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View Full Version : DIRECT INGUINAL HERNIA(Etiology-Pathology-Clinical picture-Complications-Investigations-Treatment)



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06-08-2008, 08:19 AM
Definition:
It develops through weakness or defect of the fascia transversalis in the posterior wall of the inguinal canal (Hasselbach’s (inguinal) triangle). Sometimes the defect is small and localized and in other cases there is generalized pulge. Often the patient has poor lower abdominal musculature, as shown by the presence of elongated bulgings (Malgaigne’s bulges)

Incidence:
Ÿ 35% of inguinal hernias. Ÿ 12% of cases are bilateral.
Ÿ Unilateral cases have increased risk for development of contralateral hernia.
Ÿ Wamen practically never develop a direct ingunal hernia.
Aetiology: Always it is of acquired origin:
1- Weakness of the floor due to:
a- Senile atrophy of the muscles.
b- Paralysis of conjoint tendon due to injury of ilioinguinal nerve (which may occur in extended Mc Burney's incision)
2- Increased intra-abdominal pressure as in:
a- Senile enlargement of prostate.
b- Chronic cough and constipation.So; it is common in old age.
Pathology:
(1) Sac: fold of peritoneum with wide neck So, strangulation is rare.
Dual (syn. Saddle-bag; pantaloon) hernia is hernia with two localized sacs which straddle the inferior epigastric artery
(2) Contents: As O.I.H.
(3) Coverings: Skin, fascia, ext. oblique aponeurosis, conjoint tendon & transversalis fascia.
(4) Descent directly forward: never reach scrotum.
Diagnosis:
· Symptoms & Signs, The same as O.I.H. with the reported differences.
· Often the patient has poor lower abdominal musculature, as shown by the presence of elongated bulgings (Malgagne' s bulges)
Treatment:
I- Treatment of the cause
II- Truss ® in old unfit patient.
III- Operation: As O.I.H. but the sac is not to excised, only inverted and covered by the plicated fascia transversalis (Shouldice technique) or mesh (Lechtenstein technique).
The darn operation is no longer acceptable because of high recurrence and slow rehabilitation.
SOURCE: DR. AYMAN SALEM'S BOOK
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