WHAT IS INGUININAL REGION?
The inguinal region is an area of weakness of the anterior abdominal
wall due to the penetration of the testes and spermatic cord (in males) or the round ligament of the
uterus (in females) during embryologic development.
WHAT IS INGUINAL LIGAMENT?
Inguinal Ligament is the coiled lower border of the external oblique muscle and extends from
the anterior superior iliac spine to the pubic tubercle. There are two rings of inguinal ligament
DEEP INGUINAL RING
SUPERFICIAL INGUINAL RING
WHAT IS DEEP INGUINAL RING?
Deep Inguinal Ring is an oval evagination of the transversalis fascia located lateral to the inferior
epigastric artery. The transversalis fascia continues into the inguinal canal as the internal fascia of the
structures passing through the inguinal canal.
The deep inguinal ring is an oval opening in the fascia transversalis and lies approximately 0.5 in. (1.3
cm) above the inguinal ligament. The margins of this ring give attachment to the internal spermatic
fascia.
WHAT IS SUPERFICIAL INGUINAL RING?
Superficial Inguinal Ring is a defect in the aponeurosis of the external oblique muscle
located lateral to the pubic tubercle.
The superficial inguinal ring is a triangular-shaped defect in the aponeurosis of the external oblique
muscle and lies immediately above and medial to the pubic tubercle. The margins of this ring give
attachment to the external spermatic fascia.
WHAT IS INGUINAL HERNIA?
Abnormal protrusion of abdominal contents (greater omentum and intestines) into the inguinal canal is
known as inguinal hernia. This is more likely to occur in persons in whom intra-abdominal pressure is
frequently increased, e.g. by chronic cough, by work involving frequent lifting of heavy weights, etc.
An inguinal hernia occurs above the inguinal ligament, whereas a femoral hernia occurs below the
inguinal ligament. Inguinal hernias are of two types:
indirect and direct.
WHAT ARE THEINGUININAL REGION?
These are the following types of hernia
1. Direct Inguinal Hernia
2. Indirect Inguinal Hernia
3. Femoral Hernia
WHAT IS DIRECT INGUINAL HERNIA?
Protrudes directly through the anterior abdominal wall within the Hesselbach triangle Protrudes medial to the inferior epigastric artery and vein
Common in older men; rare in women
Clinical signs include mass in inguinal region that protrudes on straining and disappears
at rest (i.e., easily reduced), constipation, prostate enlargement, and felt with pulp of finger
A direct hernia passes through Hesselbach's triangle which is bounded medially by the lateral border of
the rectus abdominis, laterally by the inferior epigastric artery, and below by the inguinal ligament. The
triangle is divided into medial and lateral parts by the obliterated umbilical artery. Direct hernias
through the medial and lateral parts of the triangle are referred to as direct medial or lateral hernias
respectively. Direct inguinal hernia occurs in old age after 75 year, when the abdominal muscles
become weak. It is frequently bilateral and incomplete.
• It is common among elderly men with weak abdominal muscles but is rare among women.
• The hernial sac bulges forward through the posterior wall of the inguinal canal medial to the inferior
epigastric vessels.
• The neck of the hernial sac is wide.
WHAT IS INDIRECT INGUINAL HERNIA?
Protrudes through the deep inguinal ring to enter the inguinal canal and may exit through
the superficial inguinal ring into the scrotum
Protrudes lateral to the inferior epigastric artery and vein Protrudes above and medial to the
pubic tubercle
Common in young men
More common than a direct inguinal hernia Clinical signs include tender painful mass in the inguinal
region that continues into the scrotum, and felt
with the tip of the finger
Indirect inguinal hernias may be congenital, or may occur in the young through areas of congenital
weakness produced by descent of the testis During the descent of the testis, a pouch of
peritoneum descends through the inguinal canal into the scrotum : this is the processes vaginalis.
Subsequently, the proximal part of the processes becomes obliterated, while the part around the testis
becomes the tunica vaginalis. Abnormal persistence of the processes is an important causative factor in
the production of inguinal hernias
• The hernial sac is the remains of the processus vaginalis.
• An indirect inguinal hernia is more common than a direct inguinal hernia.
• It is much more common in males than in females.
• It is more common on the right side.
• It is most common in children and young adults.
• The hernial sac enters the inguinal canal through the deep inguinal ring and lateral to the inferior
epigastric vessels. The neck of the sac is narrow.
• The hernial sac may extend through the superficial inguinal ring above and medial to the pubic
tubercle (femoral hernia below and lateral to the pubic tubercle).
• The hernial sac may extend down into the scrotum or labium majus.
WHAT IS FEMORAL HERNIA?
Protrudes through the femoral canal below the inguinal ligament
Protrudes below and lateral to the pubic tubercle
Protrudes medial to the femoral vein More common in women on the right side
Prone to early strangulation
WHAT ARE THE COVERINGS OF INGUINAL HERNIA?
Coverings of Inguinal Hernia From what has been said above it will be clear that
every hernia has some contents, e.g. intestines, that lie in a sac formed by peritoneum. The structures
separating the peritoneal sac from the surface of the body are the coverings of the hernia. These are as
follows, from inside out.
In an indirect inguinal hernia :
(a) Extraperitoneal tissue.
(b) Internal spermatic tissue.
(c) Cremasteric fascia.
(d) External spermatic fascia.
(e) Skin.
In a lateral direct hernia:
Same as for indirect hernia except that instead of
the internal spermatic fascia there is the fascia
transversalis (of the posterior wall of the inguinal
canal).
In a medial direct hernia :
(a) Extraperitoneal tissue.
(b) Fascia transversalis.
(c) Conjoint tendon.
(d) External spermatic fascia.
(e) Skin.
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