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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