Review Question - QID 214628

This patient is presenting with an abdominal wall defect located lateral to the rectus abdominis muscle and medial to the inferior epigastric artery (branch of the external iliac artery), which is most consistent with a direct inguinal hernia. Direct inguinal hernias are the result of intra-abdominal contents protruding through a defect in the transversalis fascia.

An inguinal hernia is an abnormal protrusion of intra-abdominal contents through weakened transversalis fascia (direct) or the internal inguinal ring (indirect). Direct inguinal hernias are commonly secondary to conditions that increase intraabdominal pressure (e.g., constipation and COPD) and protrude through Hesselbach triangle (medial border: rectus abdominis, lateral border: inferior epigastric vessels and inferior border: inguinal ligament). Direct inguinal hernias can protrude through the external (superficial) inguinal ring. Indirect inguinal hernias commonly result from incomplete obliteration of the processus vaginalis during fetal development and protrude through the internal (deep) inguinal ring (lateral to the inferior epigastric artery and therefore outside Hesselbach triangle). Inguinal hernias are often asymptomatic but may progress to pain and features of intestinal obstruction. They are diagnosed clinically, and treatment depends on the severity of symptoms. Asymptomatic hernias are treated conservatively, while complicated (incarcerated or strangulated) and uncomplicated hernias with moderate symptoms are treated surgically.

Incorrect Answers:
Answer 1: Protrusion of intra-abdominal contents through the internal inguinal ring results in an indirect inguinal hernia. Indirect inguinal hernias commonly result from incomplete obliteration of the processus vaginalis during fetal development and protrude through the internal (deep) inguinal ring (lateral to the inferior epigastric artery and therefore outside Hesselbach triangle).

Answer 2: Protrusion of intra-abdominal contents through a prior incision results in an incisional hernia. Incisional hernias are common and can occur after any prior abdominal (not superficial) operation.

Answer 3: Protrusion of intra-abdominal contents through a space between the inguinal ligament and Cooper ligament results in a femoral hernia. Femoral hernias protrude through the femoral canal and therefore typically present as a groin (not abdominal) bulge.

Answer 5: Protrusion of intra-abdominal contents through the umbilical ring results in an umbilical hernia. Umbilical hernias can be congenital (often resolve spontaneously) or acquired (risk factors include obesity, heavy lifting, a long history of coughing, or multiple pregnancies).

Bullet Summary:
Direct inguinal hernias result from weakness in the transversalis fascia allowing intra-abdominal contents to protrude through the abdominal wall defect.