INGUINAL HERNIAS PART 1: Anatomy and

Physiology, Diagnostics 3rd BIMO

Surgery 2 | Dr. Refuerzo LEC 15.1
February 7, 2023

OUTLINE spermatic cord crosses a defect in the external

I. Introduction oblique aponeurosis
II. Anatomy ● The spermatic cord traverses the inguinal canal,
A. Boundaries of Inguinal Canal and it contains three arteries, three veins, two nerves,
B. Hesselbach’s triangle the pampiniform venous plexus and the vas deferens
C. Femoral Ring
D. Blood Supply ● Additional important structures surrounding the
E. Nerve Supply inguinal canal include the iliopubic tract, the lacunar
F. Triangle of Doom ligament, Cooper’s ligament, and the conjoined
G. Triangle of Pain tendon
H. Circle of Death
III. Pathophysiology ● The iliopubic tract is an aponeurotic band that begins
IV. Types of Inguinal Hernia at the anterior superior iliac spine and inserts into
A. Indirect Inguinal Hernia Cooper’s ligament from above
B. Direct Inguinal Hernia ● The iliopubic tract helps from the inferior margin of
C. Femoral Inguinal Hernia
V. Nyhus Classification System the internal inguinal ring as it courses medially, where
VI. Clinical Classification of Hernia it continues as the anteromedial border of the femoral
VII. Diagnosis canal
A. History ● The lacunar ligament, or ligament of Gimberat, is the
B. Physical Examination
C. Imaging triangular fanning of the inguinal ligament as it joins
the pubic tubercle
● Cooper’s (pectineal) ligament is the lateral portion of
Must Know Book Lecturer
the lacunar ligament that is fused to the periosteum
of the pubic tubercle
I. INTRODUCTION ● The conjoined tendon is commonly described as the
fusion of the inferior fibers of the internal oblique and
● Approximately 75% of abdominal wall hernias occur transversus abdominis aponeurosis at the point
in the groin where they insert on the pubic tubercle
● Lifetime risk of inguinal hernia is 27% in men and 3% ● Laparoscopic inguinal hernia repair requires a
in women thorough knowledge of inguinal anatomy from a
● The incidence of inguinal hernias in males has a posterior perspective
bimodal distribution, with peaks before the first year ● Intraperitoneal points of reference are the five
of age and after the age 40 peritoneal folds, bladder, inferior epigastric vessels,
● The most common subtype of groin hernia in men and psoas muscle
and women is the indirect inguinal hernia ● Between the peritoneum and the posterior lamina of
● Inguinal hernia is a defect in the groin and the transversalis fascia is Bogros’s (preperitoneal)
intra-abdominal wall and organs that protrudes in the space. this are contains preperitoneal fat and areolar
inguinal area tissue
● ENDOABDOMINAL FASCIA (Transversalis ● The most medial aspect of the preperitoneal space,
Fascia)--layer in the abdominal wall that will prevent that which lies superior to the bladder, is known as
the protrusion of organs through the abdominal tract the space of Retzius
○ defect will result to hernia
● Most common predisposing factor is increased in
A. BOUNDARIES OF INGUINAL CANAL
abdominal pressure
● Femoral hernias occur more commonly in women
but not the most common type ● Anteriorly: External oblique aponeurosis
● Laterally: Internal oblique muscle
II. ANATOMY ● Posteriorly: Transvesalis fascia and Transversus
abdominis
● The inguinal canal is an approximately 4 to 6 cm ● Superiorly: Internal oblique and Tranvesus abdominis
long, cone shaped region situated in the anterior ● Inferiorly: Inguinal (Poupart’s) Ligament
portion of the pelvic basin
● The canal begins on the posterior abdominal wall,
where the spermatic cord passes through a hiatus in
the transversalis fascia also known as the deep
(internal) inguinal ring
● the canal concludes medially at the superficial
(external) inguinal ring, the point at which the

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 D. BLOOD SUPPLY

● The vascular space is situated between the posterior

and anterior laminae of the tranvesalis fascia, and it
houses the inferior epigastric vessels which are
supplied by external iliac artery and anastomoses
with superior epigastric a continuation of the internal
thoracic artery
● Epigastric veins course parallel to the arteries in the
rectus sheath

E. NERVE SUPPLY

● Nerves of interest in the inguinal region

o Ilioinguinal
o iliohypogastric
o Genitofemoral
o Lateral femoral cutaneous
● The ilioinguinal and iliohypogastric nerves arise
together from the first lumbar nerve (L1)
B. HESSELBACH’S TRIANGLE
Ilioinguinal Nerve
● Superolaterally: Inferior Epigastric Vessels ● emerges from the lateral border of the psoas major
● Medially: Rectus Sheath and passes obliquely across the quadratus lumborum
● Inferiorly: Inguinal Ligament ● it pierces the transversus and internal oblique
muscles to enter the inguinal canal and exits through
the superficial inguinal ring
● it supplies somatic sensation to the skin of the upper
and medial thigh
● In males, it also innervates the base of the penis and
upper scrotum
● in females, it innervates the mons pubis and labia
majora

F. TRIANGLE OF DOOM

● Medial: Vas deferens

● Lateral: Vessels of the spermatic cord
● Contents:
C. FEMORAL RING o External iliac vessels
o Deep circumflex iliac vein
● Anteriorly: Iliopubic tract and inguinal ligament o Femoral nerve
● Posteriorly: Cooper’s ligament o Genital branch of the genitofemoral nerve
● Medially: Lacunar ligament
● Laterally: Femoral vein

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 G. TRIANGLE OF PAIN
● bordered by the iliopubic tract and gonadal vessels,
and it encompasses the lateral femoral cutaneous,
femoral branch of genitofemoral and femoral nerves
● Several studies have documented strenuous physical
activity as a risk factor for acquired inguinal hernia
● Microscopic examination of skin of inguinal hernia
patients demonstrated significantly decreased ratios
of type I to type III collagen

H. CIRCLE OF DEATH

● A vascular continuation formed by:

o common iliac
o internal iliac
o obturator
o inferior epigastric
o external iliac

III. PATHOPHYSIOLOGY

● Inguinal hernias may be congenital or acquired

● Most adult inguinal hernias are considered acquired
defects in the abdominal wall
● The most likely risk factor for inguinal hernia is
weakness in the abdominal wall musculature
● Congenital hernias, which make up the majority of
pediatric hernias, can be considered a developmental
defect rater that an acquired weakness
● Failure of the peritoneum to close results in a patent
processus vaginalis (PPV)

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 IV. TYPES OF INGUINAL HERNIA V. NYHUS CLASSIFICATION SYSTEM

A. INDIRECT INGUINAL HERNIA Nyhus Classification categorizes hernia defects by

location, size and type.
● congenital
● Children (1st decade of life)
● Patent Processus Vaginalis
● Lateral to the inferior epigastric vessels
● enter inguinal canal at the deep inguinal ring
● cass pass into the scrotum
● more common (⅔ of hernia)

B. DIRECT INGUINAL HERNIA VI. CLINICAL CLASSIFICATION OF HERNIA

● Acquired REDUCIBLE HERNIA

● Adults (4th decade of life) ● is one which can be pushed back into the abdomen
● Weakness of the abdominal wall by putting manual pressure to it
● Directly behind the superficial inguinal ring
● Medial to the inferior epigastric vessels, within IRREDUCIBLE/INCARCERATED HERNIA
Hesselbach’s triangle ● is one which cannot be pushed back into the
● Cannot descend into the scrotum abdomen by applying manual pressure
● Obstructed Hernia - one in which the lumen of the
C. FEMORAL INGUINAL HERNIA herniated part of intestine is obstructed
● Strangulated hernia - in one in which the blood
● Femoral hernias protrude through the small and supply of the hernia contents is cut off, thus, leading
inflexible femoral ring to ischemia. The lumen of the intestine may be patent
● They traverse the empty space between the femoral or notc
vein and the lymphatic channels Clinical Parameters of Strangulation:
● Fever
● Tachycardia
● Exquisite tenderness
● Erythema tenderness
● Erythema of underlying skin
● leukocytosis
● Obstructive symptoms

VII. DIAGNOSIS

A. HISTORY

● The most common symptom of inguinal hernia is a

groin mass that protrudes while standing, coughing,
or straining
● Symptoms that are extrainguinal such as change in
bowel habits or urinary symptoms are far less

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 common but should be recognized as having the
potential to be ominous
● The pain is thought to be due to compression of the
nerves by the sac, causing generalized pressure,
localized sharp pain, or referred pain
● Patients will often reduce the hernia by pushing the
contents back into the abdomen, thereby providing
temporary relief. As the defect size increases and
more intra-abdominal contents fill the hernia sac, the
hernia may become harder to reduce and
incarcerate, prompting urgents surgical intervention
● Certain elements of the review of systems such as
chronic constipation, cough, or urinary retention
should prompt the surgeon to perform a thorough
workup to rule out any underlying malignancy
B. PHYSICAL EXAMINATION
● Essential for diagnosis
● The patient should be examined in a standing
position
● Ideally, the patient should be examined in a standing
position to increase intra-abdominal pressure, with
the groin and scrotum fully exposed
● Inspection is performed first, with the goal of
identifying an abnormal bulge along the groin or
within the scrotum. if an obvious bulge is not
detected, palpation is performed to confirm the
presence of the hernia
● Palpation is performed by advancing the index finger
through the scrotum towards the external inguinal
ring (Digital exam)
● The patient is then asked to perform a Valsalva
maneuver to increase intraabdominal pressure
● Examination of the contralateral side affords the
clinician the opportunity to compare the presence and
extent of herniation between sides
● In addition to inguinal hernia, a number of other
diagnoses may be considered in the differential of a
groin bulge
SURG INGUINAL HERNIAS PART 1: Anatomy and Physiology, Diagnostics
C. IMAGING
● In the case of an ambiguous diagnosis, radiologic
investigations may be used as an adjunct to history
and physical examination. Imaging in obvious cases
is unnecessary
ULTRASOUND
● Least invasive technique and does not impart any
radiation to the patient
● Anatomic structures can be more easily identified by
the presence of bony landmarks; however, because
there are few bones in the inguinal canal, other
structures such as the inferior epigastric vessels are
used to define groin anatomy
● Positive intra-abdominal pressure is used to elicit the
herniation of abdominal contents
● Sensitivity of 86%, specificity of 77%
CT-SCAN
● Provide static images that are able to delineate groin
anatomy, to detect groin hernias, and to exclude
potentially confounding diagnoses
● Sensitivity of 80%, specificity of 65%
MRI
● Most commonly utilized in cases where physical
examination detects a groin bulge, but where
ultrasonography is inconclusive
● The expense of MRI precludes its routine use to
diagnose inguinal hernias
REFERENCES
Dr. Refuerzo’s ppt
Schwartz’s Principles of Surgery, 10th Ed.
FREEDOM WALL
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