University of Alexandria

Inguinal hernia Examination

GI Surgery UnitFaculty of Medicine

University of AlexandriaBy: Mohamed Mourad

Assistant lecturer of general surgery

University of Alexandria

History (elective presentation)

Age– Infant– Late teens and early adolescent– 40-60 years

Sex Occupation

– Heavy object lifting

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History (elective presentation)

Local Symptoms– Swelling– Discomfort

Ask about PPT factors– Chronic constipation– Cough– Straining with micturation

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History (emergency presentation)

Irreducible Obstructed Strangulated

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University of Alexandria

University of Alexandria

University of Alexandria

Normal development and occlusion of processus vaginalis

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Standing position Exposure (nipple to

knee) Inspection

– Site Right or left Above or below groin

cease Reaches the scrotum or

not– Size – Shape

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Standing position

Palpation from front– Scrotal neck test

technique Inguinal, scrotal, inguinosrotal

– Superficial ring test Technique Direct, indirect inguinal

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Superficial ring test

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Standing position Palpation from side

– Stand at the same side of the hernia– Findings

Site Size shape Temperature Tenderness Composition Reducibility Expansile impulse with cough

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Standing position

Expansile impulse with cough– Technique– The swelling should become tense and

expand with cough not moves up and down only

It is diagnostic for hernia but can be absent in complicated ones.

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Expansile impulse with cough

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Standing position

Pubic tubercle test (refers to site of reduction of the hernia not the position of the whole hernia)– Above and medial– Above and lateral– Below and medial– Below and latera

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Standing and supine position

Reducibility– Can be tried on standing position, if failed,

repeat in supine position– Technique– Finding

Reducible, irreducible Direction of reduction Difficulty in reduction

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Standing and supine position

Deep ring test– Only if the hernia is reducible– Technique – Findings

Indirect, direct inguinal hernia– Why false results?

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Standing and supine position

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Standing and supine position

Three finger test (Zieman’s technique)

technique Findings

Indirect, direct, femoral hernia

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Standing or supine position

Percussion– Intestinal or omental contents

Auscultation– Peristalsis.

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DO NOT FORGET

To examine the contra-lateral side of the hernia,

To examine the scrotum, To examine the abdomen.

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Examine the abdomen

For any cause can elevate the intra-abdominal pressure– Ascites– Enlarged prostate– Intestinal obstruction– Pregnancy

Scar of previous operation

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Indirect inguinal hernia Direct inguinal herniaAny age but common in young Elderly Via deep inguinal ring and long the inguinal canal

Via transversalis fascia (hasselbach’s triangle)

Patent or reopen processus vaginalis Weak abdominal wall/muscle

Unilateral in 2/3 case (right side more common)

Bilateral in > ½ case

Enter scrotum (complete) Does not enter scrotum (incomplete)

Reduced by patient/doctor (manually) Reduced on lying down (automatically)

Narrow neck- more liable to strangulate

Broad neck

Zieman technique- impulse on index finger

Impulse on middle finger

Deep ring occlusion test- control Bulge out

Little finger invagination test- impulse on finger tip

Impulse on pulp

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Differential diagnosis

Femoral hernia Inguinal lymphadenopathy Saphena Varix Femoral aneurysm Lipoma Ectopic testis Psoas abscess

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Differential diagnosis

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Some definitions

Strangulated hernia ? Incarceration ? Richter’s hernia? Maydl’s hernia? Sliding hernia? Pantaloon hernia?

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Types of indirect inguinal hernia

Incomplete;– Bubonocele—limited within the inguinal

canal– Funicular—limited just above the

epididymis Complete;

– traverses to the bottom of the scrotum

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Diagnosis Right, Left, Site (inguinal, femoral), Direct or indirect, Complete or incomplete, Hernia, Content (omentum or bowel), Uncomplicated (Reducible) or complicated

(irreducible, obstructed, strangulated), PPT factors.

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Inguinal hernia examination

Thank You