Hernia Types and Management😶‍🌫️

Inguinal Hernia

Inguinal Hernia Features

• Most common type of hernia overall.

• Indirect inguinal hernia.
• Most common type of inguinal hernia
• Most common hernia in females

• Note: Femoral hernia is more common in females (F>>M).

Clinical Tests for Inguinal Hernia

• Deep ring occlusion test: 
• Single best test.

• Zieman's three-finger test, Ring invagination test: 
• Low sensitivity.

Inguinal Hernia Anatomy

Inguinal Canal

• Intermuscular canal in anterior abdominal wall.

• Extends from deep inguinal ring to superficial inguinal ring

• Length: 4 cm (3.8cm/3.75 cm)

Inguinal Rings

• Deep Inguinal Ring (Inlet):
• Location: 1.25 cm above the midinguinal point.
• Formation: Invagination of Fascia transversalis.

• Superficial Inguinal Ring (Outlet):
• Location: Above and medial to the pubic tubercle.
• Formation: Split in the aponeurosis of the External oblique muscle.

Inguinal Canal Boundaries

Summary

Anterior Wall:

• External oblique aponeurosis

• Laterally by Internal oblique 
• proximal 1/3
 

Posterior Wall:

A: Lumbar fascia
B: Transversus Abdominis
C: Conjoint tendon
D: Inguinal Ligament

• POSTEROmedially → Conjoint tendon (Internal oblique & Transversus abdominis).

• laterally → reflected part of Inguinal ligament.

• Fascia transversalis.

Roof:

• Arched fibers of Internal oblique and Transversus abdominis muscles.

Floor:

• Inguinal ligament.

• Lacunar ligament.

Inguinal Ligament / Poupart's Ligament

• Formation: 
• Thickening of aponeurosis of external oblique muscle.

• Extent: 
• From Anterior Superior Iliac Spine (ASIS) to pubic tubercle

Key Anatomical Points

• Midpoint of inguinal ligament: 
• Midpoint between ASIS and pubic tubercle.

• Midinguinal point: 
• Midpoint between ASIS and pubic symphysis.

• Deep inguinal ring: 
• Located 1.25 cm above mid inguinal point.

Extensions of Inguinal Ligament

• Pectineal ligament / Cooper's ligament:
• Extends from pubic tubercle → iliopectineal line.

Inguinal Canal Contents

True Contents:

• Male: Spermatic cord.

• Female: Round ligament of uterus.

Associated/False Contents:

• Ilioinguinal nerve (L1)
• typically found in the medial part.

• Genital branch of genitofemoral nerve (?)

Spermatic Cord

• Coverings (from superficial to deep):
• External spermatic fascia (from External oblique aponeurosis).
• Cremaster muscle and fascia (from Internal oblique).
• Internal spermatic fascia (from Fascia transversalis).

• Note: Transverse abdominis does not contribute to spermatic cord coverings.

• Contents:
• Vas deferens
• Artery to vas deferens
• Testicular artery
• Cremasteric vessels
• Pampiniform venous plexus
• Genital branch of genitofemoral nerve
• Autonomic nerves

Cremasteric Reflex

• Muscle Involved: Cremasteric muscle.

• Nerve Involved: Genitofemoral nerve (Root value: L1, L2)
• Afferent → Femoral N
• Efferent → Genital N

Indirect Inguinal Hernia:

• Path: 
• Enters the inguinal canal through the DIR
• passes along the canal
• exit the Superficial Inguinal Ring.

• Lateral to the inferior epigastric vessels.

• Often congenital

Types of Indirect Inguinal Hernia

• Inguinoscrotal

• Funicular

• Bubonocele

Direct Inguinal Hernia:

• Path: Occurs via Hesselbach's triangle.

• Directly through the posterior wall of the inguinal canal

• Medial to the inferior epigastric vessels.

Hesselbach's Triangle

• Boundaries:

Boundary	Structure
Medial Border	Lateral/Outer border of Rectus abdominis muscle
Lateral Border	Inferior epigastric vessels (or artery)
Base/Floor	Inguinal ligament

• Note:
• Indirect hernia: Lateral to HT.
• Direct hernia: Through HT.

Hernia Types and Features

• Simple/Uncomplicated:
• Reducible
• Positive cough impulse
• Forceful taxis possible

• Obstructed:
• Irreducible
• Negative cough impulse
• Forceful taxis → contraindicated (risk of "reduction en masse")

• Strangulated:



• Obstructed + compromised blood supply
• Skin inflamed
• Negative cough impulse

• Reduction en masse:
• Contraindicated in both strangulated and obstructed
• Reducing contents + constricting ring together,
• maintaining obstruction.

Contents of Hernia

Hernia Surgery Types

Mesh in Hernia Repair

• Best Mesh Material:
• Low weight (less shrinkage)
• Thin fibers
• Large pores

• Placement:
• Minimum 2 cm overlap around defect (to prevent recurrence).

• Mesh Materials:
1. Synthetic Mesh:
• Avoid in infection and strangulation.
• Examples:
• Prolene, Vipro (Not used intraperitoneally (bowel adhesions))
• PTFE (can be used intraperitoneally).
2. Biological Mesh:
• Can be used with infection.
• Examples:
• Acellular human dermis (Alloderm)
• Acellular porcine dermis

Myopectineal Orifice of Fruchaud:

• Significance: 
• Mesh placement here
• covers inguinal, femoral, and obturator hernia defects.
 

• Boundaries:

Boundary	Structure
Superior	Arching fibers of internal oblique & Trasverse Abdominis
Inferior	Pectineal/Cooper's ligament → Pecten Pubis
Lateral	Tendon of iliopsoas
Medial	Outer border of rectus

• Superolat → IO (Internal Oblique) IP (Iliopsoas)

• Infero med → PR (Pectineal → Rectus)

• Mnemonic: Ee fraud (Frauchad) → Io enna Ip aki PR cheyyunne

Hernioplasty for Inguinal Hernia

Open Surgery:

• Lichtenstein's tension-free Mesh hernioplasty
• most common
• Preferred over Bassini repair.

• Complications:
• Hemorrhage.
• Injury to vas/cord structures.
• Loss of sensation over lateral thigh
• Lateral cutaneuous N of thigh
• M/c N in Lap, McRoberts manoeuvre, Meralgia parasthetica
• Loss of cremasteric reflex
• Genitofemoral N
• Most common nerve injured at superficial ring:
• Ilioinguinal nerve.
• M/c in open hernia surgery
• Loss of sensation over root of penis
• Sensory innervation to
• upper medial thigh
• root of the penis
• mons pubis in males.
• Nerve entrapped below mesh
• Iliohypogastric nerve.
• chronic inguinal pain
• Loss of sensation over suprapubic region
• Recurrence.
• Wound infections.

Laparoscopic Inguinal Surgery

Types:

Structures encountered during surgery:

• Mnemonic:
• If ur external → ur doomed
• Mera → Pain → is always lateralised

Corona Mortis (Circle of Death):

• Aberrant obturator from Inferior epigastric
• Normally → obturator from Internal iliac

• Injury results in torrential bleeding.

• [Abnormal communication between obturator and iliac vessels]

Iliopubic Tract

Definition

• aka deep crural arch or Thompson’s ligament.

• Thickened band of transversalis fascia.

• Runs parallel and posterior to the inguinal ligament.

Anatomy

Derivatives

• Transversalis Fascia
• Ileopubic tract
• Internal spermatic fascia

• External Oblique Aponeurosis
• Inguinal Ligament
• Pectineal/Coopers ligament,
• Lacunar ligament,
• Reflected part of IL
• External spermatic fascia

Clinical Significance

• Laparoscopic herniorrhaphy.
• Sutures, tacks, or staples placed in iliopubic tract and inguinal ligament

• Important in posterior (preperitoneal) approach
• e.g., Nyhus technique

Special Types of Inguinal Hernia

Sliding Hernia:

• Posterior boundary formed by visceral structure
• Visceral structure can be injured during sac dissection.

• most common: sigmoid colon

• Left >> right.

• Seen in elderly males.

Sportsman's Hernia (Gilmore's Groin):

• Common in athletes.

• Tear in posterior wall muscle.

• Extreme pain.

• Small/unpalpable sac.

• Imaging: MRI is the investigation of choice (IOC).

• Management: Laparoscopic repair.

• Mnemonic: Sportsaman gil gil (Glimore) ennn prnj nikkumbo → Back tear avum (Posterior tear)

Hernia Classifications

European Hernia Society Classification

Inguinal Hernia:

• Defect measured by finger breadth.

• Primary/Recurrent

• Lateral (Indirect)/Medial (Direct)/Femoral

Ventral Hernia:

Nyhus Classification for Inguinal Hernias (Not imp)

• YH → IH → Inguinal Hernia

Other Hernias

Femoral Sheath

• Formed by
• fascia transversalis → anterior
• fascia iliaca → posterior

• Encloses the femoral vessels below the inguinal ligament.

• Does not enclose femoral nerve.

• Smallest compartment

• Allows vein expansion

• Site for femoral hernia

• Contains Deep inguinal lymph nodes 
• also called Femoral ring nodes or Cloquet's node

• Contents (from lateral to medial):
1. Femoral artery
2. Femoral vein
3. Femoral ring 
• Lymph node of Cloquet
• Lymphatics
• Fat and loose connective tissue

Femoral Canal

• Most medial compartment of the femoral sheath

• Bounded by:
• Superiorly: Inguinal ligament
• Medially: Lacunar ligament
• Inferiorly: Pectineal ligament (Cooper’s ligament)

• Mnemonic:
• Superiorly → inferior → inguinal
• Medial → lateral → lacunar
• Inf → pokkathil → pectineal

Femoral Hernia

• Location: Through femoral ring (small defect).

• Prevalence: F >> M.

• Increased risk of strangulation/obstruction (ring cannot dilate).

• Specific Feature: Richter's hernia can be seen.

• On Examination: 
• Swelling lies below and lateral to the pubic tubercle.

• Differential Diagnosis: 
• Inguinal hernia,
• psoas abscess,
• inguinal lymph node,
• saphena varix.

• Management: 
• Open surgery,
• laparoscopic hernioplasty (most common).

Ventral/Abdominal Wall Hernias

Incisional (most common ventral hernia)

• Epigastric hernia.

• Umbilical hernia.

• Paraumbilical hernia.

• Traumatic hernia.

• Spigelian hernia.

• Lumbar hernia.

• Parastomal hernia.

Hernioplasty for Ventral Hernias

Mesh Placement Type	Location
Onlay	On top of rectus sheath
Inlay	Within rectus sheath
Retromuscular	Behind rectus muscle
Preperitoneal	Above peritoneum
Intraperitoneal	IPOM (most common): PTFE mesh

Omphalocele

 

• Failure of reduction of physiological hernia.

• Sac present
• Cord attached to it.
• Comes through the midline
• Covering membrane of sac is present.

• Defect through umbilicus, (Sac → Central)
• Large defects (liver can herniate)

• Chronic

• Associated with congenital anomalies
• Beckwith Wiedemann syndrome
• Trisomy 13, 18, 21

Gastroschisis

 

• Defect is due to incomplete folding of embryo.

• Most common and acute and life threatening
• Risk of atresia, infection/perforation

• Split in the Anterior abdominal wall.
• Herniation from the defect
• Adjacent to the cord.

• Paraumbilical
• Defect adjacent to umbilicus

• Sac absent → Contain only intestinal loops
• (can get dry/shriveled)

• Fewer congenital anomalies

Management (Both): 

• Surgical (gradual closure to avoid abdominal compartment syndrome)

Spigelian Hernia (Intra-Parietal Hernia)

• INFRAUMBILICAL, ABOVE ARCUATE LINE

• Hernia comes out of rectus sheath

• Due to absence of posterior rectus sheath

• Location:
• Outer border of rectus close to spigelian line
• midpoint between umbilicus and pubic symphysis

• Features:
• Lies between muscle layers (narrow defect)
• High rate of strangulation
• Palpation: Not palpable externally.

• Diagnosis:
• Often detected only if strangulation is present.

• Mnemonic:
• Spigelian → Spy cannot be detected unless he is strangulated

Obturator Hernia:

The Little Old Lady's Hernia

• Geniculate branch of Obturator N

• Patient Profile:
• Typically seen in elderly, multiparous women.
• Characterized by a narrow defect, increasing chances of strangulation.

• Clinical Features (C/F):
1. Bowel obstruction.
2. Howship Romberg Sign: 
• Adduction + internal rotation
• shooting pain along the obturator nerve.
3. Hannington Kiff Sign
4. Relieves with Hip Flexion

• Mnemonic: Old lady (Obturator → elderly) her housil (Howship) kiss (Hannington kiff) cheyyan adupichitt internal rotate (Add. + IR) cheythapo full pain () ayi. At house (Howship)

Richter's Hernia

• Pathology:
• Small defect
• bowel wall is involved.
• Commonly seen in:
• Femoral hernias >>
• Paraumbilical hernias.
• Obturator hernias.

• Clinical Features (C/F):
• First sign is gastroenteritis.
• Strangulation can be missed as it often presents atypically.

Maydl's Hernia

• Characteristics:
• Wide defect.
• 'W' shaped hernia.
• Involves >1 bowel loop hernias.
• Strangulation usually affects the intra-peritoneal part first.