Slide 1

 Superficial inguinal ring
is a triangular opening in the
aponeurosis of ext. oblique, 1.25 cm(half inch )from pubic
tubercle (above) normally not admit the tip of little finger.
 Deep inguinal ring is an oval shape in transversalis fascia
(fascial envelop of the abdomen, below which are
peritoneal fat then peritoneum), u. shape. 1.25cm above the
mid point of inguinal ligament the competency depends
on integrity of fascia .
 The inguinal canal in infant where the deep & superficial
rings are almost superimposed.
 But in adult the canal is oblique, 3.75cm in length, directed
downward & medially from deep to superficial ring.
 In .male
 In female
the canal transmit
*spermatic cord
*ilioinguinal N.
*genital branch of
genit0femoral N.
the canal transmit *round ligament
the spermatic cord
1- Ant.
.( External oblique aponeurosis & conjoined m.
laterally )
2- post.
.inf. epigastric A. (branch of ext. iliac A.)
. Fascia transversalis
. Conjoined tendon (end of 2 muscles int.
& transversis abdominis)
3- sup
.conjoined muscle
4- inf.
.inguinal ligament
Difference between Inguinal hernia
(direct & indirect)& Femoral hernia...
 Indirect inguinal H.
Oblique inguinal H.
* travels down the canal out side the spermatic card
* the neck lat. to inf. epigastric A.
* above & medial to pubic tubercle
 direct inguinal H.
Forward inguinal H.
*comes ant. directly forward through post. wall of canal
*the neck med. to inf. epigastirc A.
*except saddle bag H. in which the hernia consists of two sacs
that straddle the inf. Epigastric A. , one sac being medial & the
other lat. to the A.
 Femoral H.
*the neck of the sac is below & lat. to the pubic tubercle
oblique hernia
 It is the most common H. commonly in the young while
direct is most commonly in middle age or after.
 In first decade of life
is more common on R. side in
male associated with undescending R. testes
 In second decade of life
the L & R. is equal , 30% of
indirect inguinal H. is bilateral & if not diagnosed clinically,
it diagnosed by U\S so must send for sonar even it is unilat.
Types of indirect inguinal H...
3 types:1-Bubonocele (Greek = grain)
The H. is just within the canal.
2-Funicular (Latin = short cord)
The H. is just above the epididymis ( the processes vaginalis is
closed just above epi. The content of sac can be felt separately
from testis.
3-Complete or scrotal .
 There is mass within scrotum
 It is rarely present at birth but commonly encountered in infants
 The testis appear to lie within the lower part of the hernia
 Also can occur in adolescence or adulthood.
.Occur at any age , M:F
1- pain in groin or referred to testis when performing heavy works
or strenuous exercise or any condition lead to increase intra
abdominal pressure.
2- in cough
the bulging may be seen & felt (visible & palpable
cough impulse) which may remain persist until reduced...&
may appear once the pt. stand.
3- sensation of weight & dragging on mesentery which produce
epigastric pain .
4- in infant the hernia appear on crying & it is translucent
(gossamer) even in early adulthood but never in adults.
5- in young female the ovary may prolapsed to the sac.
1- hydrocele of canal of nuck
2- femoral hernia
most common DDx problem
* Indication of operation in infant:1- After 3 ms. of age as elective surgery.
2- Before that in emergency. Specially if it is irreducible,
obstructed or strangulated.
1) Vaginal hydrocele
but hydrocele can get above it (no content , just fluid)
hernia cannot get above it (we feel content)
2) Encysted hydrocele
of the cord
3) Spermatocele
obstruction of epidydimis lead to accumulation of spermatic
4) Femoral hernia
5) Incomplete descending of testes
6) Lipoma of the cord
But lipoma not change with position & cough.
1-Herniotomy .
. In infant & early childhood in whom the canal is not well
. Herniotomy
excision of sac and transfixion of the neck.
.in older children & adult
.Herniorrhaphy Herniotomy + strengthening of the post .
wall of canal to prevent recurrence.
1-Bassini:interrupted silk suture between conjoined tendon & inguinal ligament.
2- Darning.
continuous suturing by nylon
3- mesh
which is either
4- obliteration of canal
. In elderly & complicated cases specially obstructed type
. Excision of all the content of canal ( cord & testes ) .
5- overlapping
. Exteralization of cord , making it lie subcutaneously.
. Overlapping the external oblique behind the cord & bind it with the
post .wall
*in case when the operation is contraindicated because
there is complication of anesthesia or the operation it self
or if the patient refuse the operation .
the pt. should be wear a truss.
Types of Anesthesia used:1- general
2- spinal
3- epidural
4- local infiltiration
in case of strangulated hernia
present as emergency
Before operation we should :. Replace fluid & electrolytes depletion by i.v. fluid
. Give brod spectrum antibiotics & metronidazole for
anaerobic microorganisms.
. NG. tube for decompression to avoid vomiting & inhalation
strangulated H. is more liable for infection so mesh is not
because it lead to increase the infection
so the repair
will failed & there is high rate of recurrence.

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