INSPECTION

1. inspect the patient on standing position and exposed below the waist
- to note the full extent of a hernia
- to inspect direct hernias and varicoceles

I. shape of the swelling

- pyriform in indirect hernia
- location of the swelling
- unilateral or bilateral
- Measure the exact size in cm when hernia are fully distended by asking the patient to
cough
II. Overlying Skin
- redness – red oedematous , shiny skin – strangulated hernia
- oedema
- surgery scar- recurrent , if irregular possible post infection
- discolouration-truss
- Peristalsis – enterocele
III. Cough impulse
- hernia with no expansile impulse – omentocele with adhesions , obstructed hernia,
strangulated hernia
IV. Position of the Penis

PALPATION

I. Temperature and Tenderness

II. Reach the top of the swelling
- if not reach – inguinoscrotal swelling
III. Relation to the pubic tubercle
- inguinal hernia- medial to PT and above inguinal ligament
- femoral hernia–lateral to PT an below inguinal ligament
IV. Relation to testis
- acquired stop above the testis
- congenital – include testis within its sac , testis also may get reduce into the abdomen
along with the intestine when the hernia is reduced
- if testis absent and scrotum empty –undescended testis with hernia
V. Note the consistency
 if soft do translumination if +ve hydrocele, -ve – thickened wall , infection ,
calcification
 Fluctuation +ve – cystic
- Soft + elastic = enterocele
- firm +doughy = omentocele
- tense + tender = strangulated hernia
- bag of worms = varicocele
VI. Test reducibility
- ask patient lie down

Aeracshah
 - direct- reduce itself , indirect – manually reduced
- if difficult to reduce , ask the patient to flex the thigh , abducted and rotated internally
to relax the pillar superficial inguinal ring and the oblique .
- in obstructed hernia – cannot be reduced even in relax and under anaesthesia

Deep Ring Occlusion Test – occlude the deep inguinal ring and ask the patient to cough

- indirect will not bulged out (+ve) when finger removed it come out
- direct – bulged medial to occluding finger on coughing (-ve)

Invagination Test

a) size of the superficial inguinal ring

b) direction of the hernia tract
c) direction of the expansile impulse
d) sphincteric strength of the conjoint tendon
Not done in – small superficial inguinal ring, in a child
VII. Test for cough impulse
Zieman’s technique
- index – deep inguinal ring (indirect )
- middle – superior inguinal ring (direct )
- ring finger – saphenous opening ( femoral hernia)

PERCUSSION (usually not really done )

- ask patient to cough to expand and percuss

- resonant – intestine –enterocele
- other – dull

AUSCULTATION

- Peristalsis – enterocele
- absent sound – omentocele

TO COMPLETE THE EXAMINATION EXAMINE THE OPPOSITE SITE

Aeracshah