INDIRECT (OBLIQUE)INGUINAL HERNIA
AETIOLOGY 1.congenital unobliterated processus vaginalis 2.acquired raised intra abd pressure &weak abd wall CLINICAL TYPES 1.bubonocele sac limited to inguinal canal 2.funicular sac reach down to neck of scrotum 3.complete(scrotal) sac descend to bottom of scrotumCLINICAL FEATURES
1.painless inguinal or inguinoscrotal swelling unless complicated 2.expansile impulse on cough unless complicated 3.swelling reducible unless complicated Occur at any age, uni or bilateral, shape oblong,direction of descent downward forward&medially,direction ofreduction upward backward&laterally,may descend toscrotum,may attain large size,liable for complications,internal ring test does not protrude TREATMENT SURGERY.Truss indicated only if there is contraindications to surgery e.g terminally ill patient. PREOPERATIVE treat any cause increase inta abd pressure OPERATIVE A.Herniotomy excision of sac.it is enough in infant & children B.Herniorrhaphy for adult 1.Bassinis repair 2.McVays repair 3.Shouldice repair C.Hernioplasty (mesh)DIRECT INGUINAL HERNIA
AETIOLOGY common in elderly male,often has weakness of the lower abd muscles with chronic cough&straining. PATHOLOGY hernia protrudes through Hasselbachs triangle which is bounded medially by rectus muscle,laterally by inferior epigastric vessels&inferiorly by medial half of inguinal ligament CLINICAL FEATURES Affect old males,bilateral common,shape is hemispherical,direction of descent forward.direction of reduction is backward,rare descent to scrotum,small size,rare complications,internal ring test hernia protrude, TERATMENT 1.TREAT cause of increase intra abd pressure 2.herniotomy is not needed if sac is small & composed of extraperitoneal fat 3.herniorrhaphy or hernioplastyFEMORAL HERNIA
DIFFERENTIAL DIAGNOSIS 1.inguinal hernia 2.inguinal lymphadenopathy 3.saphena varix 4. Aneurysm of femoral artery 5.lipoma 6.psoas abscess 7.iliopsoas bursa TREATMENT Atruss is contraindicated because the possibility of strangulation is high.surgery is the only line of treatment APPROACH 1.Low approach 2.High approach(Lotheissens operation) 3.preperitoneal approach(McEvedys operation) -sac is excised -the defect(femoral ring)is obliterated by either: *suturing the inguinal ligament to pectineal ligament by polypropylene sutures *synthetic mesh