 BISMILLAH AL REHMAN AL

RAHIM.
 GROIN HERNIAS
INGUINAL HERNIA
FEMORAL HERNIA
By ;

Abrar Hussain Zaidi

 CONTENTS

    Anatomy
        Examination
       Surgical problems
     
 Groin:

The area where the upper thigh meets the

trunk. More precisely, the fold or
depression marking the junction of the
lower abdomen and the inner part of the
thigh.
INGUINAL CANAL
 Definition

 The oblique passage in the anterior

abdominal wall, through which passes
the spermatic cord in the male and the
round ligament of the uterus in the
female

 A conduit in the abdominal wall through

which a testis descends into the scrotum.
INGUINAL CANAL -
ANATOMY
Site
The inguinal canal is situated just
above the medial half of the inguinal
ligament.
Length
Approximately 4cm (1.57 inches).
Direction
It is oblique, directed inferiorly, anteriorly
and medially.
INGUINAL CANAL-ANATOMY
INGUINAL CANAL-ANATOMY
Boundaries- Anterior wall

External oblique aponeurosis

 Reinforced in lateral 1/3 by internal
oblique muscle
Boundaries- Lateral
Deep inguinal ring
 Opening in fascia transversalis

 1 cm above the inguinal ligament

 Midway between anterior superior

iliac spine and symphysis pubis
 Medial to it lie the Inferior Epigastric
vessels
Boundaries-Medial

 Superficial inguinal ring

Triangular defect in external
oblique aponeurosis
Overlies the pubic crest which
forms the base of the opening
Boundaries-Posterior wall

 Fascia transversalis
 Reinforced in medial 1/3 by
conjoint tendon
 Boundaries- Floor
Inguinal ligament
 Lower border of external oblique
aponeurosis
 Medially is continuous with lacunar
ligament
Gives attachment to fascia lata on the
inferior border
Boundaries- Roof

 Arched fibers of conjoint tendon

Contents of inguinal canal
Spermatic cord and ilioinguinal nerve
in males

Round ligament of uterus and

ilioinguinal nerve in females
 Spermatic cord

 VAS DEFERENCE
 VESSELS
 COVERINGS
The abdominal wall in the groin area
is made up of different structures
From deep to superficial layers;

 Peritoneum - the lining of the abdominal cavity

(becomes the hernia sac)
 Subperitoneal fat - fat beneath the peritoneum
 Transversalis fascia - sheet of fibrous tissue that
envelops the peritoneum
 Transversus abdominis muscle
 Internal oblique muscle
 External oblique muscle
 Subcutaneous fat
 Skin
Spermatic cord-Coverings
Each anterior abdominal wall layer
gives it
a covering to sheath
From within outwards the coverings are
derived as follows
o Internal Spermatic fascia from fascia
transversalis
o Cremasteric fascia from internal
oblique
o External spermatic fascia from
external oblique
Spermatic cord - Contents
 Vas deferens
 Artery to vas deferens (branch of inferior
vesical artery)
 Testicular artery (branch of abdominal
aorta)
 Testicular vein
 Testicular lymphatics
 Testicular nerve fibers
 Processus vaginalis
 Cremasteric artery (branch of inferior
Epigastric artery)
 Nerve to cremaster (genital branch of
genitofemoral nerve)
INGUINAL HERNIA
 INGUINAL HERNIA

DEFINITION
Protrusions of abdominal cavity
contents
through the inguinal canal.

 They are very common - 7% of the

population
 Hernia repair is one of the most
frequently performed surgical
 INGUINAL HERNIA-
Pathology
 A defect in the wall
 A sac
 Coverings
 Contents inside the sac
 Defect in the wall
 Congenital –Inguinal Canals

-umbilicus

 Acquired
Traumatic/operative
Weakness of wall
Combination
A hernia consists of:
 A sac
 Its coverings
 Its contents
TYPES OF INGUINAL HERNIAS
 DIRECT
 INDIRECT
 Hernias can be:

 Reducible
 Irreducible
 Obstructed or incarcerated
 Strangulated
 CAUSATIVE FACTORS
 CONGENITAL
 AQUIRED

WEAK ANT ABDOMINAL WALL

COUGH
CONSTIPATION
WIEGHT LIFTING
PREVIOUS SURGERY

Raised intra-abdominal pressure

 CLINICAL PRESENTATION
 Bulge in the groin area that can
become more prominent when
coughing, straining, or standing up.
 Often painful, and the bulge commonly
disappears on lying down.
 CLINICAL PRESENTATION
The hernia often increases in size on
coughing or straining -cough impulse
+VE

It reduces in size or disappears

when relaxed or supine
 CLINICAL PRESENTATION

The inability to "reduce", or place the

bulge back into the abdomen usually
means the hernia is "incarcerated,"
/obstructed /strangulated --
necessitating emergency surgery.
 CLINICAL PRESENTATION

 Irreducible hernias have either a

narrow neck or the contents adhere
to the sac wall

 Obstructed hernias contain

obstructed but viable intestine
 CLINICAL PRESENTATION
 Irreducible but non-obstructed hernias
may cause little pain,
Content are usually -omentum

 If the hernia causes obstruction:

colicky abdominal pain, distension and
vomiting may occur
The hernia will be tense tender and
irreducible
 CLINICAL PRESENTATION
If strangulation occurs

 Blood circulation is compromised

 The lump will become red and tender
Patient is ill ,toxic and has clinical
signs
of intestinal obstruction
 Diagnosis

Diagnosis is based on clinical

features

Herniography Ultrasound or CT

Rarely required
In occult hernia
 History
 Define any causative factor
 General assessment
 INGUINAL HERNIA
EXAMINATION
 Standing position
 Lying position

 Inspection
 Palpation
 Percussion
 Auscultation
 INGUINAL HERNIA
EXAMINATION
 Describe the swelling
 Cough impulse
 Reducibility
 Contents

 Abdominal examination/+PR.
 Systemic examination
INGUINAL HERNIA EXAMINATION
INGUINAL HERNIA EXAMINATION
INGUINAL HERNIA EXAMINATION
 INGUINAL HERNIA
TREATMENT
 CORRECTION OF CAUSATIVE
/AGGRAVATING FACTORS

 PREPARATION

 SURGERY open / Laparoscopic

 POST OPERATIVE CARE

 SURGICAL TREATMENT
PRINCIPLES

 Mange the contents

 Excise the sac
 Strengthen the posterior
wall
SURGICAL TREATMENT

Surgical Procedures

 HERNIOTOMY
 HERNIORRHAPHY
 HERNIOPLASTY

ELCTIVE VS EMERGENCY
SURGERY
Surgical repair - techniques

 Bassini+/- Tanner Slide

 Darnning

 Shouldice
Surgical repair - techniques

 Lichtenstein / mesh reair

Shouldice or Liechtenstein now
regarded as 'gold standard' as judged
by low risk of recurrence
 Laparoscopic repair
HERNIORRHAPHY
 1) Reflected medial leaf after a strip has been separated; 2) Internal oblique muscle
seen through the splitting incision made in the medial leaf; 3) Interrupted sutures
between the upper border of the strip and conjoined muscle and internal oblique
muscle; 4) Interrupted sutures between the lower border of the strip and the inguinal
ligament; 5) Pubic tubercle; 6) Abdominal ring; 7) Spermatic cord; and 8) Lateral leaf.
 COMPLICATIONS OF INGUINAL
HERNIA
 OBSTRUCTION
 STRANGULATION
 INFLAMATION

 OPERATIVE COMPLICATIONS

 EARLY POSTOPERATIVE COMPLICATIONS

 LATE POSTOPERATIVE COMPLICATIONS
 POST OPERATIVE CARE

 Pain management
 Prophylaxis against infection
 Preventive measures against
recurrence
INGUINAL HERNIA ?
 FEMORAL
HERNIA
 FEMORAL HERNIA
 Femoral hernias occur just below
the inguinal ligament
 Abdominal contents pass
through a naturally occurring
weakness called the ‘femoral
canal’.
 Femoral Canal

 located below the inguinal

ligament on
the lateral aspect of the pubic tubercle.
 Passageway by which many lymphatics
from lower limb pass to abdomen.
Boundaries - Femoral Canal
 Anterior --Inguinal ligament,
 Posterior--Pectineal ligament
 Medial ---Lacunar ligament
 laterally --Femoral vein.
 Femoral Canal - CONTENTS

 It normally contains a few

lymphatics, loose areolar
tissue and occasionally a
lymph node called Cloquet's
node.
 The function of this canal
appears to be to allow the
femoral vein to expand when
necessary to accommodate
increased venous return from
the leg during periods of
 Femoral Hernia-Definition
 Protrusion of Abdominal
contents through the ‘femoral
canal’.
Femoral Hernia-Clinical Features
Symptoms
 More common in women, usually elderly
and
frail (although they can happen in
children).
 Typically present as a groin lump.
 May or may not be associated with
pain.
 Often, they present with a
complication;
irreducibility , intestinal obstruction
 Femoral Hernia-Clinical
Features
Signs

 The obvious finding -- a lump in the groin.

 Cough impulse is often absent and should not
be relied
on
 The lump is more globular than the pear
shaped lump
of the inguinal hernia.
 The bulk of a femoral hernia lies below the
inguinal
The incidence of strangulation in
femoral
hernias is high.

A femoral hernia has often been found to

be the cause of unexplained small
bowel obstruction.
Femoral Hernia-Differential Diagnoses

2. Inguinal hernia
3. Enlarged inguinal lymph node
4. Aneurysm of the femoral artery
5. Saphena varix
6. Psoas abscess
7. Undescended testis/Ectopic testis
 Femoral hernia -
Management
 Uncomplicated femoral hernias - repaired
as an EARLY elective procedure

 Often require emergency surgery

 Femoral hernia - Management

Three classical approaches to the femoral

canal

 Low (Lockwood)

 Transinguinal (Lotheissen)

 High (McEvedy)
 Femoral hernia - Management
Irrespective of approach the operative aims
are;

 Dissection of the sac

 Reduction / manage the contents

 Ligation of the sac

 Approximation of the inguinal and pectineal

ligaments
FEMORAL HERNIA REPAIR
 POST OPERATIVE CARE
 Pain management
 Prophylaxis against infection
 Preventive measures
 Manage associated problems
FEMORA L HE RNI A - ?
 Special types of hernia

Richter's hernia
 Partial enterocele

 presents with strangulation and obstruction

Maydl's hernia
 W loop strangulation

 Strangulated bowel within abdominal cavity

 Littre's hernia

 Strangulated Meckel's diverticulum

 Can cause small bowel fistula
 Mortality of elective hernia repair

 The mortality of elective hernia repair

increases with age
 < 60 yrs