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