Examination of

Hernia

DR MIN OO
Surgery
 Outline
Definition
Types
Predisposing factors
Basic features of a hernia
Inguinal hernia
Applied anatomy
Examination of inguinal hernia
Differences b/t direct and indirect inguinal hernia
Some definitions
Video click for inguinal hernia examination

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Learning out come
To understand the basic principle for examination of hernia.

To know the various types of herniae.

Able to understand the applied anatomy for the inguinal region.

Able to demonstrate the examination of inguinal hernia.

Comprehend the differences between direct and indirect inguinal

hernia.

To appreciate the some confused definitions.

To be able to develop the skill for the examination of a herniae

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 What is hernia?

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 Hernia protrusion of a viscous or part of
viscous through an abnormal opening in the
walls of its containing activity.

25th edition,Bailey`s & Love`s Short practice of surgery

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 WHY HERNIA
OCCUR?

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 Predisposing factors ???

Obesity
Straining Smoking

Abdominal
Coughing Causes distension

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 Composition of hernia
Sac Covering Contents
Derived Omentum- omentocele
from the Intestine- enterocoele
Sac is a
layers of
diverticulum of
abd wall Portion of circumference of
peritoneum
through intestine- Richters Hernia
which the Portion of bladder (or a
Consist of sac passes diverticulum)
mouth,neck, Ovary with or w/o
body and corresponding Fallopian
fundus tube
Meckels diverticulum-
Littres hernia
Fluid

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 Classification

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 Irrreducible Hernia-
Reducible Hernia- contents cannot be
contents can be returned to the
returned to abdomen abdomen but there is
no other complication

Obstructed Hernia-
irreducible hernia Strangulated Hernia-
containing intestine blood supply is
that is obstructed with obstructed
good blood supply

Inflammed Hernia-
contents of the sac
become inflammed
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 Basic features of hernia???
Occur at weak point (Congenital or acquired)

Reducible on lying down or with direct pressure

Have an expansile cough impulse

(Visible & palpable)

Note: last 2 signs may be absent if constricted at

the neck
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 Causes of abdominal Herniae
Anatomical weakness Acquired weakness
Structures passing through Trauma
High intra-abdominal
the abdominal wall pressure
Muscle fail to develop Coughing
Straining
Scar tissue
Abdominal distension

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 Various types of Herniae?(common)

Inguinal

Umblical

Incisional

Femoral

Epigastric

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 Other rare herniae
Spigelian

Obturator

Lumbar

Gluteal

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 Inguinal
Hernia

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Surface anatomy ?????

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 Relation to the surrounding
structures
1.Anterior wall
Medially-external obliqueaponeurosis
Lateral- internal oblique muscle
2.Posterior wall
Medially strong conjoint tendon
Lateral- fascia transversalis
3.Floor
Medial- Lacunar ligament
Lateral- inguinal ligament
4.Roof
Arching of fibers of int oblique and
transverse muscles.

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 Examination of the hernia
Ask permission

Exposure

Position

Third party

Privacy

Manner

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 Ask the patient to stand up
Lying position ..why not?
Not possible to see the true size.
proper examination even not detect at all.
If suspect since early,start with standing position
If found during routine abdominal exam, complete
abd exam first and ask the patient to stand up to
examine properly.

NOTE: examine both inguinal regions

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 Look at the swelling from the front

Exact size and shape

Visible expansile cough impulse

Distinguish from femoral hernia

Extend of lumpdown into the scrotum ??

Other scrotal swelling .

Any other swelling on the normal side

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 Feel from the front

Exam the scrotum and content

First whether inguino-scrotal or true scrotal by

getting above the upper edge ( get above )

Dont exam the external ring or canal as it is

painful

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 Feel from the side
Having exam the scrotal content & cant get above the lump

assuming the inguinal hernia proceed to examination of the

lump.??? Inguinal Hernia examination

Stand at the side of the patient same side of hernia

Place on hand at the back of to support the patient

Examinating hand and fingers parallel to the inguinal ligament.

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 Expansile cough impulse
Firmly compress the lump with fingers
Ask the patient to turn head toward to opposite side &
to cough
If Tense and expansile = cough impulse (+)

Note:
Localized swelling in the spermatic cord and undescended testis
come out during cough but not bigger nor tense .
(+) is diagnostic for hernia
(-) can not exclude diagnosis (e.g adhesion )

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 Is the swelling is reducible?
Position????
Can control at internal ring =indirect
Can not control = direct

Note:
Reduction point to pubic tubercle
above and medial inguinal
Below and lateral .femoral
Only for reducible one

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 Remove the finger and watch the
reappearance

Direction and the way reappearance help to deduct the

origin of hernia

Obliquely downward = indirect

Directly project forward = direct

NOTE:
Difficult in obese patient

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 Percuss and auscultate
Intestine = resonant and audible bowel sound

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 Feel the other side

Move the other side and exam the inguinal region

Commonly bilateral particularly in direct inguinal hernia

Ask the patient to cough to make obvious small bulge

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 Examine the abdomen

Any possible increased intra-abdominal

pressure

e.g ..????

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Cardiovascular & respiratory assessment

Fitness

Any chronic respiratory problem..

Increased intraabdominal pressure

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 Differences b/t
direct and indirect inguinal hernia

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 Indirect inguinal hernia Direct inguinal hernia
Any age but common in young Elderly
Via deep inguinal ring and long the Via transversalis fascia (hasselbachs
inguinal canal triangle)
Patent or reopen processus vaginalis Weak abdominal wall/muscle

Unilateral in 2/3 case (right side more Bilateral in > case

common)
Enter scrotum (complete) Does not enter scrotum (incomplete)

Reduced by patient/doctor (manually) Reduced on lying down (automatically)

Narrow neck- more liable to strangulate Broad neck

Zieman technique- impulse on index Impulse on middle finger

finger
Deep ring occlusion test- control Bulge out

Little finger invagination test- impulse on Impulse on pulp

finger tip

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 Clinical features

Indirect inguinal hernia

Direct inguinal hernia
- sudden pain at the groin
- seen protruding directly forward
- swelling in inguinal canal which
- usually readily reducible
may extend into scrotum
- gradual onset
- become visible when patient
- Severe pain is rare If there is no
stand or cough
complication such as incarceration or
- dragging/ discomfort
strangulation
- passes above and medial to
pubic tubercle
- palpable cough impulse
- audible bowel sound +/-
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 D/Dx of inguinal hernia???

Femoral hernia

Vaginal hydrocele

Hydrocele of cord or canal of nuck

Undescended testis

Lipoma of cord

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 Some definition ?????

Strangulated hernia ?

Richter`s hernia?

Maydl`s hernia?

Sliding hernia?

Incarceration ?

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 Video for inguinal hernia examination

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 THANK YOU

HAVE A NICE DAY

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