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Inguinal Herniae

1. Herniae = abnormal protrusion of a viscus through its containing wall
2. Indirect herniae
   • Remnants of the patent processus vaginalis
   • Arise from abdominal cavity passing obliquely through the deep inguinal ring travelling through the inguinal canal with the spermatic cord
   • May continue through the superficial inguinal ring into the scrotum
3. Direct herniae
   • Result of a weak posterior wall to the inguinal canal
   • Weakness causes abdominal contents to bulge through the wall into the inguinal canal but the hernia is not within the spermatic cord

Spermatic cord contents

1. 3 arteries
   • Testicular artery (from aorta)
   • Artery to the vas (from inferior vesicular artery)
   • Cremasteric artery (from inferior epigastric artery)
2. 3 nerves
   • Ilioinguinal nerve (L1 on the front of the cord)
   • Nerve to cremaster (from genitofemoral nerve)
   • Autonomic nerves (sympathetic finres from T10)
3. 3 others
   • Vas deferens
   • Pampiniform plexus of veins (drains right testis into inferior vena cava and left testis into renal vein)
   • Lymphatics (drain testis to para-aortic lymph nodes)

Approach

• Expose patient from umbilicus to knees

1. Inspect
   • Look at groin for old surgical scars (?recurrent herniae)
   • "Have you noticed a lump in the groin"?
2. Palpate
   • Define the anatomy
   • Palpate pubic tubercle and anterior superior iliac spine, demonstrate inguinal ligament
   • Demonstrate hernia arises above the line
   • Demonstrate lump has expansile cough impulse
   • Other aspects of the lump may be defined
   • Decide whether the lump is confined to the inguinal region or descends into the scrotum
   • ?Reduce the hernia
   • Try to control the hernia at the deep inguinal ring - if controlled = indirect hernia, if not = direct hernia
3. Percuss
4. Auscultate
   • Bowel sounds may be present

Completion

1. Examine scrotum for incidental scrotal lumps
2. Examine contralateral groin for herniae

Differential diagnoses

1. Soft tissues
   • Sebaceous cyst
   • Lipoma
2. Vascular
   • Femoral artery aneurysm
   • Sapheno varix
   • Lymphadenopathy
3. Herniae
   • Inguinal
   • Femoral
4. Renal/urogenital
   • Ectopic testis
   • Transplanted kidney (!) 

[Inguinal hernia repair] 

Complications of hernia repair

1. Immediate
2. Early
3. Late
4. Specific
   • Urinary retention
   • Bruising
   • Pain
   • Haematoma
   • Infetion
   • Ischaemic orchitis - 0.5%
   • Recurrence - < 0.5%; normally due to inadequate ring and posterior wall closure 

Recovery from Inguinal hernia repair

• Early mobilisation important
• Keep area clean, especially after clips/sutures have been removed
• Able to bathe immediately
• May need to be off work for 6 weeks if job involves lifting
• Should avoid prolonged coughing
• Should take laxatives if they get constipated