Inguinal Hernias – Inguinal Region

by James Pickering, PhD

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    00:01 So, inguinal hernias, we have got on our abdomen a series of slits of openings that allow the testes... that allowed the testes to migrate from the posterior abdominal wall through into the scrotum. So, these are potential sites of weakness. On the screen at the moment, we can see a gentleman who has a right inguinal hernia. This is going to be the protrusion.

    00:29 A hernia is a protrusion of a structure through the wall that surrounds it, okay? So, the protrusion of a structure, in this case a piece of intestines, through the wall that surrounds it. In this case, intestines passing through the anterior abdominal wall.

    00:50 They don’t puncture the skin, obviously, but they are penetrating those muscular membranous layers and we can see this inguinal hernia here, we can see this bulge, it’s present on the right hand side, it’s not present on the gentleman’s left hand side.

    01:04 So, he has a right inguinal hernia. What’s happened here? How does it occur? Well, as I said, and we can see here in some details, it’s the protrusion of an organ through the wall of the compartment that contains it. So, if we think about how this could occur, changes in intra abdominal pressure. I mentioned that’s an important function of the muscles of the anterior abdominal wall. So, as chronic coughing or sneezing where you are contracting those muscles, changes in intra abdominal pressure, lifting, if you are bending over then that’s going to be putting pressure on the abdominal wall muscles. The content of the abdomen, the intestines, as we will see later on the abdomen is full of the intestines.

    01:53 So, these intestines can be forced out through a weakness. Potential sites of weakness? The inguinal rings that form the inguinal canals. We have two, if you remember, inguinal rings. We have two, therefore, sites of weakness, a superficial and a deep and depending on the degree of increases of intra abdominal pressure or depending on the degree of closure of the deep inguinal ring as the testes pass through during development can lead to one of these inguinal hernias.

    02:31 We again have two different types depending on the intestine passing through even the superficial, which we’d call it direct, or passing through the deep, which we’d call an indirect inguinal hernia.

    02:43 So, let’s have a look at the mechanism of how this could occur. So again, we are going back to the previous diagram. Here, we have got our inferior epigastric artery and we are going medial this time to our inferior epigastric artery. On this side, we have got our inferior epigastric artery and we are going lateral. This is the midline, so, we are going lateral to it. What do we find lateral to the inferior epigastric artery? We find the deep inguinal ring. So, here we have the deep inguinal ring. Medial to inferior epigastric artery, we find the conjoint tendon. The conjoint tendon that was formed by internal oblique and transversus abdominis muscle fibers to strengthen the posterior wall of the inguinal canal in line with the superficial inguinal ring, but with continued increases in pressure, this can be pushed upon and exacerbate that weakness.

    03:45 So, if we just, first of all, look at the direct inguinal hernia, the direct inguinal hernia which is associated with the superficial inguinal ring. The protrusion occurs at the level of the superficial inguinal ring where the testes are pushing against the conjoint tendon. It occurs medial, this is the midline remember, it occurs medially to those inferior epigastric arteries. But importantly, it passes through the superficial inguinal ring, but it takes with it, a hernial sac. That means it’s very much like pushing your finger through a balloon and as your finger goes through that balloon, it still takes a covering of the balloon with it. So, here we can see the peritoneum and we can see the transversalis fascia and here, we can see that we have created this hernial sac and this hernial sac can actually be popped back in. So, if you cough, a piece of intestine can go through and then if you just palpate your groin, your inguinal region then you can push this hernial sac back in and you can do this routinely until you can go and seek some medical assistance.

    05:04 So, here we have a direct inguinal hernia, this doesn’t really enter the scrotum.

    05:10 This is in contrast to an indirect inguinal hernia, so it is called a congenital one because it’s to do with a patent processus vaginalis. So, what’s that? That is a failure of the deep inguinal ring to sufficiently close once the testes has migrated through. So, here we can see the vas deference would be passing through the deep inguinal ring. If the deep inguinal ring doesn’t close up, you have got this opening and this allows a piece of intestine to pass through this deep opening, but now, it’s not in any way limited by hernial sac because it’s just utilising the passageway that is the inguinal canal, where previously a direct one was limited by this hernial sac. Now, this indirect one, through the deep inguinal ring, lateral to epigastric arteries and veins is now running within the inguinal canal itself and therefore, this piece of intestine can actually enter into the scrotum and you could have a very swollen scrotum, we have the contents, we have the intestines being within it and this is particularly serious because you wouldn’t want a piece of intestine to become constricted with contractions of those muscles and then it to become ischemic and die off within the scrotum. So, this needs to be dealt with very quickly.

    06:41 So, we can see we have two different types of hernia. A direct one associated with superficial inguinal ring and an indirect one associated with the deep inguinal ring.

    06:53 And that’s it. We have looked at the inguinal region and specifically, the inguinal canal.

    07:00 We started off by looking at some important surface landmarks, the anterior superior iliac spine, the inguinal ligament running towards the pubic tubercle or the pubic crest.

    07:09 And then we looked at the boundaries of the inguinal canal, the openings, the superficial, deep inguinal rings and the contents, the spermatic cord in the male and the round ligament of the uterus in the female. And then to finish up, we looked at indirect and direct hernias, being an indirect, being a congenital and positioned lateral to epigastric vessels entering the scrotum and the direct which is more acquired, happens with activities, medial to inferior epigastric vessels and this one rarely enters the scrotum.

    About the Lecture

    The lecture Inguinal Hernias – Inguinal Region by James Pickering, PhD is from the course Abdomen.

    Included Quiz Questions

    1. Lateral
    2. Medial
    3. Inferior
    4. Superior
    5. Anterior
    1. It is not caused by failure of embryonic closure of processus vaginalis
    2. Indirect hernia is congenital
    3. It occurs lateral to inferior epigastric vessels
    4. The contents usually go to the scrotum
    5. It is a medical emergency
    1. Ilioinguinal nerve
    2. Genitofemoral nerve
    3. Iliohypogastric nerve
    4. Subcostal nerve
    5. Obturator nerve
    1. Sigmoid colon
    2. Ascending colon
    3. Cecum
    4. Descending colon
    5. Transverse colon
    1. Ilioinguinal
    2. Iliohypogastric
    3. Genitofemoral
    4. Subcostal
    5. Obturator
    1. Round ligament of the uterus
    2. Ilioinguinal nerve
    3. Iliohypogastric nerve
    4. Spermatid cord
    5. Broad ligament of the uterus

    Author of lecture Inguinal Hernias – Inguinal Region

     James Pickering, PhD

    James Pickering, PhD

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    Very good lecture
    By Ana G. on 15. February 2019 for Inguinal Hernias – Inguinal Region

    Very clear . The image is excellent. The causes of the hernia are taken in other lectures and this one is focused on the way that is made. perfect for a first approximation to surgery.