.25 cm above the mid-inguinal point. Midinguinal point is mid-point between the anterior
superior iliac spine and pubic symphysis (Note: Mid-
point of the inguinal ligament is centre point between
anterior superior iliac spine and pubic tubercle). Patient
B
Figs 17.10A and B: In inguinoscrotal swelling one cannot
get above the swelling. In scrotal swelling one can get above
the swelling. It is convenient and easier to use left hand
for right side inguinoscrotal / scrotal swelling and right hand
for left side to check the ‘get above the swelling’ eventhough
any hand can be used.
is asked to lie down to reduce the hernial contents.
Thumb is placed over the mid-inguinal point. Patient
is asked to cough. If there is expansile impulse on
coughing on the medial side of the thumb, even after
deep ring occlusion, it is then direct inguinal hernia.
If there is no impulse on coughing then patient is asked
to stand with thumb occluding the deep ring. Patient
is once again asked to cough; impulse on the medial
side of the occluded thumb is looked for to rule out
the direct inguinal hernia. If there is no impulse even
on standing, it is indirect inguinal hernia. The occluded
thumb is removed and patient is asked to cough to
show the swelling and impulse due to indirect inguinal
hernia (Figs 17.11A and B).
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A
B
SRB’s Clinical Surgery
A
What is the prerequisite for ring occlusion test?
Hernia should be reduced completely prior to do deep
ring occlusion test. One cannot do deep ring occlusion
test/invagination test/Zieman’s test if hernia is irreducible.
How is finger invagination test done?
Patient is asked to lie down. Contents are reduced
completely. Using the little finger, scrotal skin is
invaginated from below upwards near upper part of
the testis. Finger is reached towards the superficial
inguinal ring/external ring. Normally external ring does
not admit the tip of the little finger. Finger is rotated
inwards so that nail is towards the cord side and pulp
is towards the ring. Right hand is used for right side
and left hand for left side. Patient is asked to cough.
If the impulse is felt on the tip of the finger, then it
is indirect inguinal hernia. If impulse is felt on the
pulp then it is direct inguinal hernia. In case of complete
inguinal hernia or funicular hernia external ring
is patulous which can be very well assessed by
B
Figs17.11A and B: Ring occlusion test is done to find out
whether hernia is direct or indirect. If after occluding the
ring swelling appears on the medial side, it is direct hernia.
If swelling does not appear on occlusion and coughing it is
invagination test. Index finger can also be used for
indirect hernia.
the test. In direct hernia finger goes directly; in indirect
hernia finger goes upwards and outwards. One should
also remember that patulous wider ring does not mean
that patient should always have hernia (Figs 17.12A
and B).
Invagination test should be done very gently,
otherwise it will be very painful. It cannot be done
in children.
Silk glove sign: Index finger is invaginated across
scrotum towards the external ring. When patient
coughs, inguinal hernia is felt as a slit-like sensation.
How is Zieman’s test done?
The hernial contents are reduced. Index finger is placed
over the deep ring. Middle finger is placed over the
superficial ring and ring finger over the saphenous
opening. Patient is asked to cough.
Examination of Hernia
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409
A
Figs 17.12A and B: Little finger is used to do invagination test.
Figs 17.13A and B: Zieman’s test—done on both sides.
Three fingers are used to do Zieman’s test.
If impulse touches (Figs 17.13A and B and 17.14):
• Index finger it is—indirect inguinal hernia.
• Middle finger it is—direct inguinal hernia.
• Ring finger it is—femoral hernia.
Testing Inguinal Hernia in Children
Fullness is seen over the groin when compared to
opposite side is seen. In difficult small hernia, child
is made to cry or jolt or jump, later superficial ring
is palpated to feel the cord which will be thicker than
opposite side. Rolling the contents of the inguinal canal
by finger will give the sensation of finger of a rubber
glove which is wet inside (Fig. 17.15).
Gornall’ s test—Child is held from back to place both
hands in front over the abdomen which is pressed with
B
Fig. 17.14: Anatomical location of indirect, direct and
femoral hernias.
fingers and child is lifted up. This raises the intraabdominal pressure to make hernia more prominent
(Fig. 17.16).
Inguinal Hernia in Females
Hernia in females is rare. Inguinal hernia is commonest
type of hernia in females. Femoral hernia is common
in females. Expansile impulse on coughing is
diagnostic. Invagination test is not possible in females.
Palpation of labium majus demonstrates thickness
compared to opposite side indicating hernia in canal
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Fig. 17.15: Right sided hernia in a child. Only herniotomy
is done for inguinal hernia in children. Repair/mesh are not
used. Herniotomy is also done for hydrocele in children
of Nuck. Patient should be properly examined in
through inguinal approach. Hydrocele in children is due to
patent processus vaginalis.
standing position otherwise hernia is more likely to
SRB’s Clinical Surgery
be missed. Reducible inguinal hernia is obvious by
its clinical features. But femoral hernia needs to be
differentiated by its definitive anatomical location.
Differential diagnosis for irreducible inguinal hernia
in females—A hydrocele of canal of Nuck is smooth,
fixed, fluctuant and brilliantly transilluminant swelling.
Bartholin cyst is confined to labium majus; one can
get above the swelling; it does not extend to superficial
inguinal ring; it is not transilluminant (Fig. 17.17).
Groin abscess is smooth, soft, fluctuant and tender;
but it is often difficult to differentiate it from strangulated hernia. Associated abdominal symptoms favors
strangulated inguinal hernia.
How inguinal hernia is differentiated from femoral
hernia?
Inguinal hernia is above and medial to the pubic
tubercle. Femoral hernia is below and lateral to the
pubic tubercle.
Fig. 17.16: Gornall’s test.
What is taxis?
Taxis (taxis means arrangement) is a method used to
reduce a complete inguinal hernia. Hip and knee are
flexed and thigh is adducted. One hand is held near
the fundus of the sac in the bottom of the scrotum,
other hand placed adjacent to external ring, and
contents are gently reduced towards the proximal side.
Often patient can himself do this technique in a better
way. It is contraindicated in obstructed/strangulated
hernia or femoral hernia or Maydl’s hernia. Taxis
should be done very gently.
How is tone of abdominal muscle checked and why?
Abdominal muscle tone is checked by head and
shoulder rising (without supporting the elbows) or leg
rising tests. It is initially inspected for any bulges in the
abdominal wall which signifies Malgaigne bulgings.
Later abdomen should also be palpated for muscle tone.
Firmness signifies adequate tone whereas suppleness
signifies poor muscle tone. Poor muscle tone indicates
that patient needs hernioplasty using mesh. Abdominal
muscle tone is also checked by Valsalva maneuver.
‘Use five fingers of the hand to complete all tests
for hernia’.
• Thumb—for deep ring occlusion test.
• Index, middle and ring fingers for Zieman’s test.
• Little finger for superficial ring invagination test.
Rules of hernia examination
• Never forget to check expansile impulse on coughing
and reducibility.
• Never forget to examine opposite side.
• Never forget to do per-rectal examination.
• Never forget to examine bulbar urethra.
• Never forget to check abdominal muscle tone.
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