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Inguinal hernias

1. ANATOMY OF INGUINAL CANAL

  • Deep inguinal ring – located at the halfway point of inguinal ligament
    • Provides an entrance for abdominal contents to exit
      • Contents in males – spermatic cord and ilioinguinal nerve
      • Contents in females – round ligament of the uterus and ilioinguinal nerve
  • Hesselbach’s triangle
    • Medially – rectus abdominis
    • Laterally – inferior epigastric vessels
    • Inferiorly – ilioinguinal ligament
  • Walls of inguinal canal – MALT
    • M – superior (roof)
      • 2 MUSCLES – Internal oblique and transverse abdominis
    • A – anterior
      • 2 APONEUROSES – internal oblique and external oblique
    • L – inferior (floor)
      • 2 LIGAMENTS – Inguinal ligament + lacunar ligament
    • T – posterior
      • 2 Ts – Transverse fascia + conjoint tendon medially

2. INGUINAL HERNIAS

Types of inguinal hernias

According to anatomic site 
  • Indirect – goes through deep inguinal ring, lateral to the inferior epigastric artery (IEA)
    • Can descend into scrotum
    • Most common in children
  • Direct – occurs through posterior wall of inguinal canal through Hesselbach’s triangle, sac is medial to the IEA
    • Cannot descend into scrotum
    • Common in old age
According to extent 
  • Incomplete
    • Bubonocele – sac is confined to inguinal canal
    • Funicular – sac crosses the superficial ring but doesn’t reach the bottom of the scrotum
  • Complete – sac descends to bottom of the scrotum

According to content

  • Eneterocele, omentocele, cystocele

Clinical types

  • Reducible, irreducible, obstructed, strangulated

Rare type of inguinal hernias

  • Sliding hernia –  protrusion of a retroperitoneal organ through an abdominal wall defect
  • Richter’s hernia – only the antimesenteric wall of the bowel herniates without compromising the entire lumen
  • Littre’s hernia – hernia containing Meckel’s Diverticulum
  • Maydl’s hernia – presence of two small bowel loops within a single hernial sac, more prone to strangulation and necrosis (  W shaped )

Classification of hernias

Gilbert’s Classification NYHUS Classification

Clinical features

  • Most common in males
  • Dragging pain and swelling in groin – better seen on coughing and standing
  • Usually reducible
  • Deep inguinal ring (DIR) occlusion test
    • In lying down position, DIR is occluded with the thumb and patient is asked to cough
    • If swelling appears medial to thumb – DIRECT HERNIA
    • If swelling appears on releasing the thumb – INDIRECT HERNIA

Investigations

  • Inspection – lump size, shape, position, scrotal extension, observe cough impulse
  • Palpation – inguinal lump, feel scrotum
  • Per rectal exam
  • Reducibility
  • Always feel the other side

Complications

  • Recurrence
  • Groin pain
  • Haematoma
  • Infection
  • Testicular atrophy
  • Contraction
  • Seroma

Treatment

Open repairs

  • Herniotomy (excision of hernial sac) and herniorrhapy/hernioplasty (strengthening of the posterior wall of the inguinal canal by repair or mesh)
  • Bassini repair – approximation of the inguinal ligament to the conjoined tendon with sutures
  • Shouldice – 4-layered repair of floor of inguinal canal with running sutures
  • Lichtenstein repair – hernia gap closed using a synthetic mesh, which is sutured to the inguinal ligament

Laparoscopic repairs

  • TAPP – transabdominal preperitoneal repair
  • TEP – total extraperitoneal repair
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