Bader Al-Mukhtar RCSI-MUB SC (2)

Hernia:

History:
1. Lump:
Duration
When was first noticed
Location left or right
Is it always there or does it diappear?
Progression changes in size
Painful or painless
Is it reducible?
Skin changes over the lump
2. Risk factors
History of heavy lifting
Chronic constipation, cough
Pregnancy, ascites, obesity
3. Bowel obstruction
Colicky abdominal pain
Abdominal distension
Vomiting
Constipation

Above the inguinal ligament

Inguinal hernia
Undescended testis
Encysted hydrocele or lipoma of the cord
Iliac node
Large femoral hernia (rare)
Below the inguinal ligament
Femoral hernia
Lymph node
Saphena varix (sensation of a 'jet of water' on palpation, disappears when
supine)
Femoral aneurysm (pulsatile)
Psoas abscess (associated with fever, flank pain and flexion deformity)

1. Inguinal hernias

Anatomy
o The inguinal canal extends from the pubic tubercle to the anterior superior
iliac spine. In the male, it carries the spermatic cord (vas deferens, blood
vessels and nerves). In the female, it is much smaller and carries the round
ligament of the uterus.
o After testicular descent, the canal closes but the site is weakened.

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Bader Al-Mukhtar RCSI-MUB SC (2)

o The internal ring is an opening in the transversalis fascia lying at the

midinguinal point, halfway between the anterior superior iliac spine and the
pubic symphysis (about 1.5cm above the femoral pulse (at mid-inguinal
point).

o The external ring is an opening of the external oblique aponeurosis and is

immediately above and medial to the pubic tubercle (see Fig. 9.14).
o Direct inguinal hernia: this is herniation at the site of the external
ring.
o Indirect inguinal hernia: this is the most common site (85% of all
hernias). Herniation is through the internal ring with bowel or
omentum travelling down the inguinal canal and may protrude through
the external ring into the scrotum. More likely to strangulate than
direct inguinal hernias.

Examination of the hernia:

o With the patient first erect and then supine on the bed start the examination
with inspection and then palpation in each position.

Inspection:
1. Scars from previous surgery
2. Obvious lumps and swellings.
3. Ask the patient to turn the head away and to cough (with your eyes
fixed in the region of pubic tubercle noting the presence of any visible
cough impulse).
4. Ask the patient to cough again with the examiner inspecting the
opposite side.

Palpation:
1. Begin with the fingers placed over the pubic tubercle.
2. With 2 fingers on the mass, ask the patient to cough once again ask the
patient to cough and a palpable pulsatile or expansile cough impulse
is felt.
3. If hernia is present attempt to reduce it (only done with the patient lie
supine) or initially ask the patient to reduce it.
4. With the hernia reduced, try pressing over the site of the internal ring
and asking the patient to cough. An indirect hernia will remain
reduced whereas a direct hernia will protrude once more.

Auscultation:
1. Listen over the lump for the presence of bowel sounds which might
indicate the contents of the hernia sac.

Finally:
1. Look at the scrotum for the distension of the hernia, which will make it
more likely to be an indirect hernia.

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Bader Al-Mukhtar RCSI-MUB SC (2)

Table 9.2 Differentiation of inguinal hernias

Indirect inguinal hernia Direct inguinal hernia
Can descend into the scrotum Very rarely descends to the scrotum
Reduces upwards, laterally, backwards Reduces upwards and backwards
Remains reduced with pressure at the Not controlled by pressure over the
internal ring internal ring
The causative defect is not palpable Defect in the abdominal wall is palpable
Reappears at the internal ring and flows Reappears in the same position as before
medially reduction

2. Femoral hernias

Examination
o Examine with the patient standing up and undressed from the waist down.
o Examine as you would any other hernia and attempt reduction.
o If present, a femoral hernia will appear as a lump just lateral and inferior to
the pubic tubercle, about 2cm medial to the femoral pulse.

Box 9.19 Differential diagnosis of a femoral hernia

o Inguinal hernia.
o Very large lymph node.
o Ectopic testicle.
o Psoas bursa or abscess.
o Lipoma.