CLARKE INTERNATIONAL UNIVERSITY

DIPLOMA CLINICAL MEDICINE AND COMMUNITY HEALTH

SURGERY COURSE WORK ONE
REG.NO. 2021DCMFT-F40

Abdominal defects
Inguinal Hernia
An inguinal hernia is the protrusion of intra-abdominal contents through a defect in the
abdominal wall. It can be fat, bowel, or, in some cases, the genitourinary tract.
The site of this hernia is confirmed if the hernial sac passes medial to and above the index finger
placed on the pubic tubercle, however, if it is lateral to and below, then the hernia must be
femoral in site.

If it has been decided that the hernia is inguinal, then one needs to know these further
points:

 What are the contents of the sac? Bowel tends to gurgle, is soft and compressible, while
omentum feels firmer and is of a doughy consistency.
 Is the hernia fully reducible or not? It is best to lie the patient down to decide this. Ask
the patient if he is “able to push the hernia back in” and, if so, ask him to do so and
confirm yourself. (It is more painful if the examiner reduces it.)
 Is the hernia direct or indirect? Again, it is best to lie the patient down to decide this.
Inspection of the direction of the impulse is often diagnostic, especially in thin patients.,
Another helpful point is to place one finger just above the mid-inguinal point over the
deep inguinal ring. If a hernia is fully controlled by this finger, it must be an indirect
inguinal hernia.
Types of inguinal hernias
 Direct hernia (Incomplete hernia). A direct hernia tends to bulge straight out through
the posterior wall of the inguinal canal.
Direct inguinal hernia is protrusion of abdominal contents through the transversalis
fascia within Hesselbach's triangle. The borders of Hesselbach's triangle are the inferior
epigastric vessels superolaterally, the rectus sheath medially, and inguinal ligament
inferiorly.
Direct inguinal hernia is seen in adults, especially in men over ageing. On ageing,
abdominal muscles weaken leading to direct inguinal hernia.
  Indirect hernia (Complete hernia). An indirect hernia occurs when abdominal contents
protrude through the internal inguinal ring and into the inguinal canal. This occurs lateral
to the inferior epigastric vessels. The hernia contents may extend into the scrotum.
In an indirect hernia, the impulse can often be seen to travel obliquely down the
inguinal canal.
These are the most common and inborn type of hernias that might occur in males and
females but are quite common in males. Usually, in males, the testicles start from the
abdomen and descend to the groin area to reach the scrotum (a sac-like pouch that
holds the testicles) through an opening; when this opening doesn't close at birth, a
hernia form. In females, this type of hernia (inguinal hernia female) is caused by the
sliding of reproductive organs (sliding inguinal hernia) or small intestine into the groin
area as a result of abdominal weakness.
 Incarcerated Inguinal hernia.
When tissue in the groin becomes stuck, it results in an irreversible incarcerated inguinal
hernia. This implies that it cannot be moved back to its original position.
The blood supply to the tissue is intact in incarcerated inguinal hernias and tends to lead
to strangulation (compression of blood or air-filled structures). It is common in all groin
hernias, with an estimated frequency of 6%. In about 10% of cases, an inguinal hernia
will become incarcerated, which can result in intestinal blockage, strangling, and
infarction (obstruction of blood supply). The most dangerous and potentially fatal of
these complications is strangling.
Diagnosis is usually made by physical examination; the hernia sac content may vary in
this condition.
 Strangulated Inguinal Hernia.
Inguinal hernias that have been strangulated are more dangerous and occur when the
blood supply to an intestine is interrupted. This condition frequently happens if there is
a large number of contents within the hernia and a small musculature opening.
Symptoms of inguinal Hernias.
Inguinal or groin hernia signs and symptoms are as follows:
Groin bulge (groin is the area between the thigh and lower abdomen).
Discomfort, pain, or heaviness in the groin region.
Scrotal bulge (scrotum is a sac-like pouch that holds testicles in males).
Swelling in the scrotal region.
Pain on coughing, exercising or bending.
Aching or burning sensation at the hernial bulge.
Symptoms of strangulated inguinal hernia include:
 Fever.
  Severe pain on progression.
 Tachycardia (rapid heart rate).
 Nausea and vomiting.
Other Types of abdominal hernias.
o Umbilical hernia -
o Epigastric hernia
o Spigelian hernia -
o Interparietal hernia -
o Supravesical hernia
o Lumbar hernia
o Obturator hernia
o Sciatic hernia
o Perineal hernia
o Gastroschisis and
o Femoral hernia

Causes of Hernias
 A hole or weak area that exists from birth.
 Persistent cough or sneezing
 Long term straining to urinate or defecate
 Regular hard physical activities or heavy manual labour.
 Congenital variation
 A gap or weak region left over from prior abdominal surgery
 Multiple pregnancies.
 Jobs where standing is required for longer period.
 Tissue deterioration
Predisposing Factors to hernias
The risk factors for inguinal hernia are as follows:
 Heredity or family history: There is a genetic component regarding inguinal hernias, and
the genes associated with inguinal hernia susceptibility have also been linked to
connective tissue homeostasis.
 Male gender: Inguinal hernia is more common in men because they have a broader
inguinal canal than women, so they are more likely to develop this type of hernia.
 Obesity or overweight: Obesity has been theorised to increase the risk of inguinal hernia
through raising abdominal pressure.
 Chronic constipation: Constipated people who strain may have increased abdominal
pressure and an increased risk of hernia formation.
  Cystic fibrosis (genetic disorder that affects the pancreas, lungs and digestive tract): A
study has stated that there is a risk for hernia, hydrocele, and undescended testis in
males with cystic fibrosis, and to a lesser extent in male siblings and fathers. This
increased risk may be associated with the genes involved in cystic fibrosis and leads to
the reflection of altered embryogenesis of the Wolffian-derived structures (duct from
where the epididymis, vas deferens, ejaculatory duct and seminal vesicles of males will
develop).
 Chronic cough: Severe or persistent coughing increases the pressure on the walls of
abdominal muscles and might cause an inguinal hernia.
 Premature birth or premature infants: The inguinal canal from where the testes descend
from the abdomen into the scrotum fails to close at birth, resulting in inguinal hernias
(inguinal scrotal hernia). This condition is common in premature infants and is also seen
in approximately 1 to 5% of children.
 Pregnancy: Pregnancy increases intra-abdominal pressure due to the enlargement of
the gravid uterus, which might cause a hernia. In addition, hormonal changes may lead
to hernia formation in pregnant women.
 Men with a history of prostatectomy (surgical removal of the prostate gland): Men who
have undergone surgery for prostatectomy, i.e., robotic-assisted radial prostatectomy,
have a risk of developing an inguinal hernia due to incontinence.
 Ageing: In adults on ageing, there might be a chance to develop an inguinal hernia. On
ageing, the connective tissues and muscles of the lower abdominal wall across the
inguinal canal get weaker and tend to develop the inguinal hernia.
Complications of Inguinal Hernia
The complications of inguinal hernia are as follows:
 Pressure or pain and enlargement of hernia: If the hernia is left untreated, it will become
larger and create pressure. In men, this condition results in bulging down into the
scrotum, which results in pain and swelling.
 Incarceration: Occurs when the hernia's protrusion (and its contents) become lodged in
a weak spot of the abdominal wall. It may result in bowel obstruction, accompanied by
excruciating pain, nausea, vomiting, and the inability to urinate.
 Bowel obstruction in the small intestine: Herniation of the small intestine becomes
trapped and pinched, which may cause the blockage. This condition stops the individual
from being able to poop or pass the gas, resulting in severe abdominal pain, nausea and
vomiting.
 Strangulation: The blood flow to a strangulated hernia has been interrupted. As a result,
the tissue may become inflamed, infected and eventually die (tissue necrosis).
Strangulation is a medical emergency and requires immediate medical or surgical
treatment.
Diagnosis of inguinal Hernias.
Diagnosis for inguinal or groin hernias is as follows:
 Thorough history taking (family, medical or medication histories) of an individual.
 Physical examination
 Ultrasonography (USG)
 Computed tomography (CT scan)
 Magnetic resonance imaging (MRI scan)
Types of Management of Inguinal Hernias
1) Lifestyle modifications
2) Wait and watch approach
3) Surgical approaches
Lifestyle modifications
o Through strengthening abdominal muscle by regular exercises.
o Quitting smoking as smoking reduces collage production in the body thus reducing tissue
strength especially in the abdominal region interfering with healing following surgery.
o Eating a healthy and balanced to reduce the predisposing factors to hernias diet.

Surgical Approaches

 Open inguinal herniorrhaphy

 Tissue Repairs
 Prosthetic Repairs
 Laparoscopic inguinal herniorrhaphy
 Transversus Abdominis Muscle Release (TAR)
 Transabdominal Preperitoneal Procedure (TAPP)
 Total Extraperitoneal Procedure (TEP)
 Extended totally extraperitoneal repair (eTEP)
 Extended Transversus Abdominis Muscle Release (eTAR)
Prevention of Inguinal Hernias.
Indirect hernias (from birth) can’t be prevented. However, the direct inguinal or groin hernias
may be prevented by the following measures:
Learn proper lifting techniques for heavy goods
Avoid constipation and cure it when necessary to avoid straining during bowel
movements
If the person has a chronic cough, treatment is needed for cough
Get treated for an enlarged prostate who struggles to urinate
Lose the additional weight and maintain a healthy weight
Inguinal hernia exercises are needed to build core strength for the fitness of abdominal
muscles
Avoid or quit smoking. Get the doctor's cessation plan by talking to him
Take a healthy diet which is rich in fiber
Avoid lifting heavy objects

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