Direct, Indirect and Femoral Hernia for Undergraduates

1. Inguinal swellings

2. What is a hernia? External abdominal hernias – Protusion of the abdominal viscus through a weak spot in the abdominal wall.

3. Anatomy of the inguinal region

4. Boundaries of the inguinal canal

5. Weak spot on the anterior abdominal wall through which the Direct inguinal hernia protrudes. Bounded by- Medially – Outer border of Rectus Abdominalis Laterally – By the infEpigastric vessels Below – Medial part of the inguinal ligament

6. Contents of the inguinal canal Ilioinguinal nerve - Medial part of the canal. it pierces through the internal oblique distributing filaments to it, enters the inguinal canal midway and the accompanies the spermatic cord till the Sup inguinal ring. Males – Spermatic cord and its coverings and the remnants of the processusvaginalis Females – Round ligament and the remnants of the processusvaginalis

8. GFN – Genitofemoral Nerve

9. Testicular plexus of sym nerves

10. LV –Lymph vessels

11. PPV –Pampiniform plexus

12. TA – Testicular artery

13. Artery to the vas

15. Coverings of an Indirect Inguinal Hernia Peritoneum Extraperitoneal fat Int Spermatic fascia Cremasteric fascia Ext spermatic fascia Superficial fascia Skin

16. Direct Inguinal Hernia Most important point is that neck is medial to the inferior epigastric vessels while indirect hernia’s neck is lateral to the vessels. Always acquired with one rare exception Rarely attains a large size and never descends into the scrotum and rarely gets strangulated because it has a wide neck.

19. Clinical Features Pain – Dragging or aching type Sensation of heaviness and weight Painful and tender » Strangulated Swelling Others Intestinal obstruction – if hernia is obstructing the lumen of the intestine. i.e colicky pain, vomiting, abdominal distension Vomiting is an ominous sign and can indicate infection or impending rupture.

20. Femoral Hernia Abdominal contents pass through the femoral ring and come out through the saphenous opening. 3rd most common hernia after inguinal and incisional and is more common in females. Most liable to get strangulated.

21. Anatomy Femoral sheath is a continuation of transversalis fascia into the thigh anteriorly and fascia iliacaposteriorlywhich fuse near the inguinal ligament. It is divided into three compartments. The medial most compartment is called the femoral canal and contains efferent lymphatics, sometimes a small lymph node (lymph node of Cloquet) and areolar tissue. The opening of the femoral canal is called the femoral ring through which femoral hernia occurs. The ring is generally closed by the femoral septum which is extraperitoneal tissue.

23. To the femoral triangle

24. The saphenous opening or the fossaovalis is an opening in the fascia lata 4cm below and Lateral to the pubic tubercle. Sharp upper and outer margins called falciform process. This process is important because it turns the femoral hernia upwards after it comes out of the opening. Covered by loose areolar tissue called the cribriform fascia. Traversed by the long saphenous vein and lymphatics.

25. Course of a Femoral hernia Comes out through the femoral ring Passes through the femoral canal Comes out through the saphenous opening Pushed up by the folds and moves up through the subcutaneous tissue of the thigh and can even reach above the inguinal ligament.

26. Coverings of Femoral hernia Peritoneum Femoral septum Fatty content of the femoral canal Anterior layer of the femoral sheath Cribriform fascia Superficial fascia Skin

27. Clinical features and signs Age and Sex – Rare in young people. Majority between 60 and 80 years. F>>M ( but the most common hernia in females is inguinal hernia) R>L ; B/L is seen in 20% cases. Pain is lesser than that of inguinal hernia and can go unnoticed until strangulation Swelling- Small globular swelling lateral to and below the pubic tubercle. More obvios on standing and straining. Other symptoms – Abdominal colic, vomiting, distension and constipation.

29. Thank You