Direct and Indirect inguinal Hernia

We're going to talk about hernia specifically inguinal hernia we can look at their signs and symptoms the risk factors and I guess what we what how it actually happens and how did how do we differentiate between the different types of inguinal hernias.

 So hernia itself is defined as a  protrusion bulge or projection of an organ or part of an organ through the body wall that normally contains it and  there are different types of hernias and it can be divided mainly into internal and external.

External Hernias:

We will mainly be talking about external hernias now external hernias include inguinal hernia which is the most common of all these which is 80% then you have incisional hernia , 10% femoral hernia ,5% umbilical hernia , 4% epigastric hernia less than one and then you have others.

Groin Hernias:

So the inguinal hernia and the femoral hernia are known together as groin hernias because they occur around the groin area.

Inguinal Hernia ( direct hernia) 

So let us actually talk about the inguinal hernia because that's what we're going to talk about mainly here because it is the most common so what we actually see in an inguinal hernia is the intestine which is the organ actually bulging out or pushing out of the wall that normally contains it which is the abdominal wall in this case so the abdominal wall is actually comprised of from the outside the skin the subcutaneous .

Abdominal Muscle:

The abdominal muscles and there are three abdominal muscles here from the outside it's the external oblique the internal oblique and then you have the transverse abdominus. 

So again an inguinal hernia is essentially the bulge or protrusion of an organ this being the intestine through the wall that normally contains it which is the abdominal wall.

Signs and Symptoms:

So what are some signs and symptoms of someone  who has an inguinal hernia well obviously it depends on the severity and how much it's actually bulging out and if it's strangulated .

But the signs and symptoms altogether are obviously there's a visible one that's a sign a heavy discomfort around the gut you can have pain and aching one exertion so maybe like lifting up something you can experience constipation .

And I guess you can also say that the lump enlarges upon coughing as a sign sort of some risk factors for someone to develop an inguinal hernia.

History of Hernia: 

Well these include a history of hernia older age male 6 being Caucasian having a chronic cough kind of constipation. I guess a weak abdominal wall and then also smoking is a risk factor so again inguinal hernia is you have the bulging of the small intestine here through the abdominal wall .

Diagramatical Explanation

So let's look at this from an anterior view so here we have the groin area here is a linear Alba which makes up part of the abdominal muscle .  

Right and then here you have the abdominal muscles from the outside you have the external oblique which has been opened up which has been sort of opened up .

As you can see here and then you have the internal oblique and then below the internal oblique you have the transverse solace of abdominis fashion and here we are actually just pulling pulling on the spermatic cord it's been retracted .

So we're pulling over it and because we're pulling it we can actually see below the spermatic cord .

Important artery:

Next to it we have important artery which is actually a landmark keep note of this and the artery is the inferior epigastric artery and the inferior epigastric artery is an important landmark because it sort of differentiates between the different types of inguinal hernia .

Conjoined Tendon:

We'll talk about that as we go and then here I guess above the penis area you have the conjoined tendon and it's sort of medial to the inferior epigastric artery now let's look at the same image so we're looking at the the muscle layers the inferior epigastric artery and the spermatic cord .

View of image from different angle:

Let's look at this image but from a different angle let's cut a cross-section of the body and look at it from the top so here you have your small intestine or intestines and then we have the peritoneum which actually holds all your that sort of covers is the inner lining of the digestive Dumbo cavity .

And then the next layer you have the transverse Ollis abdominis with a fashion and then you have the internal oblique external oblique and then you have the external oblique aponeurosis and then you have the subcutaneous and then you have the skin so these are the layers from the inside of the abnormal wall to the outside .

Spermatic Cord:

And then you have the spermatic cord which originates behind the transversal is fashion it goes down and it goes through all these layers and down to the scrotum so it goes through travels immediately and down to the scrotum and then medial to the spermatic cord. 

Epigastric Artery:

Behind the transverse Atlas fashion you have the epigastric artery which is again is an important landmark and it's medial and then you have the also the conjoint tendon .

Points to remember:

So I hope that made sense just remember these these layers and remember the spermatic cord how it travels immediately and then they also the inferior epigastric artery .

So let's talk about inguinal hernia and again what we will see is that we will see these intestines they will actually go through sort of bulge through these this these abdominal walls.

So now I'm just going to draw the inguinal hernia as we saw as we saw before and here is the intestine which is bulging sort of through the abdominal wall pushing against the abdominal wall .

And here we have the same image of the right side of the sort of groin area and and then we have hernias the inguinal hernias.

Types of Inguinal Hernias

There are two types of inguinal hernia we have what's known as a diary in directs or in direct inguinal hernia is the one that sort of push pushes bulges through the abdominal wall and actually goes into the scrotum .

So it sort of follows the spermatic cord the spermatic cord pathway and then you have a direct inguinal hernia which is just in hernia that sort of bulges through the abdominal wall and doesn't actually god own the scrotum.

Differentiation between 2 types:

So what differentiates these two types of inguinal hernias the direct and indirect is the important land mark that we talked about which is  the inferior epigastric artery and here we have the inferior epigastric artery and essentially if the inguinal hernia occurs medially to the inferior epigastric artery it's a direct hernia but if it occurs if it begins laterally then it's an indirect herania.

Indirect Hernia:

Now talking about indirect hernia it's it goes it follows the spermatic cord pathway because that indirect hernia actually travels from originates from the deep inguinal ring it goes through the deep inguinal ring and the superficial inguinal ring .

And so this is obviously the same popular spermatic cord and so that this the intestine will actually follow this pathway follow the spermatic cord pathway and into the scrotum.

Hessel bach triangle:

Now an important landmark are a important region to know to remember for hernias is known as the Hessel bach  triangle and so the borders of the Hensel bach triangle is the  inguinal ligament inferiorly you have their inferior epigastric laterally and then you have the rectus abdominus medially .

So let's look at these two types of inguinal hernias in a bit more detail so again you have two types of inguinal hernias you have the indirect inguinal hernia any of the direct inguinal hernia so let's begin by talking about the

Indirect Inguinal Hernia

Indirect inguinal hernia is the most common type of hernia it is it's where the intestines protrude at the deep inguinal ring and it's lateral to the inferior epigastric artery so it starts laterally.

Diagramatically explanation:

So if we draw that same diagram that we drew the cross-section and we're looking at from  this from the top from a superior view you know we have the layers that peritoneum, the transversal is fascia ,the internal oblique, the external oblique and then you have the external oblique aponeurosis.

And here is your deep inguinal ring essentially a hole where the spermatic cord originates from the peritoneum and then you have this superficial inguinal ring where the spermatic cord will exit .

Indirect hernia occurs lateral laterally:

So I'm actually drawing the spermatic cord here in yellow and it's not quite right it should be within it should originate from the deep inguinal ring and then you have the inferior epigastric artery and remember an indirect hernia occurs lateral. 

Laterally to the inferior epigastric artery and so an indirect hernia is where the intestine will go through the deep inguinal ring and then through the superficial inguinal ring and an essentially bulge out .

Pathway:

So I hope that made sense and again the indirect inguinal hernia occurs lateral to the epigastric inferior epigastric artery and essentially follows the same pathway the spermatic cord as shown so a  directory is where we have a protrusion medial to the inferior epigastric artery within the hazal box triangle .

Hazel Bach Triangle:

And remember we learned about the hazal bach triangle so hence the Bach triangle is where direct hernias occur and the  directories occur as a result of weakness in the floor of the inguinal canal and it passes through the superficial ring only it doesn't go through the deep and superficial the direct and WA no hernia only goes through the superficial .

Diagram from the top:

And we will see how so again we're looking at this diagram from the top and here  the spermatic cord in yellow and here we have the inferior epigastric artery and here is your deep inguinal ring where the spermatic cord originates right .

And then here you have the superficial inguinal ring where the spermatic cord also goes through well in a direct inguinal hernia it only goes through the superficial inguinal ring .

So what essentially what we see essentially is the intestine will go through these layers and the intestine will just go  through the superficial inguinal ring medial to the inferior epigastric .

And not go in contact with the deep inguinal ring so again the direct inguinal hernia occurs medial to the inferior epigastric .