Herniotomy Photo Gallery
Examination of Hernial Orifices
Types of hernias
There are several different classifications of hernias.
Inguinal hernia - A hernia that is located above and medial to the pubic tubercle. They can be either direct or indirect.
- Direct inguinal hernia - A hernia that arises from a defect in the posterior wall of the inguinal canal and then passes through the superficial inguinal ring. They are more common in elderly patients.
- Indirect inguinal hernia - A hernia that passes through the deep inguinal ring, along the inguinal canal and out through the superficial inguinal ring. It may extend down into the scrotum. “Indirect hernias compromise 85% of all hernias and are more common in younger men.
Femoral hernia - A hernia that is inferior and lateral to the pubic tubercle. They are firmer than inguinal hernias and are more common in women. They are also more prone to obstruction and strangulation than inguinal hernias due to the narrow neck of the femoral ring.
Incisional hernia - A hernia that develops along the scar tissue of a surgical incision.
Other types of hernias include umbilical, paraumbilical and epigastric.
Anatomy of the Inguinal region
In order to fully understand the examination, it is essential to be familiar with the anatomy of the inguinal region. Important surface landmarks that are commonly confused include:
The mid-inguinal point: Found half-way between the Anterior Superior Iliac Spine (ASIS) and Pubic Symphysis (PS). This marks the point where the femoral pulse can be palpated.
The mid-point of the inguinal ligament: Found half-way between the ASIS and Pubic Tubercle (PT). This landmark signifies where the deep (internal) inguinal ring lies. This can help to determine whether the hernia is direct or indirect, whilst carrying out a clinical examination.
The superficial (external) inguinal ring is the end of the inguinal canal. It lies superior and medially to the pubic tubercle.
The inguinal canal contains the spermatic cord in males and the round ligament in females. It also contains the ilioinguinal nerve in both males and females.
It is important to be able to describe the borders of the inguinal canal as it is a common question that may be asked at the end of the examination.
- The floor of the canal is formed by the inguinal ligament and the lacunar ligament medially.
- The roof is formed from the fibres of the transversus abdominis and internal oblique muscles.
- The anterior wall is formed by the external oblique muscles.
- The posterior border is formed by the transversalis fascia laterally and the conjoined tendon along its medial one third.