Table of Contents Anatomy Direct vs indirect inguinal herniaDirect inguinal hernia (40%) Indirect inguinal hernia (60%)Inguinal hernias vs femoral hernia Hernia terminology Management QuestionsSome related OSCE stations An inguinal hernia is the protrusion of abdominal contents through the inguinal canal. Anatomy of the inguinal canal and inguinal ligament Anatomy Inguinal ligament = ASIS to pubic tubercleInguinal canal = deep inguinal ring to superficial inguinal ring Inguinal ring positions Deep inguinal ring (start of inguinal canal) = midpoint of the inguinal ligamentSuperficial inguinal ring (end of inguinal canal) = superior to the pubic tubercleBorders of the inguinal canal MALTMuscle (internal oblique) – ROOFAponeurosis (external oblique) – ANTERIORLigament (inguinal ligament) – FLOORTendon (transversalis fascia) – POSTERIORContentsMales: spermatic cord and ilioinguinal nerveSpermatic cord contents3 arteries: testicular artery, artery to vas deferens, cremasteric artery3 nerves: genitofemoral nerve, autonomic nerves, ilioinguinal nerve (outside cord)3 other structures: vas deferens, pampiniform plexus of veins, lymphatic vesselsFemales: round ligament of the uterus and ilioinguinal nerve Direct vs indirect inguinal hernia Direct inguinal hernia (40%) Herniated abdominal contents come directly out of abdomen in a straight line Penetrate through the superficial inguinal ringIf reduced, cannot be controlled by applying pressure over the deep inguinal ring Indirect inguinal hernia (60%) Herniated abdominal contents run in the inguinal canalPenetrate through the deep inguinal ringCan 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 vaginalisIf reduced, can be controlled by applying pressure over the deep inguinal ring Inguinal hernias vs femoral hernia Femoral hernia is inferior and lateral to the pubic tubercle (through femoral canal) – more common in femalesDirect inguinal hernia is superior to the pubic tubercle (position of superficial inguinal ring) – more common in malesIndirect inguinal hernia can occur anywhere between the deep inguinal ring and the scrotum Hernias Hernia terminology Oops! This section is restricted to members. Management Watch and wait: for small, asymptomatic herniasOpen repair: for irreducible, obstructed or strangulated herniasOpen/laparoscopic mesh repair: for large or symptomatic hernias Questions What are three differential diagnoses of a groin lump? Oops! This section is restricted to members. What is is the difference between the midpoint of the inguinal ligament and the mid-inguinal point? What is the significance of each? Oops! This section is restricted to members. Please list some complications of a hernia mesh repair Oops! This section is restricted to members. Some related OSCE stations Abdominal examHerniaLots more stations can be found here!