Normal Anatomy



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Inguinal Hernia

Normal Anatomy


  • Inguinal canal is a 3d cylinder between the deep and superficial inguinal rings

    • Superior Wall – fibres of internal oblique and transversus abdominis

    • Posterior wall – conjoined tendon on internal oblique, transversus abdominis and fascia transversalis

    • Anterior wall – aponeurosis of the external oblique

    • Inferior wall – inguinal ligament, lacunar ligament and the ilio-pubic tract

  • Inguinal Canal

    • Spermatic cord – in men

    • Ilioinguinal nerve

    • Genito-femoral nerve

Pathology


  • A bulge or protrusion of tissue (usually intestine) from the abdominal cavity

  • Tissue may or may not be able to moved back

    • Reducible Hernia

      • hernia sac can be manipulated and tissue moved back in
    • Incarcerated/Irreducible


      • the content of the hernia sac cannot be returned to the abdominal cavity

        • can lead to complications

          • Strangulated

            • The blood supply to the entrapped contents is compromised

            • Medical emergency

Mechanism of Injury

Insidious


  • Multifactorial

  • More common in males

  • Pathological changes in the connective tissue of the abdominal wall

  • Chronic coughing and manual labour jobs have NOT been shown to increase risk of intra-abdominal pressure

Classification

Direct Hernia


  • Portion of the intestine protrudes directly outward through a weak point in the abdominal wall

  • Superior to the inguinal ligament

  • Painless

  • Reduces when lying supine

  • Round swelling near pubis area of deep inguinal ring

Indirect Hernia


  • Portion of the intestine pushes downward through the deep inguinal ring into the inguinal canal

  • Through the deep inguinal ring

  • Can pass into the scrotum (men) or labia (women)

  • Pain with straining

  • May decrease when lying supine

  • Swelling that increases with intraabdominal pressure

Examination

Subjective


  • Intermittent or persistent bulge in the groin

  • May report groin pain- can be pain free

  • Pain worse with Valsalva maneuvers

  • Heavy or dragging sensation in the groin

  • Scrotal pain in men

  • Worse at the end of the day or after prolonged activity

  • Activities that increase intra-abdominal pressure worsen symptoms (pain and/or bulging)

    • Coughing

    • Lifting

    • Straining

  • More noticeable following heavy meal or standing for long periods

  • Bulge disappears in a supine position

Objective

Special Testing


  • Internal examination of inguinal ring

Further Investigations


  • Rarely required

  • Ultrasound

  • MRI

Management


  • Surgery considered for symptomatic, large or recurrent hernias

  • Small, minimally symptomatic hernias managed conservatively

  • Physiotherapy post operatively for rehabilitation

Conservative


  • Advised to monitor for symptoms of incarceration or strangulation

Plan B


  • Hernia repair

    • Open

    • Laparoscopic


References


(Irwin and McCoubrey 2012, LeBlanc, LeBlanc et al. 2013, Broadhurst and Wakefield 2015, Fitzgibbons and Forse 2015)

Broadhurst, J. F. and C. Wakefield (2015). "Adult groin hernias: acute and elective." Surgery (Oxford) 33(5): 214-219.

Fitzgibbons, R. J., Jr. and R. A. Forse (2015). "Clinical practice. Groin hernias in adults." N Engl J Med 372(8): 756-763.

Irwin, T. and A. McCoubrey (2012). "Adult groin hernias." Surgery - Oxford International Edition 30(6): 290-295.



LeBlanc, K. E., L. L. LeBlanc and K. A. LeBlanc (2013). "Inguinal hernias: diagnosis and management." Am Fam Physician 87(12): 844-848.








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