13. inguinal/femoral hernia

Bimodal

Infants (congenital)

Older adults (acquired weakness)

age distribution of inguinal hernias

Heavy lifting 🏋️

Chronic cough (COPD)

Constipation/straining

Pregnancy

Obesity or connective tissue weakness

Smoking (poor tissue integrity)

risk factors for inguinal hernias

Rectus abdominis (medial)

Inferior epigastric vessels (lateral)

Inguinal ligament (inferior)

what are the borders of Hesselbach's triangle?

indirect inguinal hernia

most common type of hernia

• Deep inguinal ring

• Lateral to inferior epigastric vessels

*can extend into scrotum

_{“MDs don’t LIe”}

• _{Medial = Direct (s = hesselbac)}

• _{Lateral = Indirect (deeeep)}

_{Relative to the inferior epigastric vessels.}

location of indirect hernia

INdirect = INfants

Often congenital (patent processus vaginalis)

most common cause of indirect hernia

Medial to inferior epigastric vessels

Through Hesselbach triangle

_{“MDs don’t LIe”}

• _{Medial = Direct (s = hesselbac)}

• _{Lateral = Indirect (e=deeep)}

_{Relative to the inferior epigastric vessels.}

location of direct hernias

More common in women

High risk of strangulation

Finding	Incarceration	Strangulation 🚨
Reducible?	❌ Non-reducible ⭐	❌ Non-reducible
Pain	Increasing/local pain	Severe, constant pain ⭐
Hernia	Firm/tender	Very tender, tense
Skin	Usually normal	Erythema, warmth, discoloration 🚨
GI symptoms	N/V, possible obstruction	N/V + obstruction, may progress to ileus
Systemic signs	Usually absent	Fever, tachycardia, toxicity 🚨
Labs	May be normal	↑ WBC, metabolic/lactic acidosis, ↑ lactate
Meaning	Bowel trapped	Blood supply compromised → ischemia/necrosis
Treatment	Urgent evaluation; reduction may be attempted if no strangulation signs	🚨 Emergency surgery — DO NOT attempt forceful reduction

Big red flags: severe worsening pain, erythema, fever, tachycardia, peritoneal signs, elevated lactate.

incarceration vs strangulation of a hernia

hydrocele

- collection of serous fluid within the tunica vaginalis surrounding the testicle.

	Communicating hydrocele	Noncommunicating hydrocele
Cause	Patent processus vaginalis ⭐	Processus vaginalis closed; fluid remains
Connection to abdomen?	Yes	No
Size changes?	Yes — larger with crying/standing, smaller when supine	Usually constant
Associated with	Indirect inguinal hernia ⭐	Usually isolated
Transilluminates?	✅ Yes	✅ Yes
Treatment in child	Often observe initially; surgical repair if persistent/associated hernia	Usually observe in infants

Scrotal mass	Transilluminates?	Classic clue
Hydrocele	✅ YES	Painless fluid around testicle
Varicocele	❌	“Bag of worms”
Testicular tumor	❌	Firm, painless solid mass
Inguinal hernia	❌	Reducible; may increase with Valsalva
Epididymitis	❌	Painful + urinary symptoms
Testicular torsion	❌	Sudden severe pain, high-riding testicle

scrotal mass that transilluminates

= testicular cancer until proven otherwise

→ scrotal ultrasound first.

→ radical inguinal orchiectomy is the diagnostic + therapeutic approach.

⚠ If suspicious for cancer:

Never biopsy through the scrotum because it can disrupt lymphatic drainage and potentially seed tumor.

painless/ firm / solid testicular mass, no transillumination

truss

hernia belt for nonoperative hernias

DO NOT observe (operate)

can you manage femoral hernias non-operatively?

Lichtenstein repair

-Tension free hernia repair with a patch (mesh)

-open repair

TEP = “Entirely Extra-Peritoneal”
→ Never enters the abdomen

(totally extraperitoneal)

OR

TAPP = “Through Abdomen → PrePeritoneal”
→ enters the peritoneal cavity, opens a peritoneal flap, places mesh underneath, then closes the flap.

(transabdominal preperitoneal)

_{^{Both vs open repair}}

_{^{TEP/TAPP = posterior approach → mesh covers the entire myopectineal orifice, protecting against direct, indirect, and femoral hernias.}}

_{^{Board pearl: For a bilateral inguinal hernia or recurrent hernia after an anterior/open repair, a laparoscopic/minimally invasive posterior approach (TEP or TAPP) is especially useful.}}

_{^{If a patient previously had a posterior/laparoscopic repair, recurrence is generally approached from the opposite plane → open anterior repair.}}

laparoscopic repiar types for hernias

femoral hernia

hernia type with the highest strangulation risk

sliding inguinal hernia

_{^{Why surgeons care?}}

_{^{During repair, you cannot simply dissect or excise the entire “sac” because what looks like the sac wall may actually be colon or bladder → risk of organ injury.}}

_{^{Board pearl:}}

_{^{Sliding hernia = organ forms part of the hernia sac wall.}}

_{^{Don't confuse it with a sliding hiatal hernia, where the GE junction and proximal stomach slide above the diaphragm.}}

Hernia where part of the sac wall is formed by an organ

Colon (most common)

Bladder

Sliding hernia

Large, chronic hernia

May have urinary symptoms (if bladder involved)

strangulated hernia

Hernia with compromised blood supply

older men

most common population of bilateral inguinal hernias

Laparoscopic repair preferred

• Can fix both sides simultaneously

• Less pain, faster recovery

preferred management of bilateral inguinal hernias

ilioinguinal nerve

nerve deficit associated with groin/scrotal numbness

iliohypogastric

nerve deficit associated with lower abdominal sensation

genitofemoral nerve

nerve: ok cremaster reflex, scrotal sensation

Category	Contents
Arteries	Testicular artery, cremasteric artery, artery to ductus deferens
Veins	Pampiniform plexus → testicular vein
Nerves	Genital branch of genitofemoral nerve (cremaster reflex), sympathetic/autonomic fibers
Duct	Vas (ductus) deferens
Lymphatics	Testicular lymphatics → para-aortic (lumbar) nodes
Other	Remnant of processus vaginalis

note:

_{^{The ilioinguinal nerve travels through the inguinal canal alongside the spermatic cord, but is NOT actually contained within the spermatic cord.}}

injury to spermatic cord causes damage to:

hint: 3 nerves, 3 arteries, 3 other structures:

ischemic orchitis

Can happen after hernia repair

Swollen painful testicle

2/2 pampiniform plexus thrombosis or testicular artery ligation

Treat with NSAIDS

Orchiectomy is rare

Poor surgical technique

Tension on repair

Infection

Patient factors (obesity, smoking)

causes of hernia recurrence

mesh repair

best way to prevent hernia recurrence

Infection

Chronic pain

Mesh complications (rare)

risks associated with mesh use

organ forms sac wall

define a sliding hernia

lap hernia repair

best approcah for bilateral/recurrent hernias

Classic presentation:

Young man (15–35) + painless, firm testicular mass that does NOT transilluminate

Feature	Testicular cancer
Pain	Usually painless
Consistency	Firm/hard, solid
Transillumination	❌ No
Location	Intratesticular
Lymphatic spread	⭐ Para-aortic (retroperitoneal) lymph nodes
Major risk factor	Cryptorchidism
Initial imaging	Scrotal ultrasound
Tumor markers	AFP, β-hCG, LDH
Diagnosis/treatment	Radical inguinal orchiectomy
Avoid	❌ Transscrotal biopsy

NEVER biopsy testicular ca bc where will it spread?

Tumor	Histology
Seminoma	“Fried-egg” cells with clear cytoplasm + lymphocytes
Embryonal	Primitive, pleomorphic cells; glandular/papillary patterns
Yolk sac	⭐ Schiller-Duval bodies
Choriocarcinoma	Cytotrophoblasts + syncytiotrophoblasts
Teratoma	Multiple mature/immature tissue types from different germ layers

extra

Tumor	Typical age	Classic presentation / board clues	Tumor marker
Seminoma	30–40	⭐ Painless testicular mass; homogeneous; radiosensitive; relatively later spread	β-hCG may ↑, AFP NEVER ↑
Embryonal carcinoma	20–30	Painless mass; aggressive, often heterogeneous with hemorrhage/necrosis	AFP ± β-hCG ↑
Yolk sac tumor	<3 years	⭐ Most common testicular tumor in young children; Schiller-Duval bodies	AFP ↑
Choriocarcinoma	20–30	Small testicular primary but early hematogenous metastases → lungs/brain; may cause gynecomastia	⭐ β-hCG markedly ↑
Teratoma	Children & young adults	Contains tissues from multiple germ layers; behavior depends strongly on age	Markers variable

Super high-yield age associations

Child <3 + testicular mass → Yolk sac tumor → AFP ↑

30–40 + painless testicular mass → Seminoma → AFP normal

One more board age pearl: In an older man (~60+) with a testicular mass, think testicular lymphoma (usually diffuse large B-cell lymphoma), rather than a germ-cell tumor.

	Varicocele
Cause	Dilated pampiniform plexus veins
Side	Left > right
Palpation	“Bag of worms”
Pain	Usually painless; may cause dull aching/heaviness
Standing/Valsalva	Becomes larger/more prominent
Supine	Decreases/disappears
Transillumination	❌ No
Complication	Infertility + testicular atrophy
Diagnosis	Usually clinical; Doppler US if uncertain

Adolescent/young man with painless scrotal swelling or heaviness that worsens with standing or Valsalva and improves when supine.

Clinical situation	Preferred approach
Bilateral inguinal hernias	⭐ TEP or TAPP
Recurrent hernia after OPEN/anterior repair	⭐ TEP or TAPP (posterior approach)
Unilateral primary hernia	Open, TEP, or TAPP depending on patient/surgeon
Need to inspect abdominal cavity / uncertain diagnosis	TAPP
Larger/complex hernia where more working space helps	Often TAPP
Want to avoid entering peritoneal cavity	TEP
Significant prior lower abdominal/preperitoneal surgery	TAPP may be easier; approach individualized
Recurrence after TEP/TAPP	⭐ Open anterior repair (switch planes)

	TAPP	TEP
Full name	Transabdominal preperitoneal	Totally extraperitoneal
Enter abdominal/peritoneal cavity?	✅ YES	❌ NO
Basic route	Abdomen → open peritoneum → preperitoneal space	Directly into preperitoneal space
Mesh location	Preperitoneal	Preperitoneal
Peritoneum opened?	✅ Yes, then closed over mesh	❌ No
Working space	Larger, easier visualization	Smaller, technically more difficult
Can inspect abdominal cavity?	✅ Yes	❌ No
Intra-abdominal complications	Higher potential risk	Lower risk
Adhesion/bowel injury risk	Slightly higher	Lower
Learning curve	Generally easier	More technically demanding