Direct vs Indirect Inguinal Hernias

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Introduction

An inguinal hernia is an abnormal protrusionΒ ofΒ abdominopelvic contentsΒ through theΒ superficial inguinal ring into the groin. The superficial inguinal ring lies above the pubic tubercle and marks the end-point of the inguinal canal.

Inguinal hernias are by far the most common type of hernia. Patients often present with aΒ lump in the groin that comes and goes and has slowly increased in size over time.

Inguinal hernias can beΒ direct orΒ indirect:

  • Direct: abdominal contents are forced through a weakness in the posterior wall of the inguinal canal
  • Indirect: abdominal contents enter the deep ring (the start) of the inguinal canal

In both types of inguinal hernia, abdominal contents exit through the superficial ring of the inguinal canal and can sometimes enter the scrotum. This is known as anΒ inguinoscrotal hernia. It is much more common forΒ indirect hernias to do this as the path through both anatomical inguinal rings offers less resistance.

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Direct inguinal hernia

AΒ direct inguinal herniaΒ is caused by a weakness in theΒ posterior wall of the inguinal canalΒ in an area known asΒ Hesselbach’s triangle.

Abdominal contents (usually just fatty tissue, sometimes bowel) are forced β€œdirectly” through this defect into the inguinal canal.

The abdominal contents enter the canal medial to the deep ringΒ and exit via the superficial ring.

Direct inguinal hernia
Direct inguinal hernia

Indirect inguinal hernia

AnΒ indirect inguinal herniaΒ follows a different trajectory.

Instead of piercing the posterior wall, the abdominal contentsΒ enter the deep ring (the start of the inguinal canal), pass along the length of the inguinal canal and exit via the superficial ring.

Indirect inguinal hernia
Indirect inguinal hernia

How to distinguish direct vs indirect inguinal hernia

Direct and indirect inguinal hernias are managed in the same way (usually a mesh repair). Distinguishing betweenΒ directΒ andΒ indirect inguinal hernias on hernia examination has limited clinical use and is unreliable. However, it can help you understand the anatomical concepts.Β 

If you place your finger over the deep inguinal ring (just above the mid-point of the inguinal ligament), you can control an indirect inguinal hernia that has been reduced (in other words, the hernia does not reappear).Β 

If you press the deep ring and the hernia still protrudes, then the hernia is emerging via a defect in the posterior wall medial to this point and is, therefore, aΒ direct hernia.

Technique

1.Β Locate the deep inguinal ring (midway between the anterior superior iliac spine and pubic tubercle).

2.Β Manually reduce the patient’s hernia by compressing it towards the deep inguinal ring, starting at the inferior aspect of the hernia.

3.Β Once the hernia is reduced, apply pressure over the deep inguinal ring and ask the patient to cough.

If a hernia reappears, it is more likely to be a direct inguinal hernia; if it does not, it is more likely to be an indirect inguinal hernia.


Editor

Dr Chris Jefferies


 

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