Hernias Inguinal canal boundaries 2.H 28 26 27 internal oblique + transversalis fascia conjoint transversalis fascia conjoint Contents of Hernia Usually peritoneum & associated Put if larger (rarely small) & also alodo content Inguinal + lachas external + internal ligament oblique aponeurosis Risk factors obesity smoking pregnancy ascites immunosuppression diabetes connective tissue multiple surgeries previous surgery muscle weakness aging pre-op surgery meds Inguinal Hernias From superficial ring above inguinal lig. medial to pubic tubercle 5x more likely in males due to aloda wall (testicular descent) repair usually by the age of 5. Indirect Hernias don't pierce abdo wall just enter medial to deep inguinal ring & exist via superficial ring patent processus vaginalis => may extend through as far as tunica vaginalis testes lateral to the epigastric a. inguinal ring traveled through scrotum Direct Hernias medial to int. epigastric a. Hesselbach's triangle sup epigastric vessels lateral inguinal lig. Layers of the Enematic Fascia Internal spermatic fascia Transversalis fascia Cremasteric fascia Internal oblique aponeurosis External spermatic fascia External oblique aponeurosis Femoral Triangle Structures Passing Through the Inguinal Canal * spermatic cord * round lig. - F * ilioinguinal n. * lachrymal a. + M * cremasteric a. * genital branch of genitofemoral n. * inguinal n. - exists through superficial inguinal ring Congenital Diaphragmatic Hernia Development defect in the diaphragm where the pleuro- peritoneal membrane has a defect/hole in diaphragm organ herniation fatal Incarcerated Hernias Can't be reduced due to size adhesions Key Points femoral a., v., lymphatics are carried in the femoral sheath the femoral ring is the sup. opening of it the inguinal canal acts as a mode of entry contents enter through the deep inguinal ring + exist through the superficial ring Important Clinical Considerations new born on mechanical ventilation → intra abdo pressure → patent processes vaginales → Indirect Inguinal Hernia Complications of Hernia incarceration → trapped by can't be reduced strangulation → cutting off of blood supply Obesity ↑ intra-abdo P → GERO stomach herniates through the diaphragm Red flags for groin lump? painful? yes → incarcerated → needs surgery irreducable? yes → strangulation → needs surgery constipation? yes → bowel obstruction that may have a large strangulation Richter's Hernia when hernia sac is small → bowel herniates BUT DOES NOT CAUSE AN OBSTRUCTION Differentiating between direct & Indirect Hernias Place the finger of the deep inguinal ring → just above midpoint of inguinal ligament if it is indirect inguinal hernia reduced contents appear to pass through the inguinal canal if it doesn't direct hernia