Hernia * is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it * The protruded parts are generally contained in a sac-like structure, formed by the membrane with which the cavity is naturally lined. * Inguinal hernia: Makes up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women. * Any condition that increases the pressure in the intra-abdominal cavity may cause the formation of a hernia, including the following: * Marked obesity * Heavy lifting * Coughing * Straining * Family history of hernias * Asymptomatic hernia * Presents as a swelling at the hernia site * No true pain or tenderness upon examination * Enlarges with increasing intra-abdominal pressure and/or standing * Incarcerated hernia * Painful enlargement of a previous hernia or defect * Cannot be manipulated (either spontaneously or manually) through the fascial defect * Nausea, vomiting, and symptoms of bowel obstruction (possible) * Strangulated hernia * Symptoms of an incarcerated hernia present combined with a toxic appearance * Systemic toxicity secondary to ischemic bowel is possible * Strangulation is probable if pain and tenderness of an incarcerated hernia persist after reduction * Direct Hernia * is most often an “acquired lesion”. * occurs when a weak spot develops in the lower abdominal musculature * In adults, stresses such as lifting heavy objects, frequent coughing or straining, pregnancy, and constipation can cause the hernia. * within the Hessleback’s triangle: (medial to the inferior epigastric vessels Lateral to the rectus abdominis muscle and above the inguinal ligament) * The hernia consists primarily of retroperitoneal fat. * Only rarely is a peritoneal sac containing bowel encountered. * Because there is typically no involvement of a sac, they do not protrude with the spermatic cord, and therefore have a lower incidence of incarceration or strangulation. * Indirect Inguinal Hernia * considered mainly to be a congenital lesion. * the protrusion passes through the deep inguinal ring and is located lateral to the inferior epigastric artery * results from the failure of embryonic closure of the deep inguinal ring after the testicle has passed through * It is called “indirect” because the bowel and peritoneum do not herniate directly through a weakness in the abdominal wall. * Rather, the bowel and peritoneum move through a patent processus vaginalis and into the scrotum. * “in”-direct hernias extend “in” through the internal ring. * The larger the defect and extension into the scrotum, the higher the risk of incarceration and/or strangulation. * Femoral Hernia * is an acquired lesion, and has no hernial sac. * The defect occurs within an anatomic triangle bounded by the inguinal ligament. * The femoral canal is located below the inguinal ligament on the lateral aspect of the pubic tubercle. It is bounded by the inguinal ligament anteriorly, pectineal ligament posteriorly, lacunar ligament medially, and the femoral vein laterally * this triangular gap is larger in females, due to the shape and angle of the pelvis, femoral hernias are much more common in women. * These hernias are also much more prone to incarcerate or strangulate, and in fact, are almost always incarcerated with retroperitoneal or omental fat (and occasionally bowel). Therefore, early repair, once the diagnosis is made, is strongly advised.

* In the male fetus, the peritoneum gives a coat to the testicle as it passes through this ring, forming a temporary connection called the processus vaginalis. * In normal development, the processus is obliterated once the testicle is completely descended. * The permanent coat of peritoneum that remains around the testicle is called the tunica vaginalis. * The testicle remains connected to its blood vessels and the vas deferens, which make up the spermatic cord and descend through the inguinal canal to the scrotum. * The deep inguinal ring, which is the beginning of the inguinal canal, remains as an opening in the fascia transversalis, which forms the muscular outer wall for the spermatic cord. * When the opening is larger than necessary for passage of the spermatic cord, the stage is set for an indirect inguinal hernia. * The protrusion of peritoneum through the internal inguinal ring can be considered an incomplete obliteration of the processus. * If a woman has an indirect inguinal hernia, her internal inguinal ring is patent, which is abnormal for females. * The protrusion of peritoneum is not called "processus vaginalis" in women, as this structure is related to the migration of the testicle to the scrotum. It is simply a hernia sac. * The destination of the hernia contents for a woman is the labium majoris on the same side, and hernias can enlarge one labium dramatically if they are allowed to progress.
The spermatic cord three layers of tissue: * external spermatic fascia, an extension of the fascia that overlies the aponeurosis of the external oblique muscle * cremasteric muscle and fascia, formed from a continuation of the internal oblique muscle and its fascia * internal spermatic fascia, continuous with the transversalis fascia