Hernias and Scrotum

Dr. Hiwa Omer Ahmed Assistant Professor in General Surgery

• ”…..an abnormal protrusion of a viscus through its containing wall”

• All ages • Both sexes • % Incidence: Inguinal 80% Incisional 10% Femoral 7%

Risk factors
• Sex; Nearly 10 times more men than women have inguinal hernias, • Family history. Your risk of inguinal hernia increases if you have a close relative, such as a parent or sibling, with the condition. • Certain medical conditions. Having cystic fibrosis, a life-threatening disorder that causes severe lung damage and often a chronic cough, makes it more likely you'll develop an inguinal hernia.

• Chronic cough. A chronic cough, such as occurs from smoking, increases your risk of inguinal hernia. • Chronic constipation. This leads to straining during bowel movements — a common cause of inguinal hernias. • Excess weight. Being moderately to severely overweight can put extra pressure on your abdomen.

• Pregnancy. This can both weaken the abdominal muscles and cause increased pressure inside your abdomen. • Certain occupations. Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia.

• Premature birth. Infants who are born sooner than normal are more likely to have inguinal hernias. • History of hernias. If you've had one inguinal hernia, it's much more likely that you'll eventually develop another — usually on the opposite side

Inguinal hernia

Femoral hernia

Umbilical hernias
• are congenital defects. Most newborn umbilical hernias close spontaneously by the second year of life. Patients with ascites have a high incidence of umbilical hernias.

Umbilical hernia


Epigastric hernias
• . occur in the linea alba above the umbilicus.

Spigelian hernias
• protrude near the termination of the transversus abdominis muscle at the lateral edge of the rectus abdominis muscle.

Incisional hernias
• occur at sites of previous incisions. Hernias occur after 14% of abdominal operations

Incisional hernia

Lumber hernia

Lumbar hernias
• occur superior to the iliac crest or below the last rib. F. Obturator hernias pass through the obturator foramen and present with bowel obstruction and focal tenderness on rectal examination

Hiatus hernia

• Position: Inguinal/femoral etc

CONGENITAL • Preformed sac • E.g. Patent processus vaginalis ACQUIRED. • Primary: Natural week points eg femoral canal. • Secondary: Injury e.g. surgical wounds.

Increased abdo pressure: • Heavy lifting • Chronic cough • BPH • Constipation • Ascites Weakened Abdo wall: • Increasing age • Malnutrion • Collagen disorders • Smoking • obesity

• To understand inguinal and femoral hernia it is necessary to understand the anatomy of the inguinal canal.

Inguinal Ligaments

Inguinal canals

Right Inguinal canal

• The inguinal canal is an oblique muscular passage through the lower abdominal wall and transmits the passage of the spermatic cord in males and the round ligament in females. It runs parallel and superiorly to inguinal ligament.

Inguinal canal

• • • • FLOOR: Inguinal ligament ANTERIOR WALL: External Oblique POSTERIOR WALL: Transversalis fascia MEDIAL-POSTERIOR WALL: Internal oblique and transversalis (when they fuse become conjoint tendon.)

3 ARTERIES: • Testicular Artery • Artery to Vas • Artery to cremaster 3 LAYERS OF FASCIA: • External spermatic fascia • Cremasteric fascia • Internal spermatic fascia. 3 NERVES: • Genital branch of genitofemoral nerve • Sympathetic fibres • Ilioinguinal nerve 3 OTHERS: • Vas deferens • Panpiniform plexus • Lymphatics

Spermatic canal contents

• • • • INDIRECT Lateral to IEA Outside Hasselbach triangle. Therefore hernia goes from DR SR scrotum. Therefore, indirect hernias are controlled @ deep ring

• • • •

DIRECT Medial to IEA Inside Hasselbach triangle. It is a bulge in fascia transversalis. Therefore if bulge medial to fingers at deep ring it is direct.

• Note that scrotal swellings are usually indirect. • However, large directs can cross superficial ring and enter the scrotum. This is rare. • An indirect and direct hernia occurring simultaneously is termed a pantaloon hernia.

• Hernias must be examined with the patient standing and in supine • Start with any posision. • Always examine both groins.

Types of hernia Obliteration of tunica vaginalis

• Patient in standing and supine position

• Visible swelling( don’t consider bilateral Malgiagne‘s bulging as hernia) • Visible cough impulse • Easily reducible • Reappear on straining, standing or coughing • Elucidate Fothergill and Carnet signs •

• PALPATION • Examine as amass and then
• • • • Palpable cough impulse Reduce Occlusion test Three Finger test ( Zimman’s test)

Assess the following:
• • • • • • • • • Position Temperature Tenderness Shape Size Tension Composition Expansile cough impulse Reducible: ? Control @ deep ring. Which way does it reappear?

• ? Bowel sounds

• Remember always examine the other side!


• • • • Meclo ; DIIH with wide neck Umbilical hernia up to 4 years of age In unfit patient

• According to age; • * up to 7 years ;>> Herniotomy * 7-17 :> Herniotomy _+ Lytle repair * 17 & on; > Herniotomy & hernioraphy or hernioplasty

• Oblique inguinal Incision • Finding the sac on anteriolateral aspect of the spermatic cord • Dissection of the sac • Returning of the content of the hernia to the abdomen • Transfixation of the neck of the sac • Ligation • excision

• Herniorrhaphy. In this procedure, an incision in the groin done called oblique inguinal incision the protruding intestine pushed back into the abdomen, then repairs the weakened or torn muscle by sewing it together 1. Lytle repair 2. Bassini or modified Bassini 3.Schouldise repair 4. Muscovige repair

• In this procedure, the surgeon inserts a piece of synthetic mesh to cover the entire inguinal area, including all potential hernia openings. The patch is usually secured with sutures, clips or staples. Hernioplasty can be performed conventionally, with a single long incision over the hernia. But it's often done laparoscopically, using several small incisions rather than one large one. the other incisions. Your surgeon then performs the operation using the video camera as a guide.

Laparoscopic hernia repair

synthetic mesh

• You can't prevent the congenital defect that may lead to an inguinal hernia, • but the following steps can help reduce strain on your abdominal muscles • and tissues: • Maintain a healthy weight. If you think you may be overweight, talk to your doctor about the best exercise and diet plan for you.

Emphasize high-fiber foods. Fresh fruits and vegetables and whole grains are good for your overall health. They're also packed with fiber that can help prevent constipation and straining. • Lift heavy objects carefully or avoid heavy lifting altogether. If you have to lift something heavy, always bend from your knees, not at your waist.

Stop smoking. In addition to increasing your risk of serious diseases such as cancer, emphysema and heart disease, smoking often causes a chronic cough that can lead to or aggravate an inguinal • hernia. • Don't rely on a truss for support. Contrary to what you may have heard, wearing a truss isn't the best long-term solution for an inguinal hernia

• A truss won't protect against complications or correct the underlying problem, although the doctor may recommend wearing one for a short time before surgery or for unfit patient.

1. 2. 3. 4. 5. 6. 7. Inguinal hernia Sapheno varix Femoral LN Lipoma Femoral aneurysm Psoas abscess Rupture Adductor longus with haematoma

1. Extends to scrotum 2. Direction of reduction
3. Controlled by pressure over deep ring


Straight back

Up & Lateral

4. Direction on release

To original position

Down & Medial

INGUINAL 1. Position relative to PT 2. Palpation 3. Percussion 4. Auscultation
Superior and medial Soft ? Resonant

Inferior and lateral Firm Dull

BS ++

BS +

• Femoral Sheath=Femoral artery and vein drag peritoneum below inguinal ligament. • Femoral canal=is the medial part of femoral sheath.

• . In femoral hernias, the abdominal viscera and peritoneum protrude through the femoral ring into the upper thigh. The femoral ring is limited medially by the lacunar ligament of Gimbernat, laterally by the femoral vein, anteriorly and proximally by the inguinal ligament, and posteriorly and distally by Cooper's ligament

• Anterior border: Inguinal ligament • Posterior border: Pectineal Ligament ( ligament of Astley Cooper) • Medial border: Lacunar ligament • Lateral border: Femoral vein

• Femoral hernias may present as a tender groin mass, and small-bowel obstruction may sometimes occur

Physical examination
• The hernia sac manifests clinically as a mass in the upper thigh, curving craniad over the inguinal region. It may appear while the patient is standing or straining and may disappear in the supine position.

Types of femoral hernia

• . Femoral hernias account for 5% of all hernias, and 84% of femoral hernias occur in women. Incarceration or strangulation occurs in 25% of femoral hernias

• A Cooper's ligament repair (McVey) through the inguinal approach is recommended

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