Abnormal findings

Abdominal hernias are protrusions of a viscus through an abnormal opening. Externa! hernias occur at the site of detects in the abdominal wall, e.g. operation scars and points of anatomical weakness. Internal hernias occur through defects of the mesentery or into the retroperitoneal space. External hernias of the abdominal wall are more prominent in the erect position, when the pressure within them rises, and during coughing when an impulse can often be fell in the hernia {cough impulse). After the identification of a hernia, an attempt should be made to replace the contents by the application of a gentle sustained pressure (reduction).

Hernias may be reducible or irreducible. Irreducible hernias may become obstructed, when the bowel lumen is occluded, and obstructed hernias may become strangulated when the vascular supply of the hernial contents is threatened. A strangulated hernia is tense and tender and shows no impulse on coughing; this is a surgical emergency if bowel infarction is to be avoided.

A femora! hernia is palpable below the inguinal ligament and lateral to ihe pubic tubercle. An inguinal hernia emerges from the abdominal wall through the external inguinal ring and is palpable above and medial to the pubic tubercle (Fig. 5.17). It is often difficult to accurately differentiate between direct and indirect inguinal hernias.

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Mri Inguinal Hernia

Fig. 5.18 MRI scan showing contents of the male pelvis. (Courtesy of Dr Andrew R. Wright)

Fig. 5.17 Examining the hernial oriiices. A femoral hernia lies below and lateral to the pubic tubercle. An inguinal hernia lies above and medial to the pubic tubercle.

An indirect inguinal hernia occurs into a persistent remnant of the processus vaginalis. It occurs in young men and may extend to the testes. Following reduction, control can be achieved by pressure over the internal inguinal ring, just above the midpoint of the inguinal ligament, A direct inguinal hernia occurs directly through the weakened posterior wall of the inguinal canal medial to the inferior epigastric artery and lateral to the rectus muscle. It is more common in older men and does not reach the testes. It will not be controlled by pressure over the internal inguinal ring.

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