Examination of Hernia

DR MIN OOSurgery

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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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Causes Coughing

Straining Obesity

Smoking

Abdominal distension

Predisposing factors ???

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Composition of hernia

Sac

• Sac is a diverticulum of peritoneum

• Consist of mouth,neck, body and fundus

Covering

• Derived from the layers of abd wall through which the sac passes

Contents

• Omentum- omentocele• Intestine- enterocoele• Portion of circumference of

intestine- Richter’s Hernia• Portion of bladder (or a

diverticulum)• Ovary with or w/o

corresponding Fallopian tube

• Meckel’s diverticulum-Littre’s hernia

• Fluid

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Classification

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Reducible Hernia- contents can be

returned to abdomen

Irrreducible Hernia- contents cannot be

returned to the abdomen but there is no other complication

Obstructed Hernia- irreducible hernia

containing intestine that is obstructed with

good blood supply

Strangulated Hernia- blood supply is

obstructed

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

• Structures passing through

the abdominal wall

• Muscle fail to develop

• Scar tissue

Acquired weakness• Trauma • High intra-abdominal

pressure• Coughing• Straining• Abdominal distension

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Various types of Herniae?(common)

• Inguinal

• Umblical

• Incisional

• Femoral

• Epigastric

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• Spigelian

• Obturator

• Lumbar

• Gluteal

Other rare herniae

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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 lump…down 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 )

• Don’t exam the external ring or canal as it is

painful

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Feel from the side

• Having exam the scrotal content & can’t 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 inguinal canal

Via transversalis fascia (hasselbach’s triangle)

Patent or reopen processus vaginalis Weak abdominal wall/muscle

Unilateral in 2/3 case (right side more common)

Bilateral in > ½ case

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 finger

Impulse on middle finger

Deep ring occlusion test- control Bulge out

Little finger invagination test- impulse on finger tip

Impulse on pulp

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Clinical features

Indirect inguinal hernia - sudden pain at the groin

- swelling in inguinal canal which

may extend into scrotum

- become visible when patient

stand or cough

- dragging/ discomfort

- passes above and medial to

pubic tubercle

- palpable cough impulse

- audible bowel sound +/-

Direct inguinal hernia - seen protruding directly forward

- usually readily reducible

- gradual onset

- Severe pain is rare If there is no

complication such as incarceration or

strangulation

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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