Review Question - QID 108546

This patient has the classic presentation of an indirect inguinal hernia, in which the small intestine follows the path of the testes’ descent through both the deep and superficial rings of the inguinal canal typically through a patent outpouching of the peritoneum.

A male patient presenting with swelling to the groin could be experiencing a range of problems including testicular tumor, hydrocele, epididymitis or cellulitis. However, a large swelling that bulges forward with cough and Valsalva and is easily reducible is strongly suggestive of an inguinal hernia. An inguinal hernia is continuous with the abdominal cavity, so maneuvers that increase intra-abdominal pressure displace the bowels and cause swelling to increase. This is an inguinal hernia because it is located above the inguinal ligament in the groin region. In contrast, femoral hernias occur below the inguinal ligament, and umbilical hernias are typically in the vicinity of the belly button. An indirect inguinal hernia most commonly passes through a persistent processus vaginalis, an outpouching of the peritoneum formed during the descent of the testes during embryologic development. The processus vaginalis normally obliterates, but sometimes remains patent, predisposing the patient to indirect inguinal hernias.

FIgure A shows a bulge above the inguinal ligament characteristically seen in inguinal hernias.

Incorrect Answers:
Answer 1: Direct inguinal hernias pass through the superficial ring only. Indirect inguinal hernias pass through both the deep and the superficial ring.

Answer 2. Indirect inguinal hernias occur laterally to the inferior epigastric vessels, pass through both the deep and the superficial rings of the inguinal canal, and are covered by all layers of the spermatic cord.

Answer 3: Direct inguinal hernias commonly pass through a weak spot in the abdominal wall behind the superficial ring; the area most at risk is called Hesselbach’s triangle. The borders of Hesselbach’s triangle are the inguinal ligament, the inferior epigastric vessels, and the rectus abdominis muscle.

Answer 4: Direct inguinal hernias may tear through the internal spermatic fascia and the cremasteric fascia as they develop. Therefore, they are covered only by external spermatic fascia.

Bullet Summary:
Indirect inguinal hernias occur laterally to the inferior epigastric vessels and pass through the inguinal canal via a patent processus vaginalis. Direct inguinal hernias occur medial to the inferior epigastric vessels, most commonly through Hesselbach's triangle, an area of weakness behind the superficial ring.