DIG Exam 3 Lopez Hernia

through deep ring, lateral to inferior epigastrics

Indirect inguinal hernia

Hesselbach’s triangle, medial to inferior epigastrics

Direct inguinal hernia

below inguinal ligament, medial to femoral vein

Femoral hernia

linea alba above umbilicus

epigastric hernia

semilunar line, usually below arcuate line

Spigelian hernia

contents return to abdomen with pressure/position

reducible

irreducible, but perfused

Painful, irreducible, no systemic toxicity, skin looks okay.

Incarcerated

ischemia/necrosis (systemic toxicity; surgical emergency)

Severe pain, systemic toxicity, overlying skin changes, peritonitis or shock → don’t delay

Strangulated

Mr. Thomas V., a 69-year-old man, reports a right groin bulge for 8–9 months that enlarges with coughing/straining and shrinks when lying down. The ache is dull, 2–4/10, worse after yard work or lifting groceries. Over the past week he notes more frequent bulging after prolonged standing. He denies nausea/vomiting, fevers, constipation, or obstructive symptoms. No scrotal pain or swelling.

Provokers: cough, lifting, prolonged standing.Relievers: lying supine, gentle manual reduction.No prior groin surgery.

Relevant history

PMH: COPD (moderate), BPH, HTN, hyperlipidemia.

Meds: tiotropium, albuterol PRN, tamsulosin, lisinopril, atorvastatin; daily aspirin 81 mg.

Allergies: NKDA.

SHx: Retired mechanic; still does heavy yard work. No alcohol/drugs.

Vitals: BP 138/76, HR 82, RR 16, afebrile, SpO₂ 97% RA.General: Comfortable at rest.

Abdomen:

Soft, non-tender, no distension.Groin (standing, then supine):

Right-sided, broad-based bulge above the inguinal ligament and medial to the pubic tubercle.

Cough impulse positive. With index finger at the external ring, the impulse is felt on the finger pad (not the fingertip).

Bulge does not extend into the scrotum; fully reducible supine with gentle pressure.

No skin changes; no tenderness out of proportion.

Femoral landmarks: femoral pulse lateral; no mass below the inguinal ligament.

Testes: Normal, non-tender, intact cremasteric reflex.Lungs: Mild expiratory wheeze.

Direct inguinal hernia

A 72-year-old man notes a broad, reducible right groin bulge that does not enter the scrotum. Impulse is felt on the finger pad at the external ring. Most likely diagnosis?

A. Direct inguinal hernia

B. Indirect inguinal hernia

C. Femoral hernia

D. Inguinal lymphadenopathy

E. Varicocele

Direct inguinal hernia

Weakness of transversalis fascia with age

Posterior wall of the inguinal canal (transversalis fascia) within Hesselbach’s triangle:

Medial border: lateral edge of rectus abdominis

Lateral border: inferior epigastric vessels

Inferior border: inguinal ligament

Direct inguinal hernia

↑ Intra-abdominal pressure: chronic cough/COPD, constipation/straining (BPH), heavy lifting.

Age-related fascial degeneration, collagen disorders, obesity.

Triggers for direct inguinal hernia

Pushes directly through the posterior wall medial to the inferior epigastric vessels into the inguinal canal; usually lies beside (not within) the cord and

Often broad-based; may pick up only external spermatic fascia as it exits via the superficial ring.

Does not go through deep inguinal ring

Direct inguinal hernia

Mr. Daniel S., a 50-year-old man, notices a left groin bulge that descends into the scrotum for the past 2 years. It appears with coughing, straining, or after the gym, and reduces when he lies down. Dull, intermittent ache (3–5/10) after prolonged standing; no sharp pain. No nausea, vomiting, fever, or obstructive symptoms. He can manually reduce the bulge.

Provokers: Valsalva, heavy lifting, prolonged standing.Relievers: Supine position, manual reduction, compression shorts.

Relevant history

PMH: Healthy; no prior abdominal surgery.

Meds: None; uses whey supplements.

Allergies: NKDA.

SHx: Warehouse job (heavy loads); non-smoker; social alcohol; no drug use. Family history negative for hernias.

Focused ROS

Denies testicular pain, dysuria, hematuria.

No weight loss, night sweats, or systemic symptoms.

Vitals: BP 124/72, HR 74, RR 14, afebrile, SpO₂ 99% RA.General: Well-appearing, athletic build.

Abdomen:

Soft, non-tender, no distension.Groin & scrotum (standing → Valsalva → supine):

Visible/palpable bulge above the inguinal ligament that tracks into the left hemiscrotum.

Cough impulse positive; with index finger at the external ring, the impulse is felt on the fingertip (advances from deep ring).

Reducible with gentle pressure or supine position; silk sign (silky cord) may be appreciated.

No skin color change; no exquisite tenderness; no signs of incarceration.Testes: Normal size/position; non-tender; no hydrocele (doesn’t transilluminate).Femoral region: No lump below inguinal ligament.Neurovascular: Intact.

Indirect inguinal hernia

A 28-year-old man has an intermittent left groin bulge that descends into the scrotum after weightlifting and reduces when supine. On exam standing with Valsalva, an impulse is felt on the fingertip at the external ring. What is the most likely diagnosis?

A. Direct inguinal hernia

B. Indirect inguinal hernia

C. Femoral hernia

D. Spigelian hernia

E. Hydrocele

Indirect inguinal hernia

Weak point: Deep inguinal ring due to a patent processus vaginalis (congenital).

Located lateral to the inferior epigastric vessels.

Indirect inguinal hernia

↑ Intra-abdominal pressure (Valsalva, lifting, athletics) acting on a pre-existing patency of the processus vaginalis.

Male sex, prematurity; connective-tissue laxity.

Trigger for indirect inguinal hernia

Patent processus vaginalis

Indirect inguinal hernia weak point

Enters via the deep ring (lateral to inferior epigastrics) → traverses the inguinal canal within the spermatic cord → exits the superficial ring; may descend into the scrotum.

Classically acquires all three cord coverings (internal spermatic, cremasteric, external spermatic fasciae).

Indirect inguinal hernia

Ms. Elena R., 72-year-old female notices a small right groin lump for ~3 months that used to appear after walking and disappear when she lay down. Today, after carrying groceries, the lump became painful and stayed out. Pain is sharp, 7/10, worse with standing/coughing, no scrotal structures (female). She has mild nausea, no vomiting, passed flatus this morning, last BM yesterday. No fever.

Provokers: prolonged standing, lifting, cough.Relievers: used to reduce supine; not reducible today.No prior groin surgery.

Relevant history

PMH: HTN, hyperlipidemia, osteoarthritis.

Meds: amlodipine, atorvastatin, albuterol PRN, occasional NSAIDs, stool softener.

Allergies: NKDA.

SHx: Retired teacher; non-smoker; 1 glass of wine/week.

Vitals: BP 146/78, HR 96, RR 16, T 37.4 °C, SpO₂ 98% RA.General: Uncomfortable, guarding right groin.

Abdomen: Soft, mildly tender RLQ without peritoneal signs; not distended; bowel sounds present.Groin (standing then supine):

Tender, firm, 2–3 cm globular mass inferior to the inguinal ligament and medial to the femoral pulse (i.e., medial to the femoral vein).

No clear cough impulse today; not reducible with gentle pressure.

Skin intact (no erythema).Contralateral groin: No masses.Extremities: Distal pulses intact.

Femoral hernia

A 76-year-old woman has a tender lump inferior to the inguinal ligament, medial to the femoral pulse, irreducible today. Nausea without vomiting. Most likely diagnosis?

A. Indirect inguinal hernia

B. Direct inguinal hernia

C. Femoral hernia

D. Psoas abscess

E. Spigelian hernia

Femoral hernia

Weak point femoral ring is a natural gap at the medial end of the femoral canal (below the inguinal ligament).

Femoral hernia

↑ Intra-abdominal pressure (cough, constipation/straining, pregnancy, obesity, ascites) pushes preperitoneal fat and then peritoneum through the femoral ring → femoral canal.

Trigger for femoral hernia

The sac descends inferior to the inguinal ligament and medial to the femoral vein, then often turns anterior through the saphenous (femoral) opening to present as a groin mass on the upper thigh.

Femoral hernia path

Ms. Maya G., 58-year-old female presents with 3 months of intermittent left lower–lateral abdominal wall pain. She notices a small, tender bulge that pops out when she stands, coughs, or lifts and flattens when she lies down. Pain is localized (no radiation), worse with Valsalva, and relieved by rest/support. No nausea, vomiting, bowel obstruction symptoms, or fevers. No prior incision exactly at the site.

Provokers: standing, coughing, lifting laundry.Relievers: supine position, abdominal binder.Denies weight loss, change in bowel habits.

Relevant history

PMH: Asthma, hypothyroidism, hypertension.

Meds: Fluticasone–salmeterol, albuterol PRN, levothyroxine, amlodipine; no anticoagulants.

Allergies: NKDA.

SHx: Desk job; nonsmoker; rare alcohol.

PSurg: Laparoscopic cholecystectomy (ports subcostal—not at current lump site).

Focused ROS

No dysuria, hematuria, gynecologic symptoms.

No prior hernias.

Vitals: BP 134/78, HR 82, RR 14, T 36.9 °C, SpO₂ 99% RA

General: Well-appearing, comfortable at rest.

Abdomen (inspect/palpate standing then supine):

Standing with Valsalva: 2–3 cm tender, firm bulge along the left semilunar (Spigelian) line, lateral to rectus and inferior to the umbilicus.

Supine: bulge reduces; defect indistinct on relaxation.

No overlying skin changes, no peritonitis.No midline/port-site defects; no inguinal or femoral masses.

Bowel sounds normal; neurovascular intact.

Spigelian hernia

A 58-year-old woman has lateral lower abdominal wall pain and a small tender lump that appears on standing/Valsalva along the semilunar line, inferior to the umbilicus; often not palpable supine. Most likely diagnosis?

A. Indirect inguinal hernia

B. Femoral hernia

C. Spigelian hernia

D. Lipoma of abdominal wall

E. Sports hernia

Spigelian hernia

Herniates through the Spigelian fascia (usually lateral to rectus, inferior to the umbilicus) into an interparietal plane (often between internal and external oblique or between internal oblique and transversus).

May remain occult when supine and protrude with Valsalva; can eventually extend through the external oblique aponeurosis to become subcutaneous.

Often has a narrow neck → higher incarceration risk.

Spigelian Hernia

Weak point Spigelian fascia along the semilunar line (junction of transversus abdominis & internal oblique aponeuroses).

Predilection for the “Spigelian belt” below the arcuate line, where the posterior rectus sheath is absent → weaker abdominal wall.

Small perforator “holes” further weaken this zone.

Spigelian hernia

↑ Intra-abdominal pressure: obesity, pregnancy, chronic cough, ascites, heavy lifting.

Lateral abdominal wall fascial attenuation; prior nearby surgery or trauma (not necessarily at the exact site).

Triggers for spigelian hernia

Ms. Karen L., 62-year-old female presents with a midline abdominal bulge first noticed 10 months ago at the for complicated diverticulitis (Hartmann’s, reversed 18 months ago). The bulge enlarges with coughing/standing/lifting and reduces when supine. She reports a dull, pulling discomfort (3–5/10) after activity, no severe pain. Over the last 2 months she feels the bulge is larger and occasionally “gets stuck” for a few minutes after heavy meals but then reduces with gentle pressure. No nausea/vomiting, no obstipation, no fever.

Provokers: Valsalva, lifting laundry, prolonged standing.Relievers: Lying down, abdominal binder.Postoperative course (index surgery): Wound infection requiring packing for 2 weeks; healed by secondary intention.

Relevant history

PMH: COPD (mild), HTN, prediabetes, osteoarthritis.

Meds: Lisinopril, inhaled tiotropium, albuterol PRN, acetaminophen; no steroids/anticoagulants.

Allergies: NKDA.

PSurg: Open sigmoid resection with temporary ostomy (midline incision; reversed). Laparoscopic cholecystectomy remote.

SHx: Retired clerk; lives with spouse; no alcohol/drugs.

Focused ROS

Denies weight loss, night sweats; intermittent constipation; no skin color change over bulge.

Vitals: BP 136/78, HR 84, RR 14, T 36.8 °C, SpO₂ 98% RA.

General: Well-appearing, ambulatory.

Abdomen:

Healed midline scar from epigastrium to supra-umbilicus. With standing + Valsalva, a reducible 7 × 6 cm midline bulge centered 2 cm above the umbilicus.

Cough impulse +.

Edges of a fascial defect palpable; tenderness mild only on strain.

No skin erythema, no peritonitis, bowel sounds normal.Supine: Bulge reduces fully with gentle pressure; fascial ring palpable.

Hernia grading (at bedside): Single midline incisional defect; no obvious loss of domain.Inguinal/femoral: No masses.

Incisional hernia

A 62-year-old woman had a midline laparotomy 18 months ago. Now has a reducible bulge along the scar with cough impulse. Most likely diagnosis?

A. Umbilical hernia

B. Epigastric hernia

C. Incisional hernia

D. Spigelian hernia

E. Rectus sheath hematoma

Incisional hernia

Incisional hernia

Incisional hernia

peristomal

A 55-year-old man complains of a midline abdominal protuberance when he sits up. No discrete fascial ring is palpated; the ridge runs from xiphoid to umbilicus; no cough impulse. The "pooch" or ridge down the middle of the abdomen and above or below the belly button, becomes more noticeable when straining or contracting abdominal muscles.. Which is the most likely diagnosis?

A. Umbilical hernia

B. Incisional hernia

C. Diastasis recti

D. Spigelian hernia

E. Epigastric hernia

Diastasis recti

A 45-year-old woman (BMI 38) has a midline bulge at the umbilicus that enlarges with cough and reduces supine; cough impulse positive. Which is the most likely diagnosis?

A. Umbilical hernia

B. Epigastric hernia

C. Incisional hernia

D. Diastasis recti

E. Spigelian hernia

Umbilical hernia

A 42-year-old man presents with a “small knot” just above his belly button that appears during sit-ups and heavy lifting and flattens when he lies down. Pain is sharp with exertion and dull at rest. He has no prior abdominal surgeries and takes no anticoagulants. Exam standing with Valsalva reveals a 1–2 cm, firm, tender, reducible nodule on the midline 4 cm above the umbilicus with a cough impulse. In the supine position the bulge reduces; a discrete fascial ring is palpable. No skin changes. Which of the following is the most likely diagnosis?

A. Umbilical hernia

B. Epigastric hernia

C. Rectus sheath hematoma

D. Subcutaneous lipoma

E. Diastasis recti

Epigastric hernia