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Inguinal hernias

An inguinal hernia is the protrusion of abdominal contents through the inguinal canal.

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Anatomy of the inguinal canal and inguinal ligament

Anatomy

  • Inguinal ligament = ASIS to pubic tubercle
  • Inguinal canal = 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 canal MALT
      • Muscle (internal oblique) – ROOF
      • Aponeurosis (external oblique) – 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 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 ring
  • If reduced, cannot be controlled by applying pressure over the deep inguinal ring

Indirect inguinal hernia (60%)

  • Herniated abdominal contents run in the inguinal canal
  • Penetrate through the deep 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 hernia is inferior and lateral to the pubic tubercle (through femoral canal) – more common in females
  • Direct inguinal hernia is superior to the pubic tubercle (position of superficial inguinal ring) – more common in males
  • Indirect inguinal hernia can occur anywhere between the deep inguinal ring and the scrotum
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Hernias

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?

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What is is the difference between the midpoint of the inguinal ligament and the mid-inguinal point? What is the significance of each?

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Please list some complications of a hernia mesh repair

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Some related OSCE stations

  1. Abdominal exam
  2. Hernia
  3. Lots more stations can be found here!
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