Definition and Types:
Protrusion of the viscus through the deep inguinal ring to pass through the inguinal canal ant. to the cord structure (Bubonocele type) then emerge from external inguinal ring (funicular or incomplete type) or may even reach the scrotum (complete type).
Incidence:
The most common type in all forms.
Right side is more common than left.
Aetiology of Oblique Inguinal Hernia (Two theories):
(I) Congenital Theory:
Due to persistence of all or part of processus vaginalis.
(II) Acquired Theory:
Formation of a sac in front of increased intra-abdominal pressure due to deficiency of factors (shutter mechanism) which prevent herniation which are:
1- Oblique course of the canal: direction of intra-abdominal pressure not with the direction of the canal.
2- Contraction of conjoint tendon during coughing or straining: support the post wall of the canal "shutter mechanism"
3- Contraction of cremasteric muscle: make the cord more thick to obstruct inguinal canal.
The congenital theory is more accepted why?
1- Oblique ing. hernia is more common in the right side "as the left testis descends first with more time to close processus vaginalis completely"
2- If the sac is removed , the hernia usually not recur.
3- In postmortem dissection of individuals who had not suffered from hernia we found a congenital performed sac in some of them..
Pathology: Sac, Content, Covering, Descent.
(1) The Sac: Types of the sac:
1- Congenital Sac: The whole processsus vaginalis is patent. the testis inside the sac.
2- Funicular Sac: Only the proximal portion of pr.vaginalis.
3- Infantile: Like funicular but the redundant vaginal portion may overlap the funicular sac and may be mistaken as a sac.
So, during operationyou must be sure of connection of the sac to peritoneal cavity
4- Saddle shaped sac "Direct indirect hernia" Direct & indirect sacs separated by inf. epigastric artery.
5- Sliding hernia; (Hernia en glissade) the wall of the sac is formed of part of the viscous which is partially covered with the nearby peritoneum.
(2) Contents: All abdominal viscera may descend except liver & pancreas.
a- Omentum ® omentocele.
b- Intestine ® enterocele which may be side wall of intestine (Richter's H) or W shaped loop (Mydle's H) or Meckle's diverticulum
(Littre's H).
c- Ovary, tube, appendix ® liable to inflammation.
d- U. B. sliding with the sac as it is partially covered with peritoneum.
(3) Covering:
Skin and fascia.
External spermatic fascia (Ext. oblique)
Cremasteric ms & fascia (int. oblique)
Int. spermatic fascia (from fascia transversalis)
(4) Descent: Downwards, forward and medially.
· Reduced in opposite direction upward, backward and laterally.
Diagnosis:
Ä Symptoms:
Heaviness in the groin with dull aching abdominal pain. Intermittent swelling in the groin which:
a- Appears on standing, coughing or straining.
b- Disappear on lying down.
The patient. may suffer from a predisposing factor; e.g. constipation, prostatic enlargement, stricture urethra.
Chronic cough or enlarged abdominal organ e.g. liver & spleen.
ÄSigns:
The following questions must be answered at the end of general and local examination.
(1) Hernia or not?
1- Site of hernial orifice. 2- Appears on standing or straining.
3- Reduced or lying down. 4- Reduction follows certain direction.
5- Expansile impulse on cough.
(2) Rt. or Lt. ? After anesthesia it is difficult to elicit hernia side.
(3) Is it inguinal or femoral?
If the swelling is above the pubic tubercle ® Inguinal.
(4) Is it direct or oblique?
If reaching the scrotum: it is oblique.
If it is limited to the groin (incomplete or bubonocele).

The following tests can differentiate:
a) External ring test:
Patient is standing.
By the little finger, invaginate the neck of scrotum and introduce it through the external ring. If the floor of Hasselbach D is weak, this is proportional with direct hernia. If the ext. ring is wide, this is proportional with the oblique inguinal hernia.
Normally it admit the tip of the finger only.
Ask the patient to cough then impulse is felt:
* At tip of the finger ® O.I.H. * At side of the finger ® direct I.H.
This test is accused to be painful and make external ring more wide. So not performed.
F N.B. Three tests are mentioned to be condemned, Invagination test, test for abdominal rebound tenderness and Hofman’s test for DVT; they are painful and/or harmful.
b) Internal ring test:
Let the patient lying supine and reduce the hernia.
Internal ring is occluded by finger placed 0.5 inch above the mid inguinal point.
Ask the patient to stand while maintaining pressure.
Ask him to cough: * Hernia not appear ® O.I.H.
* Hernia appear ® Direct H.
c) Three finger test:
Stand behind the patient.
Put: (1) Index finger over Int. ring ® (O.I.H.)
(2) Middle finger over Hasselbach's triangle. ® (D. H.)Int. ring
(3) Ring finger over saphenous opening 1.5" below & lat. to pubic tubercle ® (femoral H.)
Ask patient to cough and observe which finger feel impulse.

(5) What is the content?






Intestine







Omentum






Ovary or testis




FN.B. All hernias are opaque in transillumination except in infants it is translucent due to thin wall and gas content.
(6) Recurrent or not?
History & Scar of previous operation ® recurrent
(7) Complicated or not?
1- Irreducibility 2- Strangulation
3- Obstruction 4- Inflammation
(8) What is the predisposing factors?
Careful examination for predisposing factor and treating it reduce the incidence of recurrence.
D. D. of Oblique Inguinal Hernia:
(I) Other hernia * Direct inguinal hernia.
* Femoral hernia.
(II) Hydrocele * Congenital & infantile hydrocele.
* Encysted hydrocele of the cord.
(III) Ectopic or undescended testicle.
(IV) Endemic funiculitis.
(V) Lipoma of the cord.
(VI) Psoas abscess.
(VII) Inguinal adenitis.
Treatment:
I- Surgery:
It is treatment of choice and it is more indicated in patients with chronic cough as those peoples are more liable for strangulation
(I) Herniotomy: = Reduction of the content & excision of the sac
Indications:By itself, it is done in congenital hernia in infants and hernias in children and young adults with strong muscles. Also it is done with all herniorraphy procedures.
Incision: 1 inch above & parallel to the med. 2/3 of inguinal ligament.
Layers:
* Skin and fascia of the abdomen "No deep fascia"
* External oblique aponeurosis ® External spermatic fascia.
* Cremasteric muscle & fascia.
* Internal spermatic fascia.
Then dissect the sac down to the neck.
How can you identify the neck?
Ÿ Narrowest part. Ÿ Extraperitoneal fat.
Ÿ Pulsation of inferior epigastric artery.
(II) Herniorrhaphy: This operation consists of :
1. Excision of the hernia sac (herniotomy).
2. Repair of the stretched internal inguinal ring and fascia transversalis.
3. Further reinforcement of the posterior wall of the inguinal canal.
Indications: It is indicated when the internal ring is weak and the fascia transversalis is bulging.
Technique : It is done by:
(1) Incising the ring and fascia.
(2) Delicate dissection of fascia from the deep epigastric vessels and extraperitoneal fat.
(3) double breasting of both layers of the fascia to attain narrow internal ring and reduce bulged fascia.
C.T.


Tanner’s releasing incision


Lytle and Shouldice described the same previous technique. Scouldice added third and fourth layer of tension free suturing, using monofilament materials (polypropylene, polyamide or wire).
1- Reinforcement of the posterior wall of inguinal canal:
( This is achieved by):
(1) Suturing without tension (Shouldice repair)
(2) Reinforcement of the posterior wall of the canal with prosthetic mesh (Lechtenstein tension free hernioplasty).
The suturing method can include a rectus relaxing incision (Halested-Tanner)
Other historical techniques ( which should now be abandoned because of poor results) described by Bassini (suturing of conjoined tendon to the iguinal ligament), & Halested (suturing the external oblique aponeurosis behined the cord which become subcutaneous and liable to trauma).
Laparoscopic hernia repair : It is indicated in direct and small indirect inguinal hernias. Recurrent ,obstructed , strangulated and large irreducible indirect inguinal hernias are better repaired by (Lechtenstein tension-free mesh repair).
(II) Truss:
It is indicated only when operation is contraindicated or operation is refused. So, its use should be historical as there are very few contraindications to surgery with today’s variety of anaesthetic techniques.
Truss must be applied before the patient gets up and while the hernia is reduced. A properly fitted truss must control the hernia when the patient stand with his legs wide apart, stoop & cough violently
Contraindications for truss:
1- Irreducible hernia.
2- cases with other pathology need surgery.
3- Obese patient difficult to fix truss.
SOURCE: DR. AYMAN SALEM'S BOOK
Copyright: Vascular Society of Egypt (www.vsegypt.org) &Medical Educational web (www.meduweb.com)
Not to be reproduced without permission of Vascular Society of Egypt