An inguinal hernia is the protrusion of abdominal contents through the inguinal canal.
Anatomy
- Inguinal ligamentĀ = ASIS to pubic tubercle
- Inguinal canalĀ = deep inguinal ring to superficial inguinal ring
- Inguinal ring positions
- Deep inguinal ring (start of inguinal canal) = midpoint of the inguinal ligament
- Superficial inguinal ring (end of inguinal canal) = superior to the pubic tubercle
- Borders of the inguinal canalĀ MALT
- Muscle (internal oblique) – ROOF
- Aponeurosis (external oblique) –Ā ANTERIOR
- Ligament (inguinal ligament) – FLOOR
- Tendon (transversalis fascia) – POSTERIOR
- Contents
- Males: spermatic cord and ilioinguinal nerve
- Spermatic cord contents
- 3 arteries: testicular artery, artery to vas deferens, cremasteric artery
- 3 nerves: genitofemoral nerve, autonomic nerves, ilioinguinal nerve (outside cord)
- 3 other structures: vas deferens, pampiniform plexus of veins, lymphatic vessels
- Females: round ligament of the uterus and ilioinguinal nerveĀ
Direct vs indirect inguinal hernia
Direct inguinal hernia (40%)
- Herniated abdominal contents comeĀ directlyĀ out of abdomen in a straight lineĀ
- Penetrate through theĀ superficialĀ inguinal ring
- If reduced, cannot be controlled by applying pressure over the deep inguinal ring
Indirect inguinal hernia (60%)
- Herniated abdominal contents runĀ inĀ the inguinal canal
- Penetrate through theĀ deepĀ inguinal ring
- Can go right the way down the canal into the scrotum in men (inguinal-scrotal hernia)
- May occur due to failure of the closure of the processus vaginalis
- If reduced, can be controlled by applying pressure over the deep inguinal ring
Inguinal hernias vs femoral hernia
- Femoral herniaĀ isĀ inferior and lateralĀ to the pubic tubercle (through femoral canal)Ā ā more common in females
- Direct inguinal herniaĀ isĀ superiorĀ to the pubic tubercle (position of superficial inguinal ring)Ā ā more common in males
- Indirect inguinal herniaĀ can occur anywhere between the deep inguinal ring and the scrotum
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Hernia terminology
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Management
- Watch and wait: for small, asymptomatic hernias
- Open repair: for irreducible, obstructed or strangulated hernias
- Open/laparoscopic mesh repair: for large or symptomatic hernias
Questions
What are three differential diagnoses of a groin lump?
What is is the difference between the midpoint of the inguinal ligament and the mid-inguinal point? What is the significance of each?
Please list some complications of a hernia mesh repair
Some related OSCE stations
- Abdominal exam
- Hernia
- Lots more stations can be found here!