Clinical Classification of Hernia

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1. Reducible hernia

Normally an uncomplicated hernia is reducible. That means its

contents can be returned into the abdominal cavity but the sac remains in its

position.

2. Irreducible hernia

In this hernia the contents cannot be returned to the abdomen.

3. Obstructed or Incarcerated hernia

(Irreducibility + Intestinal obstruction)

An obstructed hernia means the hernia is associated with intestinal

obstruction due to occlusion of the lumen of the bowel.

4. Strangulated hernia

(Irreducibility + Obstruction + Arrest of blood supply to the contents)

A hernia is said to be strangulated when the contents are so constricted

as to be interfered with their blood supply.

5. Inflamed hernia

This is a very rare condition and mimics in many respects a

strangulated hernia. This hernia may occur when its content such as an

appendix, a salpinx or a Meckel’s diverticulum becomes inflamed.

DIRECT INGUINAL HERNIA

Between 10 and 15 % of inguinal herniae are direct. Over half of the

herniae are bilateral.

A direct inguinal hernia is always acquired. The sac passes through a

weakness of defect of the transversalis fascia in the posterior wall of the

inguinal canal. In some cases, the defect is small and closely related to the

insertion of the conjoint tendon; occasionally congenitally deficient, while in

others there is a generalized bulge through Hesselbach’s triangle. Often the

patient is a man with poor abdominal musculature, as shown by the presence

of Malgaigne’s bulgings. Women practically never develop a direct inguinal

hernia. Predisposing factors are a chronic cough, straining and heavy work.

Damage to the ilioinguinal nerve (Ex: By previous appendicectomy) is

another known cause.

Direct herniae rarely attain a large size and descend into the scrotum.

In contradistinction to an oblique inguinal hernia, a direct inguinal hernia lies

behind the spermatic cord. The sac is often smaller than the hernial mass

would indicate, the protruding mass mainly consisting of extra – peritoneal

fat. A finger inserted into the superficial inguinal ring passes directly

backwards into the abdomen. As the neck of the sac is wide, direct inguinal

hernias rarely strangulate.

On coughing, the impulse is felt on the pulp of the finger whereas in

an oblique hernia the impulse is felt on the finger tip, viz. oblique direct.

The inferior epigastric artery lies lateral to the aperture, but because of

its small size and the nature of its coverings, it cannot be felt, those who

pretend to feel it surrender themselves to a flattering delusion.

At operation the distinguishing features of a direct inguinal hernia are,

that the sac lies medially to the inferior epigastric artery, and the spermatic

cord is not attached to the wall of the sac. The sac is often smaller that the

hernial mass would indicate the protruding mass mainly consisting of

extraperitoneal fat. As the neck of the sac is wide, direct inguinal herniae

rarely strangulate.

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