Name: Emanuel Charles Coates

Registration #: 2018010033

Topic: Case Inguinal Hernia

CASE: INGUINAL HERNIA

A 36-year-old man presents with a 1-day history of right groin pain. The patient indicates
that the pain developed during a tennis match the previous evening and on returning
home he noticed swelling in the area. His past medical history is unremarkable. The
patient denies any history of medical problems or similar complaints. He has not
undergone any previous operations. The physical examination reveals a well-nourished
man. The results from the cardiopulmonary examination are unremarkable, and the
abdominal examination reveals a non-distended, Non-tender abdomen. Auscultation of
the abdomen reveals normal bowel sounds.

Examination of the right inguinal region reveals no inguinal mass. There is a 3-cm non-
erythematous swelling on the medial thigh just below the right inguinal ligament.
Palpation reveals localized tenderness. The lower extremities are otherwise
unremarkable.

Laboratory findings reveal a WBC count of 6500/mm3 and normal hemoglobin and
hematocrit levels. Electrolyte concentrations are within the normal range as are the
results from a urinalysis. Radiographs of the abdomen demonstrate no abnormalities.

Learning Objectives (Anatomy)

1. Enumerate and identify various layers of anterior abdominal wall.

2. Define Hernia.
3. Differentiate between various types of inguinal hernia.
4. Explain the coverings of direct and indirect inguinal hernia.
5. Differentiate between medial and lateral direct inguinal hernia.
6. Recognize the anatomic landmarks of the different types of hernias.
7. Know the presentations of inguinal, femoral, and umbilical hernias.
8. What are the complications associated with inguinal hernias.
9. Explain strangulated vs incarcerated hernias.
 1. Enumerate and identify various layers of anterior abdominal wall.
The abdominal wall covers a large area. It is bounded superiorly by the xiphoid process
and costal margins, posteriorly by the vertebral column, and inferiorly by the upper
parts of the pelvic bones.
Its layers consist of skin, superficial fascia (subcutaneous tissue), muscles and their
associated deep fascia’s, extraperitoneal fascia, and parietal peritoneum.
• Skin: - The skin is loosely attached to the underlying structures except at the
umbilicus, where it is tethered to the scar tissue.
• Superficial Fascia: - It is a layer of fatty connective tissue. It is usually a single
layer similar to, and continuous with, the superficial fascia throughout other
regions of the body This layer is divided into two layers below the umbilicus:
➢ Superficial fatty layer (fascia of Camper), it is continuous over the inguinal
ligament with the superficial fascia of the thigh and with a similar layer in
the perineum.
➢ Deep membranous layer (Scarpa’s fascia) is thin and membranous and
contains little or no fat.
• Muscles: - The muscles of the anterolateral abdominal wall consist of three
broad thin sheets that are aponeurotic in front; from exterior to interior they are
the external oblique, internal oblique, and transversus. On either side of the
midline anteriorly is, in addition, a wide vertical muscle, the rectus abdominis.
• Transversalis fascia: - Is a membranous sheet of various thickness that lines the
internal aspect of the abdominal wall, deep surface of the transversus
abdominus.
• Extraperitoneal Fat: - The extraperitoneal fat is a thin layer of connective tissue
that contains a variable amount of fat and lies between the fascia transversalis
and the parietal peritoneum.
• Parietal Peritoneum: - This is a thin serous membrane that line innermost wall
of the abdomen and is continuous below with the parietal peritoneum lining the
pelvis.
 2. Define Hernia.
A hernia is the protrusion of part of the abdominal contents beyond the normal confines
of the abdominal wall. It consists of three parts: the sac, the contents of the sac, and the
coverings of the sac. The hernial sac is a pouch (diverticulum) of peritoneum and has a
neck and a body. The hernial contents may consist of any structure found within the
abdominal cavity and may vary from a small piece of omentum to a large viscus such as
the kidney. The hernial coverings are formed from the layers of the abdominal wall
through which the hernial sac passes.

3. Differentiate between various types of inguinal hernia.

An inguinal hernia is the protrusion or passage of a peritoneal sac, with or without
abdominal contents, through a weakened part of the abdominal wall in the groin. It
occurs because the peritoneal sac enters the inguinal canal either:

Direct Inguinal Hernia

A peritoneal sac that enters the medial end of the inguinal canal directly through the
weakest part of the abdominal wall (Hesselbach triangle) is a direct inguinal hernia. It
is usually described as acquired because it develops when abdominal musculature has
been weakened and is commonly seen in mature men.

Direct Inguinal Hernia main points

• Less common hernia.
• Takes place commonly at the medial
inguinal fossa.
• It is common in old men with weak
abdominal muscles and is rare in
women.
• Does not traverse the entire inguinal
canal.
• The hernial sac bulges forward
through the posterior wall of the
inguinal canal medial to the inferior
epigastric vessels.
• The neck of the hernial sac is wide.
• Not commonly obstructed.
• Covered by transversalis fascia.
• Comes out on standing.
• Herniation travels oblique.
• Internal ring occlusion test is seen.
Indirect Inguinal Hernia
The indirect inguinal hernia is the most common of the two types of inguinal hernias
and is much more common in men than in women. It usually occurs because some part,
or all, of the embryonic processus vaginalis remains open or patent. It is therefore
referred to as being congenital in origin. The protruding peritoneal sac enters the
inguinal canal by passing through the deep inguinal ring, just lateral to the inferior
epigastric vessels. The extent of its excursion down the inguinal canal depends on the
amount of processus vaginalis that remains patent. Thus, Indirect inguinal hernia can be
divided into acquired and congenital.
➢ Congenital indirect inguinal hernia: - It occurs due to patent processus vaginalis
(an outpouching of the peritoneum), connecting peritoneal cavity with the tunica
vaginalis.
➢ Acquired indirect inguinal hernia: - It occurs due to increased intra-abdominal
pressure as during weightlifting. When intra-abdominal pressure is increased
immensely, the abdominal contents are pushed through the deep inguinal ring
into the inguinal canal

Indirect Inguinal Hernia main points

• Most common hernia.
• Takes place at the lateral inguinal
fossa.
• The hernial sac enters the inguinal
canal through the deep inguinal ring
and lateral to the inferior epigastric
vessels.
• The neck of the hernial sac is narrow.
• Commonly obstructed.
• Traverse the inguinal Canal.
• The hernial sac may extend through
the superficial inguinal ring above and
medial to the pubic tubercle. (Femoral
hernia is located below and lateral to
the pubic tubercle.)
• The hernial sac may extend down into
the scrotum or labium majus.
• It is much more common in males than
females
• It is most common in children and
young adults.
• Does not comes out on standing
• Herniation travels straight
• Internal ring occlusion test is not
seen.
Internal ring occlusion test is done after reducing the hernia, the pressure is applied
over deep inguinal ring and patient is asked to cough. If hernia does not appear, it is
indirect, and if hernia appears, it is direct.
 4. Explain the coverings of direct and indirect inguinal hernia.
In an indirect inguinal hernia if the entire processus vaginalis remains patent, the
peritoneal sac may traverse the length of the canal, exit the superficial inguinal ring, and
continue into the scrotum in men or the labia majus in women. In this case, the
protruding peritoneal sac acquires the same coverings as those associated with the
spermatic cord in men or the round ligament of the uterus in women.
Such coverings are: -
➢ Extraperitoneal tissue
➢ Internal spermatic fascia
➢ Cremasteric fascia
➢ External spermatic fascia
➢ Skin
Direct inguinal hernia unlike indirect inguinal hernias that originate lateral to the
inferior epigastric artery, direct inguinal hernias originate medial to the artery. Thus,
covered by the inner wall of the anterior abdomen peritoneum plus transversalis
fascia. This hernia does not traverse the entire length of the inguinal canal but may exit
through the superficial inguinal ring. When this occurs, the peritoneal sac acquires a
layer of external spermatic fascia and can extend, like an indirect hernia, into the
scrotum.
Direct inguinal hernia coverings are: -
➢ Extraperitoneal tissue
➢ Fascia transversalis
➢ Conjoint tendon (in medial direct hernia)
➢ Cremaster fascia (in lateral direct hernia)
➢ External spermatic fascia
➢ Skin
 5. Differentiate between medial and lateral direct inguinal hernia.
When the protrusion occurs through the weak posterior wall of the inguinal canal or
triangle of Hesselbach or the inguinal triangle the hernia is a direct inguinal hernia. The
inguinal triangle is situated deep to the posterior wall of the
inguinal canal; hence, it is seen on the inner aspect of the
lower part of the anterior abdominal wall. Its boundaries are:
-
• Medial: Lower 5 cm of the lateral border of the rectus
abdominis muscle.
• Lateral: Inferior epigastric artery. Inferiorly:
• Inferior: Medial half of the inguinal ligament.
The medial umbilical ligament (obliterated umbilical artery) crosses the triangle and
divides it into medial and lateral parts.
The medial part of the floor of the triangle is strengthened by the conjoint tendon. This
is where Medial Direct Hernia would take place.
The lateral part of the floor of the triangle is weak, hence direct inguinal hernia usually
occurs through this part, known as Lateral Direct Hernia.
Medial Direct Hernia Lateral Direct Hernia

Passes medially to the obliterated Passes laterally to the obliterated umbilical

umbilical artery artery
Neck passing through Supravesical fossa Neck passing through Medial Inguinal fossa
Cover by the Conjoint tendon Absents of Conjoint tendon
Absents of Cremasteric fascia Present of Cremasteric fascia
Image B Image A
 6. Recognize the anatomic landmarks of the different types of hernias.
Abdominal hernias are of the following common types:
Types of Hernia Anatomical Landmarks
Inguinal hernia Direct inguinal Protrudes directly through the anterior
hernia abdominal wall within the Hesselbach
triangle
Protrudes medial to the inferior
epigastric artery and vein
Indirect inguinal Protrudes lateral to the inferior epigastric
hernia artery and vein
Protrudes above and medial to the pubic
tubercle
Femoral Protrudes through the femoral canal
below the inguinal ligament
Protrudes below and lateral to the pubic
tubercle
Umbilical (acquired) Develops around the umbilicus in adults
refer to as paraumbilical.
Epigastric Occurs through the widest part of the
linea alba, anywhere between the xiphoid
process and the umbilicus.
Incisional Occur in patients in whom it was
necessary to cut one of the segmental
nerves supplying the muscles of the
anterior abdominal wall.
Spigelian Hernia Arcuate line into the lateral border at the
lower part of the posterior rectus sheath.
 7. Know the presentations of inguinal, femoral, and umbilical hernias.
Presentation of inguinal hernia
The patient can present with a number of symptoms, which can include a protrusion or
lump in the groin region and in males can include an enlargement of the scrotum, with
mild to moderate discomfort that increases through activity such as lifting a heavy
object or through urination or defecation. With larger hernias patients may present
with a dragging sensation and pain.
If the hernia is strangulated the patient may present with a fever, vomiting and/or
nausea, rapid heart rate, pain that quickly intensifies, loss of appetite and a darkened
hernial protrusion.

Presentation of femoral hernia

The most apparent symptom is a lump on the upper medial thigh or groin. The lump
may be tender or painful. It sometimes may seem to disappear when a person is lying
down and may worsen when they are straining. Aside from a small bulge, most femoral
hernias do not cause symptoms. However, severe cases may cause nausea, stomach pain
and vomiting.
More likely to present with incarceration or strangulation
If hernia is strangulated then sudden, worsening pain and extreme tenderness around
a hernia with fever, nausea, rapid heart rate, skin redness around the bulge and
vomiting.
In incarcerated femoral hernia This occurs when a hernia becomes trapped in the
femoral canal, and it cannot move back into the abdomen.

Presentation of umbilical hernia

An umbilical hernia presents as a central, midabdominal bulge. Umbilical hernias in
children are usually painless. Umbilical hernias that appear during adulthood may cause
abdominal discomfort. An umbilical hernia tends to get bigger over time. Surgical
treatment may be required, especially if it gets bigger or becomes painful. Without
treatment, there is a risk of a strangulated hernia.

8. What are the complications associated with inguinal hernias?

The main complication of an inguinal hernia is incarceration, strangulation, and
obstruction.

Post-operative complications of hernia repair include:

• Pain, bruising, hematoma, infection, or urinary retention
• Recurrence, approximately 1.0% within 5 years of surgery
• Chronic pain (persisting 3 months after hernia repair), can occur in up to 30%
patients and is disabling in ~2%
• Damage to vas deferens or testicular vessels, leading to ischemic orchitis (and
potentially sub-fertility)
 9. Explain strangulated vs incarcerated hernias.
Incarcerated hernia: Incarceration occurs when part of the fat or intestine from inside
the abdomen gets stuck in the groin or scrotum and cannot go back into the abdomen.
Figure A. shows an example. Bowel sounds can sometimes be heard. Obstruction in the
bowel can occur, leading to severe pain, nausea, vomiting, and the inability to have a
bowel movement or pass gas.

Strangulated hernia: Strangulation can occur when an incarcerated hernia is not

treated. The blood supply to the intestine can be cut off, causing “strangulation” of the
intestine. This is a very serious condition. Compression around the hernia prevents
blood flow into the hernial contents causing ischaemia to the tissues and pain. A
strangulated hernia is a surgical emergency, due to the time-dependent risk of bowel
infarction. As shown in figure B. Such a hernia may be signalled in the early stages by
severe pain and by tenderness, induration, and erythema over the herniation site. As
tissue necrosis ensues, findings may include leukocytosis, decreased bowel sounds,
abdominal distention, and a patient who appears to be toxic, dehydrated, and febrile.
Mortality is high, and treatment should be initiated immediately.

A. B.
 References

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2. Vishram Singh - Textbook of Anatomy Abdomen and Lower Limb. Volume 2
(2014, Elsevier India)
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