Repair an abdominal hernia

A 76-year-old man is scheduled to undergo repair of an abdominal hernia that is easily reduced by pushing the abdominal contents back through the external ring. During repair, the surgeon sees that the hernial sac protrudes from the abdominal wall superior to the inguinal ligament and medial to the inferior epigastric vessels. Which of the following types of hernia does this patient have?

(A) Diaphragmatic hernia
(B) Direct inguinal hernia
© Femoral hernia
(D) Hiatal hernia
(E) Indirect inguinal hernia

Correct Answer: (B) Direct inguinal hernia
Direct inguinal hernias protrude directly through the abdominal wall in Hesselbach’s triangle, which is bordered by the inguinal ligament, rectus abdominis muscle, and inferior epigastric vessels. Remember that the issue of direct versus indirect has nothing to do with whether or not the hernia enters the scrotum through the external ring, as both direct and indirect hernias can do this. Di- rect versus indirect distinguishes where the hernia enters the inguinal canal, either through the internal ring (indirect) or straight through the abdominal wall (for direct hernias, think directly through the wall). In this case, the abdominal contents pierced through the abdominal wall and through the external inguinal ring. Direct hernias are often discovered in older patients, as the hernia is a result of pressure and tension exerted over time that eventually leads the abdominal wall to give way. Direct hernias are less common and have less risk of strangulation than indirect hernias.

Answer A is incorrect. Diaphragmatic hernias are serious birth defects that are lethal unless repaired soon after birth. A defective development of the diaphragm leads to herniation of abdominal contents into the thorax, displacing the lung. Even after repair of such lesions, children may have poor pulmonary function due to poor lung development in utero.

Answer C is incorrect. Femoral hernias protrude inferior to the inguinal ligament and do not go through the external inguinal ring.

Answer D is incorrect. Hiatal hernias are hernias of the stomach protruding superiorly through the diaphragm.

Answer E is incorrect. Indirect inguinal hernias occur when abdominal contents enter the internal inguinal ring through a patent processus vaginalis, exit the inguinal canal through the external ring, and often enter the scrotum of male patients. The examiner’s finger would go through the external ring and would pass posterior to the epigastric vessels and through the internal ring. These hernias are the most common type found in both men and women, and the recommendation is that they be repaired when they are discovered to avoid the complication of strangulation and bowel infarction.
answered Apr 2, 2017 by Rajesh Bahara