Overview
The inguinal canal is a tubular structure 3 – 5 cm long running parallel to the inguinal ligament.
Men have a higher risk of developing hernias than women. The most common type of inguinal hernia in both men and women is an indirect inguinal hernia, though femoral hernias are more common in women than men.
Nyhus classification of inguinal hernias
| Type | Decription |
|---|---|
| Type I | Indirect inguinal hernia. Normal internal inguinal ring. No posterior floor defect. |
| Type II | Indirect inguinal hernia. Enlarged internal ingunial ring. No posterior wall defect. Does not extend to scrotum. |
| Type III A | Direct inguinal hernia. Posterior wall defect only. |
| Type III B | Indirect inginal hernia. Enlerged internal inguinal ring. Posterior floor defect |
| Type III C | Femoral hernia |
| Type IV A | Recurrent direct hernia |
| Type IV B | Recurrent indirect hernia |
| Type IV C | Recurrent Femoral hernia |
| Type IV D | Recurrent combined hernias |
- Signs and symptoms
- Groin mass
- Worsens with cough
- May be relieved with gentle pressure or lying doin
- Groin pain
- Generalized discomfort or heaviness
- Sharp pain in acutely incarcerated hernia
- Radiates the the scrotum, testicle or anterior thigh due to compression of the ilioinguinal/genitofemoral nerve
- Change in bowel habits e.g. constipation (due to entrapment of loop of bowel)
- Change in urinary habits e.g. difficulty with urination (due to entrapment of bladder)
- Groin mass
- Physical examination
- Place finger in inguinal canal
- Ask patient to cough
- Indirect inguinal hernia: hits tip of finger
- Direct inguinal hernia: hits side of finger
- Differentials
- Lymphadenopathy (infectious, reactive, metastatic)
- Hydrocele
- Varicocele
- Epididymitis
- Testicular neoplasm
- Testicular torsion
- Hematoma or abscess
- Undescended testes
- Femoral artery aneurysm or pseudoaneurysm
- Investigations
- Ultrasound: best initial test to identify occult hernia due to the ability to demonstrate the hernia in real time while the patient performs valsava. 86% sensitivity and 77% specificity.
- CT-scan: less sensitive and specific for identifying occult hernias that ultrasound. Can differentiate the types of hernia
- MRI: high sensitivity and specificity imaging for identifying occult hernias and differentiating the types of groin hernias.
- Herniography (peritoneography): invasive test performed under fluoroscopy. Contrast is injected into the peritoneal cavity and the images are taken whyle the patient performs valsava. Most sensitive and specific test for occult hernias.
- Treatment of an incarcerated hernia
- Ice pack
- Sedation
- Trendelenburg position
- Manual reduciton (taxis)
- Admit or observe for signs of necrosis
- Schedule surgical herniorrhaphy
Indirect inguinal Hernia
An infirect inguinal hernia is herniation of intra-abdominal contents through the deep inguinal ring and down into the inguinal canal, and possibly into the scrotum. Abdominal contents go down the canal by following the path of the spermatic cord. Can occur at any time in life. May be d/t a congenital lesion that may not manifest until later in life, and hence may not necessarily be related to activity. Diagnosis is clinical.
5-10 X more common in men. 5% lifetime incidence. Bimodal prevalence (peaks at , 1yo and > 40 yo. R > L testis (d/t late descent of Right testis) .
Bubonocele: limited to the inguinal canal
Funicular: extends to just above the epididymis
Complete: lies within the scrotum
- Symptoms
- Groin mass +/- pain
- Worsened with coughing or straining or standing
- Size decreases with recumbency
- Groin mass +/- pain
- Physical exam
- Inguinoscrotal swelling
- Bowel sound present over the mass (if bowels are present
- Cough impulse test (visible or palpable cough expansion of the mass with cough)
- Reducibility test (differentiates it from a vaginal hydrocele. Is it incarcerated?)
- Ring occlusion test (to determine whether there is a posterior wall defect; dirrect vs indirect)
- Invagination test
- Ziemman’s 3 finger test (the index middle and ring ffinger are placed on the deep, superficial, and saphenous rings respectively and the pt is asked to cough.)
- Getting above the swelling
- Transillumination: intestinal shows (fecal matter)
- Differentials
- Hydrocele (homogenous fluid with transillumination)
- Undescended testis
- Testicular torsion
- Psoas abscess
- Femoral aneurysm
- LAN
- Hematoma
- Investigations
- Ultrasound
- CT-scan
- MRI
- Treatment
- Herniorrhaphy: replacement of the abdominal contents and reinforcement of the ring with sutures
- Hernioplasty: replacement of the abdominal contents and reinforcement of the ring with mesh
- Complications
- Hematoma
- Infection
- Chronic post-p pain (Inguinodynia)
- Testicular atrophy
- Dysejaculation
Management of Inguino-femoral hernia
| Management | Type | Description |
|---|---|---|
| Herniotomy | The hernia sac is removed and closed. For children with an indirect inguinal hernia. This is not suitable in adults due to muscle weakness, hence some form of muscle strengthening (herniorrhaphy) is required | |
| Bassini repair | Anterior open tissue repair | The conjoint tendn (internal oblique and transversus abdominus) are sutured to the inguinal ligament |
| Shouldice repair | Anterior open tissue repair | Imbrication of the floor of the inguinal canal. The transversalis fascia is incised and imbricated in two layers, then the conjoint tendon is sutured to the inguinal ligament in additional layers |
| McVay (Cooper’s Ligament) repair | Anterir open tissue repair | The conjoint tendon is sutured to cooper’s ligament |
| Nyhus or Stoppa repair (posterior approach) | Posterior open tissue repair | The hernia is approached behind the transversalis fascia (preperitoneal) and a mesh is placed in the preperitoneal space |
| Lichtenstein (tension-free) repair | Open flat mesh repair | Open mesh repair. A flat mesh is placed over the posterior wall of the canal then fixed to the pubic tubercle, inguinal ligament and conjoint tendon, with a slit to allow passage of the spermatic cord |
| Transabdminal preperitoneal (TAPP) repair | Laparoscopic | Laparoscpic repair using a mesh placed in the pre-e peritoneal space accessed via the peritoneum |
| Totally extraperitoneal (TEP) repair | Laparoscopic | Laparoscpic repair using a mesh placed in the pre-eperitoneal space without entering the peritoneum |
Direct Inguinal Hernia
A direct inguinal hernia is herniation of intra-abdominal contents through the floor of the medial inguinal canal through Hesselbach’s triangle (Weakened region of transversalis fascia, posterior wall defect). Goes under the canal. Commonly an acquired lesion. Typically occurs in older men but females have a higher likelihood of getting it too. Diagnosis is clinical.
Femoral hernia
A femoral hernia is a herniation of intra-abdominal contents through the femoral canal, along the femoral sheath. The sac protrudes infero-posterior to the inguinal ligament and anterior to the pectineal ligament and pubic ramus. May continue through the saphenous opening. Usually an acquired lesion d/t Hx of multiple pregnancy or hernia repair. Diagnosis is clinical and imaging is not usually done. Requires surgical repair.
More common in men than women.
