5. Direct inguinal hernia

Question 1

INCIDENCE of Direct inguinal hernia

Answer 1

• Common in old males.

* 50 % bilateral

Question 2

ETIOLOGY of Direct inguinal hernia

Answer 2

a. Weakness of lower abdominal wall muscles with chronic increased intra abdominal pressure.
b. Paralysis of conjoint tendon

Question 3

Pathogenesis of Paralysis of conjoint tendon in ETIOLOGY of Direct inguinal hernia

Answer 3

Injury of the ilioinguinal nerve during appendectomy (only after muscle cutting).

Question 4

PATHOLOGY & TYPES of Direct inguinal hernia

Answer 4

1 - Lateral Type “Commonest” :

2- Medial Type “Rare”

Question 5

commonest type of Direct inguinal hernia

Answer 5

Lateral Type

Question 6

Pathogenesis of Lateral Type of Direct inguinal hernia

Answer 6

• Bulges through the lateral part of Hasselbach’s triangle (made of fascia transversalis only).
• Thus has a very wide neck and is less liable to complications.
• Never descends to the scrotum.

Question 7

Alternative name for Medial Type of Direct inguinal hernia

Answer 7

funicular form of Ogilvie

Question 8

Pathogenesis of Medial Type of Direct inguinal hernia

Answer 8

Passes through a defect in the conjoint tendon in front of fascia transversalis in the medial half of the triangle.

• The edge of the defect is sharp & the neck is narrow )> liable to complicate.
• It may descend to the scrotum

Question 9

Type of Direct inguinal hernia Passes through a defect in the conjoint tendon in front of fascia transversalis in the medial half of the triangle.

Answer 9

Medial Type of Direct inguinal hernia

Question 10

Type of Direct inguinal hernia bulges through the lateral part of Hasselbach’s triangle (made of fascia transversalis only)

Answer 10

Lateral Type of Direct inguinal hernia

Question 11

Type of Direct inguinal hernia has a very wide neck and is less liable to complications

Answer 11

Lateral Type of Direct inguinal hernia

Question 12

Type of Direct inguinal hernia in which The edge of the defect is sharp & the neck is narrow and liable to complications

Answer 12

Medial Type of Direct inguinal hernia

Question 13

Type of Direct inguinal hernia Never descends to the scrotum

Answer 13

Lateral Type of Direct inguinal hernia

Question 14

Type of Direct inguinal hernia may descend to the scrotum

Answer 14

Medial Type of Direct inguinal hernia

Question 15

the reason why Lateral Type of Direct inguinal hernia is less liable to complications

Answer 15

• Bulges through the lateral part of Hasselbach’s triangle (made of fascia transversalis only).
• Thus has a very wide neck and is less liable to complications.

Question 16

the reason why Medial Type of Direct inguinal hernia is more liable to complications

Answer 16

Passes through a defect in the conjoint tendon in front of fascia transversalis in the medial half of the triangle.

• The edge of the defect is sharp & the neck is narrow )> liable to complicate.

Question 17

Difference between Oblique inguinal hernia and Direct inguinal hernia by

Answer 17

Age
Side

Shape
Descent
Descent to scrotum
Reducibility
Complications

Internal ring test
External ring test

Relation of neck of sac to inferior epigastric artery
(at operation)

Question 18

Age in Oblique inguinal hernia

Answer 18

Any Age

Question 19

Age in Direct inguinal hernia

Answer 19

Usually old age

Question 20

Side in Oblique inguinal hernia

Answer 20

Uni or bilateral

Question 21

Side in Direct inguinal hernia

Answer 21

Usually bilateral

Question 22

Shape in Oblique inguinal hernia

Answer 22

Oblong

Question 23

Shape in Direct inguinal hernia

Answer 23

Hemisherical

Question 24

Descent in Oblique inguinal hernia

Answer 24

Downwards, forwards and medially

Question 25

Descent in Direct inguinal hernia

Answer 25

Forward

Question 26

Descent to scrotum in Oblique inguinal hernia

Answer 26

May occur

Question 27

Descent to scrotum in Direct inguinal hernia

Answer 27

Very rare

Question 28

Reducibility in Oblique inguinal hernia

Answer 28

Upwards, backwards, and laterally

Question 29

Reducibility in Direct inguinal hernia

Answer 29

Backwards

Question 30

Complications in Oblique inguinal hernia

Answer 30

More common

Question 31

Complications in Direct inguinal hernia

Answer 31

Less common

Question 32

Internal ring test in Oblique inguinal hernia

Answer 32

Hernia does not protrude

Question 33

Internal ring test in Direct inguinal hernia

Answer 33

Hernia protrudes

Question 34

External ring test in Oblique inguinal hernia

Answer 34

Impulse at the tip of the finger

Question 35

External ring test in Direct inguinal hernia

Answer 35

Impulse at the side | of finger

Question 36

Relation of neck of sac to inferior epigastric artery | (at operation) in Oblique inguinal hernia

Answer 36

Lateral to the artery

Question 37

Relation of neck of sac to inferior epigastric artery | (at operation) in Direct inguinal hernia

Answer 37

Medial to the artery

Question 38

Internal ring test

Answer 38

* Steps | * Results

Question 39

steps of Internal ring test

Answer 39

1. Let the patient lies down. 2. Reduce the hernia. 3. Occlude the internal ring by the thumb of opposite hand (internal ring is 1/2 inch above the mid point of inguinal ligament ). 4. Then ask the patient TO STAND UP and cough

Question 40

Results of Internal ring test

Answer 40

* If hernia descends )> direct hernia. | * If hernia descends after release of thumb )> indirect hernia.

Question 41

External ring test (not done)

Answer 41

* Steps * Results * The reason why it's not done now

Question 42

Steps of External ring test

Answer 42

Let the patient lies down & reduce the hernia. Introduce the little finger into the inguinal through external ring and ask the patient to cough.

Question 43

Results of External ring test

Answer 43

If impulse is felt at the tip )> indirect hernia If impulse is felt at the side )> direct hernia

Question 44

The reason why External ring test is not done now

Answer 44

a. Not a very sensitive test. b. Painful. c. Can stretch the external ring )> inguinal hernia can reach the scrotum

Question 45

Zeiman's 3 fingers test

Answer 45

The patient lies down then the hernia is reduced, 3 fingers are put as follows : * One on the internal ring (for indirect hernia) * One on the external ring (for direct hernia) * And the third over the saphenous opening (for femoral hernia). * The patient is asked to cough and you will see which finger receives the impulse first.