RELATIONS OF THE NECK OF GROIN HERNIAS TO PUBIC …
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157 INTRODUCTION Inguinal herniorrhaphy is the most frequently performed abdominal operation, accounting for 10- 15% of operations in general surgery . It may be higher in developing African countries such as Nigeria, as the incidence of inguinal hernia has been found to be threefold in black communities as compared to the rate in caucasians . Approximately 96% of groin hernias are inguinal and 4% are femoral. Inguinal hernias are bilateral in as many as 20% of affected adults. While inguinal hernia occur fairly equally across adult age group, the femoral hernias tend to occur more often in elderly women. The lifetime risk of inguinal hernia is approximately 10percent . The groin, one of the naturally weak areas of the abdominal wall is the most common site for abdominal hernias . These usually occur through either the inguinal or femoral canal, giving rise to inguinal and femoral hernias respectively. The inguinal canal and its openings lie above the inguinal ligament while the femoral canal lies below it . The internal and external rings form the ends of the 1-4 5-7 8 9 10, 11 Correspondence: Dr O IAlatise E- mail:[email protected] inguinal canal. Inguinal hernias are divided into indirect and direct. Indirect hernias enter the canal from the internal ring and may or may not exist at the external ring depending on whether it is bubunocele, furnicular or inguinoscrotal. The direct hernias pass through the hesselbach's triangle in the posterior wall of the canal. This triangle is located lateral to the external ring. The internal ring, an opening in the transversalis fascia, lies 2.5cm above the midpoint between the pubic tubercle (PT), and the anterior superior iliac spine . There are lots of conflicting statements as regard the location of external ring. Some authors of anatomy and surgical textbooks agree that the external ring through which most inguinal hernias eventually exit from the canal lies above the PT . Harold Ellis and Parks et al state that the external ring lies above and medial to the PT. However, Knol et al asserted that the external ring is a triangular opening in the external oblique aponeurosis with its apex superiorly and lateral to the pubic tubercle. The neck of the sac is generally regarded as the part through which the viscus enters into the sac. This is usually located at the internal ring. Clinically, what is regarded as the neck is the first 10, 12, 13 11-14 12 13 15 Nigerian Journal of Clinical Practice June 2009 Vol.12(2) :157-161 RELATIONS OF THE NECK OF GROIN HERNIAS TO PUBIC TUBERCLE EA Agbakwuru, OI Alatise, AO Adisa, AA Salako, ARK Adesunkanmi ABSTRACT Objective: Method: Design Setting Subjects and Measurements Results Conclusion Key Words: Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria (Accepted 7 April 2008) The traditional anatomical and surgical teaching is that any hernia with the neck above and medial to the pubic tubercle are inguinal. Present day surgical authors and teachers mostly adhere to this teaching but observe a difference in this relationship in clinical demonstrations. This confuses most medical students and surgical residents. This all-important clinical teaching should hence be revisited. Hence this study was to ascertain and validate clinically the true relationship of pubic tubercle and the neck of groins hernia. :Aprospective observational study. : Surgical Outpatient Clinic of Wesley Guild Hospital, Ilesa Unit of the Obafemi Awolowo University Teaching Hospital Complex, Nigeria. : Consecutive patients seen in the clinic with uncomplicated groin hernias were studied from January 1993 to December 2004. Examinations were done to ascertain the relationship of the groin hernias to the pubic tubercle. :96.8% of inguinal hernias have their necks above and lateral to pubic tubercle while all femoral hernia had their necks below and lateral to the pubic tubercle. : Location above or below the pubic tubercle should be used as the sole difference between femoral and inguinal hernias in clinical demonstrations. More observations and inguinal dissections will be necessary for further clarification. Groin hernia. Neck of hernia sac. pubic tubercle
Transcript of RELATIONS OF THE NECK OF GROIN HERNIAS TO PUBIC …
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INTRODUCTIONInguinal herniorrhaphy is the most frequentlyperformed abdominal operation, accounting for 10-15% of operations in general surgery . It may behigher in developing African countries such asNigeria, as the incidence of inguinal hernia has beenfound to be threefold in black communities ascompared to the rate in caucasians . Approximately96% of groin hernias are inguinal and 4% arefemoral. Inguinal hernias are bilateral in as many as20% of affected adults. While inguinal hernia occurfairly equally across adult age group, the femoralhernias tend to occur more often in elderly women.The lifetime risk of inguinal hernia is approximately10percent . The groin, one of the naturally weakareas of the abdominal wall is the most common sitefor abdominal hernias . These usually occur througheither the inguinal or femoral canal, giving rise toinguinal and femoral hernias respectively. Theinguinal canal and its openings lie above the inguinalligament while the femoral canal lies below it .The internal and external rings form the ends of the
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Correspondence: Dr O IAlatiseE- mail:[email protected]
inguinal canal. Inguinal hernias are divided intoindirect and direct. Indirect hernias enter the canalfrom the internal ring and may or may not exist at theexternal ring depending on whether it is bubunocele,furnicular or inguinoscrotal. The direct hernias passthrough the hesselbach's triangle in the posterior wallof the canal. This triangle is located lateral to theexternal ring. The internal ring, an opening in thetransversalis fascia, lies 2.5cm above the midpointbetween the pubic tubercle (PT), and the anteriorsuperior iliac spine . There are lots of conflictingstatements as regard the location of external ring.Some authors of anatomy and surgical textbooksagree that the external ring through which mostinguinal hernias eventually exit from the canal liesabove the PT . Harold Ellis and Parks et al statethat the external ring lies above and medial to the PT.However, Knol et al asserted that the external ring isa triangular opening in the external obliqueaponeurosis with its apex superiorly and lateral to thepubic tubercle. The neck of the sac is generallyregarded as the part through which the viscus entersinto the sac. This is usually located at the internal ring.Clinically, what is regarded as the neck is the first
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Nigerian Journal of Clinical PracticeJune 2009 Vol.12(2) :157-161
RELATIONS OF THE NECK OF GROIN HERNIAS TO PUBIC TUBERCLE
EA Agbakwuru, OI Alatise, AO Adisa, AA Salako, ARK Adesunkanmi
ABSTRACTObjective:
Method:DesignSetting
Subjects and Measurements
Results
Conclusion
Key Words:
Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State,Nigeria
(Accepted 7 April 2008)
The traditional anatomical and surgical teaching is that any hernia with the neck above and medialto the pubic tubercle are inguinal. Present day surgical authors and teachers mostly adhere to this teaching butobserve a difference in this relationship in clinical demonstrations. This confuses most medical students andsurgical residents. This all-important clinical teaching should hence be revisited. Hence this study was toascertain and validate clinically the true relationship of pubic tubercle and the neck of groins hernia.
:Aprospective observational study.: Surgical Outpatient Clinic of Wesley Guild Hospital, Ilesa Unit of the Obafemi Awolowo
University Teaching Hospital Complex, Nigeria.
: Consecutive patients seen in the clinic with uncomplicated groin hernias werestudied from January 1993 to December 2004. Examinations were done to ascertain the relationship of thegroin hernias to the pubic tubercle.
:96.8% of inguinal hernias have their necks above and lateral to pubic tubercle while all femoral herniahad their necks below and lateral to the pubic tubercle.
: Location above or below the pubic tubercle should be used as the sole difference between femoraland inguinal hernias in clinical demonstrations. More observations and inguinal dissections will be necessaryfor further clarification.
Groin hernia. Neck of hernia sac. pubic tubercle
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point of rise of the hernia sac under the coveringabdominal wall following valsava maneuvers ordefinitive cough impulses. Bennet et al and Clain ,affirmed that most groin hernias whose neck of saclie above and medial to th
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e PT are inguinal whilethose below and lateral to the PT are femoral. Darkoet al relate the sac neck to the inguinal ligament andPT with no mention of the medial or lateralrelationship. Ford and Cumming states thatinguinal hernia emerged from the abdominal wallthrough the external inguinal ring and is palpableabove and medial to the PT while femoral hernia waspalpable below and lateral to the PT. Whether theneck is regarded to be at the internal ring, inguinalcanal or external ring, clinical findings has negatedthe assertion of most surgical and anatomy text Hairet al had documented the conflict between theclinical findings and the assertions of manyanatomical and surgical authors. As a result of theseconflicting and confusing assertions, teaching andclinical demonstration of groin hernias to medicalstudents and surgical residents in most NigerianTeaching Hospitals and even developed centers havealways generated much controversy .This prospective study conducted at ObafemiAwolowo University Hospital Teaching Complex(O.A.U.T.H.C), Wesley Guild Hospital, Ilesa,Nigeria is therefore aimed at ascertaining theanatomical relationship of the PT to the neck of groinhernias.
Obafemi Awolowo University Hospital TeachingComplex (O.A.U.T.H.C), Wesley Guild Hospitalunit, Ilesa, is located in the southwest geo-politicalzone of Nigeria. All adult patients presenting in thegeneral surgical outpatient clinics from January 1993to December 2004 with groin hernias wereprospectively studied. Those with strangulated orobs t ruc ted hern ia were exc luded. Thesociodemographic data of each patient was recordedin a standard proforma after an informed consent hadbeen taken.Each patient was then examined standingand or lying supine by the consultant surgeon and theunit senior registrars.At least two senior registrars ora senior registrar and a consultant did theexamination. Clinical photograph was also taken forsome of the patients. This was done to remove theinterpersonal errors. The site of the groin swellingwas demonstrated by visible or palpable coughimpulse. Vasalva maneuver to increase intra-abdominal pressure sometimes aided thedemonstration of the hernia . The Pubic tubercle(PT) was subsequently located by running the fingeralong the linea alba in the midline of the lowerabdomen to the pubic symphysis and tracing laterally
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PATIENTSAND METHOD
to the PT, or by palpating along the tendon of theadductor longus muscle to its attachment to the pubicbone just below the PT. The type of groin hernia aswell as the subtype of inguinal hernia in each case wasdetermined and the relation of the neck of the herniato the PT was equally noted. The neck of the herniawas define as the first point of rise of the hernia sacunder the covering abdominal wall. All the diagnoseswere also confirmed at operation. Those withvariation at surgery were reclassified as appropriate.The findings in each patient were recorded and theresults were analyzed using spss version11.0.Univariate analysis was carried out to determinethe selected socioeconomic characteristics as well asthe type and site of the hernia.
Within the study period, a total of 565 patients wereseen. 529 patients (88.9%) had unilateral groinhernias while 36 (11.1%) had bilateral groin herniasgiving a total of 601 hernias. 512 patients (90.6%)were males and 53 (9.4%) were females. The agerange was 17-96 years with a median of 58.00 years.More hernias, 385 (64.1%) were found in the rightgroin than the left that had 216 (35.9%) hernias. Fivehundred and eighty (96.5%) of all groin hernias wereinguinal, while 21 (3.5%) were femoral. The inguinalhernias were made up of 443 (76.4%) indirect, 124(21.4%) direct, and 13 (2.2%) cases of pantaloonhernias. Clinically, 152 (26.2 %) of the inguinalhernias were bubonoceles, 323 (55.7%) werefunicular while 105 (18.1%) were inguinoscrotalhernias.(Table 1) The relations of the necks ofthe hernias to the pubic tubercle were also studied.The necks of all the femoral hernias were inferolateralto the PT. Of the inguinal hernias, 498 (85.9%) hadthe neck superolateral to the PT. Only 82 (14.1%)were superomedial to the P.T.(figure 1-4). The fingersand the forceps shown in the pictures are used toidentify the pubic tubercle.
Table 1:
RESULTS
Site, Type and Nature of Groin Hernia
Nigerian Journal of Clinical Practice June 2009, Vol.12(2) Neck of Groin Hernias Alatise et al
Picture1:
Picture 2:
Picture3:
Picture 4:
Finger on Pubic Tubercle and neck ofHernia and Lateral to PubicTubercle.
Forceps Pointing to the PubicTubercle
Neck of Hernia is above the PubicTubercle shown by Finger.
Bubonecle showing Neck of HerniaAbove and Lateral to Pubic Tubercle.
DISCUSSION`Pubic tubercle is an important reference point ingroin hernia. It has been used widely in clinicaldiagnoses and computerized tomography diagnosesof groin hernias . In this study, we found that of 580inguinal hernias seen, 4988 (85.9%) hernias have theneck above and lateral to PT, while only 82 (14.1%)was above and medial. This finding is at variance withwhat most authors of surgical textbooks assert
. Darko R. however differentiated betweeninguinal and femoral hernias clinically by relating theneck of the hernia to above or below PT only.Generally it is known that in indirect (oblique)inguinal hernias, the neck of the sac lies about the deepinguinal ring . Therefore in virgin inguinalcanals, hernias whose sacs initially came through theinternal rings either congenital or acquired wouldhave their neck obviously lying at or near this ring. Asthis ring is located above and lateral to the PT, necks ofmost indirect inguinal hernias would undoubtedly befound above and lateral to this Pt . In bubonocele(hernia that is still limited to the inguinal canal,funicular hernia (just outside the external ring, andeven indirect complete (oblique inguino-scrotal oringuino-labial), the neck should be expected to be atthe internal ring . The funicular direct type ofinguinal hernia, which occurs through theHasselbach's triangle is still within the inguinalcanal . All these can explain why in this study most ofthe inguinal hernia necks were found above and lateralto the pubic tubercle. The necks of the groin herniabecome more strategic when a distinction is to bemade between upturned femoral hernia and inguinalhernia particularly if the patient is obese. In someinstances femoral hernia has emerged through thecribiform fascia at the fossa ovalis, the fundus pushesforward then turns upwards to lie over and anterior tothe inguinal ligament . The dilemma can be resolvedby observing the neck that is the first point of rise ofthe hernia sac under the covering abdominal wall.This is well appreciated if Valsava maneuver is used todemonstrate a reducible hernia . This observationmay however be difficult in wide necked herniaparticularly direct inguinal types with defects in theposterior wall of the canal. Where a truss has beenworm for a long time by the patient, the tissues mayhave been so matted and crushed out with musclesconverted to fibrous tissues that the position of theneck could have been displaced . We found this in afew patients whose conjoined tendons or muscle wereso frayed out that the hernia neck was found above andmedial to the pubic tubercle. This type of herniahowever accounted for only14.1% of inguinal herniasstudied. In chronic funicular or inguinoscrotalhernias, the progressive stretching of the canal wallswith its external rings may allow for wide protrusionand consequent displacement of the external ring to
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more medial position. This was our experience insome of the patients who had open groinherniorrhaphy.The unanswered question is whetherit is the entire bulge of the hernia or the neck of the sacalone that should be used to assess the relationship tothe pubic tubercle. In as much as there is need forclinical distinction between femoral and inguinalhernias, and the different sizes of hernias, the authorssuggest that surgeons should stick to the neck ofhernia. Since all groins hernias whose neck are abovePT and inguinal ligament are inguinal, and thosebelow are femoral, the authors would suggest that forthe purpose of clarity, surgeons should use relationabove or below the PT as a reference point to neck ofhernia. Alternative suggestion might be to ask thestudents to place their finger over the femoral canalfor reducible hernias and then ask the patient tocough. This landmark is easily felt either byfollowing the adductor longus tendon to below theinguinal ligament and then placing ones fingersanterior and lateral to the tendon or alternativelypalpating the femoral artery and placing ones handapproximately a finger breath medial to it. When thepatients cough the femoral hernia should remainreduced while an inguinal hernia will appear as anobvious swelling . Furthermore, formal dissectioncan be carried out in paediatric and adult cadavers tofurther redefine anatomical relationship of the PTand the external inguinal ring
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