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A hernea is an abnormal opening in the abdominal wall, with or without protrusion of an intraabdominal structure. A hernea develops in 5% of men during their lifetime. The most common groin hernea in males or females is the indirect inguinal hernea. Femoral herneas are more common in

 Inguinal herneas

Indirect sacs pass through the internal inguinal ring lateral to the inferior epigastric vessels and lie within the spermatic cord. Two-thirds of inguinal are indirect hernea

Direct occur when viscera protrude through a weak area in the posterior inguinal wall. The base of the hernea sac lies medial to the inferior epigastric vessels, through Hesselbach's triangle, which is formed hernea by the inferior epigastric artery, the lateral edge of the rectus sheath, and the

Combined (pantaloon) herneas occur when direct and indirect herneas occur

Sliding occur when part of the wall of the sac is formed by aviscera (bladder, colon). Richter's occur when part of the bowel (rather than the entire circumference) becomes trapped. Only a "knuckle" of bowel enters the hernea sac.

Incarcerated cannot be reduced into the abdominal cavity. Strangulated are with incarcerated contents and a compromised blood supply; intense pain indicates intestinal ischemia.

Inguinal Anatomy

Layers of Abdominal Wall: Skin, subcutaneous fat, Scarpa's fascia, external oblique, internal oblique, transversus abdominous, transversalis fascia, peritoneum.

Hesselbach's Triangle: A triangle formed by the lateral edge of rectus sheath, the inferior epigastric vessels, and the inguinal ligament.

Inguinal Ligament: Ligament running from anterior superior iliac spine to the pubic tubercle.

Lacunar Ligament: Reflection of inguinal ligament from the pubic tubercle onto the iliopectineal line of the pubic ramus.

Cooper's Ligament: Strong, fibrous band located on the iliopectineal line of superior public ramus.

External Inguinal Ring: Opening in the external oblique aponeurosis; the ring contains the ilioinguinal nerve and spermatic cord or round ligament.

Internal Ring: Bordered superiorly by internal oblique muscle and inferomedially by the inferior epigastric vessels and the transversalis fascia.

Processus Vaginalis: A diverticulum of peritoneum which descends with testicle and lies adjacent to the spermatic cord. The processus vaginalis may enlarge to become the sac of an indirect inguinal.

Femoral Canal: Formed by the borders of the inguinal ligament, lacunar ligament, Cooper's ligament, and femoral sheath.

Clinical Evaluation

Inguinal usually present as an intermittent mass in thegroin. The symptoms can usually be reproduced by a purposeful Valsalva maneuver. A bowel obstruction may rarely be the first manifestation .

Physical examination. An inguinal bulge with a smooth, rounded surface is usually palpable. The bulge may become larger with straining. The hernea sac can be assessed by invaginating the hemiscrotum with an index finger passed through the external inguinal ring.

Radiologic evaluation. X-ray studies are not usually needed. Ultrasonography or CT scanning may be necessary to evaluate small herneas, particularly in the obese patient.

Differential diagnosis. Inguinal herneas are distinguished from femoral herneas by the fact that femoral herneas originate below the inguinal ligament. Inguinal adenopathy, lipomas, dilatation of the saphenous vein, and psoas abscesses may present as inguinal masses.


Preoperative evaluation and preparation. herneas should be treated surgically. Chronic cough, constipation, ascites, or urinary obstruction can increase intraabdominal pressure and should be corrected before elective herniorrhaphy. If incarceration or strangulation has occurred, broad-spectrum antibiotics and nasogastric suction should be initiated.

Reduction. In uncomplicated cases, the