Inguinal hernias may be congenital or acquired.
Inguinal hernias classified depending on whether they are medial (direct) or lateral (indirect) to the inferior epigastric artery. Indirect hernias descend along the spermatic cord from deep to the superficial inguinal ring.
Inguinal hernias can traditionally be diagnosed with physical clinical examinationØ
However, radiological diagnosis is often necessary for:
1. Diagnosis of occult hernias
2. Identification of hernia contents as well as the choice of treatment
3. Complicated inguinal hernias
Ultrasound is frequently the initial diagnostic modality of choice to evaluate uncomplicated inguinal lumps.
CT scan is better in localisation of the hernia as well as to identify potential complications
CT is also helpful in differentiating femoral from inguinal hernias when physical exam is not diagnostic Ø A hernia sac medial and superior to pubic tubercle is diagnostic of inguinal hernia Ø A hernia sac inferior and lateral to pubic tubercle is compatible with femoral hernia and often associated with venous compression
Inguinal hernias can present in a variety of ways and contain a multitude of abdominal and pelvic contents Øthe most common contents of inguinal hernias include fat and loops of bowel, but various other pelvic contents have been reported within inguinal hernia sacs
There are several risk factors for the development of inguinal hernias{ Figure 2}
The most common contents in the inguinal canal are fat and/or small or large bowel contents; the bowel contents can lead to features of bowel obstruction, an appendix in the inguinal can become inflamed and incarcerated {Amyand’s hernia- 1 %}. Other contents include stomach, Undescended testis, ovary, haematoma, seroma, abscess, varicocele, Ureters, kidneys, urinary bladder, primary and malignant lesions {metastatic or tumours of bowel} Ultrasound is the initial imaging choice with CT and MRI as the problem solving and for more specific evaluation and evaluation of complications. There are several lesions that mimic changes in the inguinal canal including femoral aneurysm, varicocele, varix, haematoma, skeletal changes {Exostosis, tumours, and callus formation} lymph nodes
Inguinal hernias may be congenital or acquired.
Inguinal hernias classified depending on whether they are medial (direct) or lateral (indirect) to the inferior epigastric artery. Indirect hernias descend along the spermatic cord from deep to the superficial inguinal ring. { Figure 5 & 6}
FAT:
Commonest hernial content, varying amount of fat seen in the hernia, fat can be complicated by inflammatory changes or lead to strangulation{ Figure 12 & 13}
INTESTINE/BOWEL:
Amongst the commonest contents in the inguinal hernias, may be unilateral or bilateral, may content small or large bowel with or without complications{ strangulation, torsion, or inflamed}- { Figure 7 & 8}; some hernias with bowel content are incidentally noted on plain films of the pelvis.
Less common inguinal hernia contents a Meckel’s diverticulum (Littre’s hernia), a segment of the bowel’s circumference (Richter’s hernia) . Very rarely the stomach and duodenum are seen in the right inguinal hernia{ Figure 12}
APPENDIX:
An Amyand hernia is an inguinal hernia containing the appendix within the hernia sac. Incidence is around 1-1.7%. The appendix can become incarcerated within the hernia sac becoming vulnerable to trauma and adhesions. It is still unknown whether the position of the appendix within the hernia sac makes it more prone to inflammation as well as whether it increases the chances of the hernia becoming incarcerated. {Figure 10 & 11}
OVARIAN:
4–37% of female inguinal hernias present with non-reducible ovaries. Ovarian torsion and infarction have been encountered in 2–33% of these patients, which necessitates treating all cases, even when asymptomatic. Ovary in the inguinal canal is usually due to an incomplete closure of the processus vaginalis of the peritoneum during embryogenesis. The hernia may contain ovary, fallopian tubes and even the uterus. While it is common in infants, very few cases are reported in adults { our case was in a 13 year old}{Figure 18}
TESTES
Cryptorchid or undescended testis is classified as abdominal, inguinal, or subinguinal. About 75% of undescended testis is classified as inguinal. Studies quote 10 times higher risk of torsion in undescended testicle . In 80% of patients with cryptorchidism, the testis is manually palpable in the inguinal canal.{ Figure 16} A retractile testis is occasionally and incidentally noted in the inguinal canal {Figure 17}
BLADDER
The incidence of bladder herniation in patients with inguinal hernia has been estimated at 1 to 3 % by some authors and as high as 10 % by others. Because of the proximity of the bladder to the inguinal and femoral canals, the degree of herniation will vary from a small to a massive protrusion. It is asymptomatic and only incidentally seen. Bladder is herniation is mostly direct and rarely indirect, occurring mostly on the right, common in older men, obesity being a predisposing risk factor, can present with abdominal pain and urinary symptoms; there are reports of tumours within such bladder herniation.{ Figure 15}
MIMICS
Several changes at the inguinal region can mimic inguinal hernias- Skeletal { osteochondroma- Figure 19}, fractures with exubrant callus formation; Vascular { round ligament varicosities - Figure 21, aneurysms - Figure 22}; Cyst of the canal of Nuck { Figure 20}; Soft tissue lesions { lipoma-- Figure 23}; prominent or enlarged inguinal hernias{ Figure 24}