2. Surgical anatomy
The superficial inguinal ring
Triangular aperture in the aponeurosis of the
external oblique muscle and lies 1.25 cm above the
The ring is bounded by a superomedial and an
inferolateral crus joined by the criss-crossed
Normally the ring will not admit the tip of the little
3. The deep inguinal ring
U-shaped condensation of the transversalis fascia
and it lies 1.25 cm above the inguinal (Poupart’s)
ligament, midway between the symphysis pubis and
the anterior superior iliac spine.
The transversalis fascia is the fascial envelope of the
abdomen and the competency of the deep inguinal
ring depends on the integrity of this fascia.
4. The inguinal canal
In infants, the superficial and deep inguinal rings are almost
superimposed and the obliquity of the canal is slight.
In adults, the inguinal canal, which is about 3.75 cm long, is directed downwards and medially
from the deep to the superficial inguinal ring.
WHAT IT TRANSMITS????
In the male, the inguinal canal transmits the spermatic cord, the
ilioinguinal nerve and the genital branch of the genitofemoral
In the female, the round ligament replaces the spermatic
5. An indirect hernia travels down the canal on the outer (lateral and anterior) side of the
A direct hernia comes out directly forwards through the posterior wall of the inguinal canal.
Indirect hernia - lateral to the inferior epigastric vessels,
Direct hernia - medial to inferior epigastric vessels
except in the saddle-bag or pantaloons type, which has both a lateral and a medial
Digital control of the internal ring may help in distinguishing between an indirect and a direct
6. Indirect Versus Direct inguinal hernias
Indirect is the most common form of hernia and its usually congenital due to
patent processus viginalis
Direct usually acquired occur in old men with weak abdominal muscles.
7. Indirect inguinal hernia
Most common form of hernia
Most common in the young age
More common on the right side in the male.
Because associated with the later descent of the right testis and a higher
incidence of failure of closure of the processus vaginalis.
In adult males, 65% of inguinal hernias are indirect and
55% are right-sided.
The hernia is bilateral in 12% of cases.
8. Types of indirect inguinal hernia
Bubonocele-the hernia is limited to the inguinal canal.
Funicular-the processus vaginalis is closed just above the
epididymis. The contents of the sac can be felt separately
from the testis, which lies below the hernia.
Complete (synonym: scrotal). A complete inguinal hernia is
rarely present at birth but is commonly encountered in
infancy. The testis appears to lie within the lower part of
9. Direct inguinal hernia
In adult males, 35% of inguinal hernias are direct.
At presentation, 12% of patients will have a contralateral hernia in addition,and there is a
fourfold increased risk of future development of a contralateral hernia if one is not present at
the original presentation.
A direct inguinal hernia is always acquired.
The sac passes through a weakness or defect of the transversalis fascia in the posterior wall of
the inguinal canal.
10. Dual (synonym: saddle-bag, pantaloon)
This type of hernia consists of two sacs that straddle the inferior epigastric
artery, one sac being medial and the other lateral to
The condition is not rare and is a cause of recurrence, one of the sacs having
been overlooked at the time of operation.
12. Repeated INCREASE in abdominal
pressure is usually due to
Bladder neck or urethral obstruction
Sever muscular effort
13. Inguinal hernia
1. Age ( young vs. old)
2. Occupation ( nature ?? )
3. Local symptoms: Swelling, discomfort and pain
4. Systemic symptoms: if there is obstruction or strangulation
5. Precipitating factors
14. Inguinal hernia
1. Inspection for site, size, shape, color and extent.
2. Palpation for surface, temp, tenderness, composition and reducibility.
3. Expansible cough impulse.
4. General exam: for common causes of increase intra abdominal pressure
15. Differential diagnosis in the male
In males the differential diagnosis includes the following:
• vaginal hydrocele
• encysted hydrocele of the cord
• femoral hernia
• incompletely descended testis in the inguinal canal – an
inguinal hernia is often associated with this condition
• lipoma of the cord – this is often a difficult but unimportant
diagnosis and it is usually not settled until the parts are displayed by operation.
Note- Examination using finger and thumb across the neck of
the scrotum will help to distinguish between a swelling of inguinal
origin and one that is entirely intrascrotal.
16. Differential diagnosis in the female
• hydrocele of the canal of Nuck – this is the most common differential diagnostic
• femoral hernia
17. Indirect Versus Direct inguinal hernias
Direct Inguinal Hernia
Indirect Inguinal Hernia
Bulge from the posterior wall of the
Pass through inguinal canal.
Cannot descent into the scrotum.
Can descend into the scrotum.
Medial to inferior epigastric vessels.
Lateral to inferior epigastric vessels.
Reduced: upward, then straight backward.
Reduced: upward, then laterally and
Not controlled: after reduction by pressure
over the internal (deep) inguinal ring.
Controlled: after reduction by pressure
over the internal (deep) inguinal ring.
The defect may be felt in the abdominal
wall above the pubic tubercle.
The defect is not palpable (it is behind
the fibers of the external oblique
After reduction: the bulge reappears
exactly where it was before.
After reduction: the bulge appears in the
middle of inguinal region and then flows
medially before turning down to the
Common in old age.
Common in children and young adults.
Operation is the treatment of choice.
It must be remembered that patients who have a bad
cough from chronic bronchitis should not be denied an
operation, for these are the very people who are in
danger of developing a strangulated hernia.
In adults, local,epidural or spinal, as well as general
anaesthesia, can be used
19. Inguinal herniotomy, which entails
Dissecting out and opening the hernial sac
Reducing any contents
Transfixing the neck of the sac and removing the remainder.
It is employed either by itself or as the first step in a repair procedure (herniorrhaphy).
By itself it is sufficient for the treatment of hernia in infants, adolescents and young adults.
20. Herniotomy and repair (herniorrhaphy)
(1) Excision of the hernial sac
(2) Repair of the stretched internal inguinal ring and the transversalis fascia
(3) Reinforcement of the posterior wall of the inguinal canal.
(4) must be achieved without tension resulting in the wound and
various techniques exist to achieve this, e.g. Shouldice operation,
fascial flaps or mesh implants.
21. Excision of the hernial sac (adult
An incision the skin and subcutaneous tissue 1.25 cm above and parallel to the
medial two-thirds of the inguinal ligament.
In large, irreducible hernias the incision may be extended laterally or into the
upper part of the scrotum.
After dividing the superficial fascia and securing haemostasis, the external oblique
aponeurosis and the superficial inguinal ring are identified.
28. The external oblique aponeurosis is incised in the
line of its fibres and the structures beneath carefully
separated from its deep surface before completing the
incision through the superficial inguinal
Ilioinguinal nerve is safeguarded.
Opening of inguinal canal
Separation of upper leaf of the external oblique
muscle from the internal oblique muscle
Separation of the lower leaf from the contents of the
inguinal canal until the inner aspect of the inguinal
ligament is seen.
The cremasteric muscle fibres may be divided
longitudinally to display the spermatic cord,
29. Excision of the sac
The indirect sac may be distinguished as a pearly white structure lying on the outer side of the
cord and, when the internal spermatic fascia has been incised longitudinally, it can usually be
dissected out and then opened between artery forceps.
Variations in dissection
If the sac is small it can be freed in toto. If it is of the long, funicular or scrotal type, or is
extremely thickened and adherent, the fundus must not be sought because in doing so the blood
supply to the testis may be compromised.
The sac is freed within the inguinal canal and divided circumferentially such that the fundus
remains in the scrotum.
Care must be taken to avoid damage to the vas and spermatic artery when freeing the sac
An adherent sac can be separated from the cord by first injecting saline under the posterior wall
from within (hydrodissection). A similar tactic is employed when dissecting the gossamer sac of
infants and children.
30. Reduction of contents
Intestine or omentum is returned to the peritoneal cavity.Omentum is often
adherent to the neck or fundus of the sac: if adherent to the neck it is freed and
if adherent to the fundus of a large sac it may be transfixed, ligated and cut
across at a suitable point.
The distal part of the omentum, like the distal part of a large scrotal sac, can be
left in situ (the fundus should, however, not be ligated).
31. Isolation and ligation of the neck of the sac.
Whatever type of sac is encountered, it is necessary to free the neck by blunt
dissection until the parietal peritoneum can be seen on all sides.
The dissection is considered complete only when the extraperitoneal fat has
been encountered and the inferior epigastric vessels have been seen on the
It used to be considered essential to open the sac to ensure that no bowel or
omentum was adherent to the neck.
If the sac is obviously empty, it is sufficient to simply reduce it, close the
internal ring and perform a herniorrhaphy if required.
If the sac is opened, all contents should be reduced and the neck transfixed
as high as possible before excising the sac.
32. Repair of the transversalis fascia and the internal ring
When the internal ring is weak and stretched and the transversalis is bulging,
the repair should include a technique of narrowing the deep ring,
e.g. the Lytle method of narrowing the ring with lateral displacement of the
The Shouldice method, whereby the ring and fascia are incised and carefully
separated from the deep inferior epigastric vessels and extraperitoneal fat
before an overlapping repair (‘double breasting’) of the lower flap behind the
upper flap is performed.
In the classic Shouldice operation, a third and fourth layer of tension-free
suturing, using monofilament materials, polypropylene, polyamide or wire, are
placed between the internal oblique aponeurosis arch and the
33. Reinforcement of the posterior inguinal wall
This is achieved by suturing without tension the tendinous aponeurotic arch of
the internal oblique to the undersurface of the inguinal ligament and to the
The Lichtenstein tension-free hernioplasty
involves placement of an approximately 16 × 8 cm (tailored to the
individual patient’s requirements) mesh as an extra lamina, anterior to the
posterior wall and overlapping it generously in all directions, including
medially over the pubic tubercle
34. Other historical techniques, which should now be abandoned
because of poor results, include overlapping the external oblique
behind the cord (making it lie subcutaneously).
Special care is needed to avoid excessive narrowing of the new external ring,
which could jeopardise the vascular supply to and the venous return from the
Completion of operation If desired, the cremasteric muscle can be
reconstituted: the external oblique is directly sutured or overlapped, leaving
a new external ring that should accommodate the
tip of a finger.
Truss may be used when operation is contraindicated or when operation is
A rat-tailed spring truss with a perineal band to prevent the truss slipping
will, with due care and attention, control a small or moderately sized inguinal
A truss must be worn continuously during waking hours, kept clean and in
proper repair and renewed when it shows signs of wear.
It must be applied before the patient gets up and while the hernia is reduced.
40. Tx- direct hernia
The principles of repair of direct hernias are the same as those of
an indirect hernia, with the exception that the hernia sac can
usually be simply inverted after it has been dissected free and the
transversalis fascia reconstructed in front of it.
This reconstruction of the posterior wall of the inguinal canal should be
undertaken by the Shouldice repair or by using a mesh implant according to
the Lichtenstein technique.
41. Laparoscopic herniorrhaphy
Minimally invasive techniques have been developed for the treatment of inguinal
Two techniques are described, a transabdominal approach (TAPP) and a
preperitoneal approach (TEP).
The TAPP approach establishes a pneumoperitoneum and places a synthetic mesh
preperitoneally by dissecting the peritoneum off the hernial orifices and
positioning the mesh beneath the peritoneum before closing the peritoneum over
The TEP approach is completely preperitoneal. The preperitoneal plane is opened
by either balloon dissection or direct dissection via a paraumbilical incision.
The hernial orifices can be identified bilaterallly and any hernia sac reduced.
Placing a large mesh over the hernial orifices.
42. TAPP repairs as the incidence of complications is higher than with the TEP
TEP repair is technically more difficult to perform and is associated with a
longer learning curve.
Laparoscopic repairs can be applied to primary, bilateral and
recurrent inguinal hernias as well as to femoral hernias.