1. Inguinal Hernia

2. Normal Anatomy
Inguinal canal is a 3d cylinder between the deep and superficial inguinal rings
Superior Wall – fibres of internal oblique and transversus abdominis
Posterior wall – conjoined tendon on internal oblique, transversus abdominis and fascia transversalis
Anterior wall – aponeurosis of the external oblique
Inferior wall – inguinal ligament, lacunar ligament and the ilio-pubic tract
Inguinal Canal
Spermatic cord – in men
Ilioinguinal nerve
Genito-femoral nerve

3. Normal Anatomy
Inguinal canal is a 3d cylinder between the deep and superficial inguinal rings
Superior Wall – fibres of internal oblique and transversus abdominis
Posterior wall – conjoined tendon on internal oblique, transversus abdominis and fascia transversalis
Anterior wall – aponeurosis of the external oblique
Inferior wall – inguinal ligament, lacunar ligament and the ilio-pubic tract
Inguinal Canal
Spermatic cord – in men
Ilioinguinal nerve
Genito-femoral nerve

4. Pathology
A bulge or protrusion of tissue (usually intestine) from the abdominal cavity
Tissue may or may not be able to moved back
Reducible Hernia
hernia sac can be manipulated and tissue moved back in
Incarcerated/Irreducible
the content of the hernia sac cannot be returned to the abdominal cavity
can lead to complications
Strangulated
The blood supply to the entrapped contents is compromised
Medical emergency

5. Mechanism of Injury Insidious Multifactorial More common in males
Pathological changes in the connective tissue of the abdominal wall
Chronic coughing and manual labour jobs have NOT been shown to increase risk of intra-abdominal pressure

6. Classification Direct Hernia Indirect Hernia
Portion of the intestine protrudes directly outward through a weak point in the abdominal wall
Superior to the inguinal ligament
Painless
Reduces when lying supine
Round swelling near pubis area of deep inguinal ring
Indirect Hernia
Portion of the intestine pushes downward through the deep inguinal ring into the inguinal canal
Through the deep inguinal ring
Can pass into the scrotum (men) or labia (women)
Pain with straining
May decrease when lying supine
Swelling that increases with intraabdominal pressure

7. Subjective Examination
Intermittent or persistent bulge in the groin
May report groin pain- can be pain free
Pain worse with Valsalva maneuvers
Heavy or dragging sensation in the groin
Scrotal pain in men
Worse at the end of the day or after prolonged activity
Activities that increase intra-abdominal pressure worsen symptoms (pain and/or bulging)
Coughing
Lifting
Straining
More noticeable following heavy meal or standing for long periods
Bulge disappears in a supine position

8. Objective Examination
Swelling in the groin at rest or coughing
Bulging in femoral or inguinal areas in standing

9. Special Testing
Internal examination of inguinal ring

10. Further Investigation
Rarely required
Ultrasound
MRI

11. Management
Surgery considered for symptomatic, large or recurrent hernias
Small, minimally symptomatic hernias managed conservatively
Physiotherapy post operatively for rehabilitation

12. Conservative
Advised to monitor for symptoms of incarceration or strangulation

13. Plan B
Hernia repair
Open
Laparoscopic

14. References
Broadhurst, J. F. and C. Wakefield (2015). "Adult groin hernias: acute and elective." Surgery (Oxford) 33(5):
Fitzgibbons, R. J., Jr. and R. A. Forse (2015). "Clinical practice. Groin hernias in adults." N Engl J Med 372(8):
Irwin, T. and A. McCoubrey (2012). "Adult groin hernias." Surgery - Oxford International Edition 30(6):
LeBlanc, K. E., L. L. LeBlanc and K. A. LeBlanc (2013). "Inguinal hernias: diagnosis and management." Am Fam Physician 87(12):