Indirect inguinal hernia

A.Prof Frank Gaillard et al.

Indirect inguinal hernias are the most common type of abdominal hernias.

It is five times more common than a direct inguinal hernia, and is seven times more frequent in males, due to the persistence of the processus vaginalis during testicular descent. 

In children, the vast majority of inguinal hernias are indirect. 

Indirect inguinal hernias arise lateral and superior to the course of the inferior epigastric vessels, lateral to the Hesselbach triangle, and then protrude through the deep or internal inguinal ring into the inguinal canal. An indirect hernia enters the inguinal canal at the deep ring, lateral to the inferior epigastric vessels. It passes inferomedially to emerge via the superficial ring and, if large enough, extend into the scrotum.

  • males: they enter the canal anterior to the spermatic cord and may extend through the external inguinal ring into the scrotum.
  • females: they tend to follow the round ligament into the labia majora

Contents may include mesenteric fat (most common), small bowel loops, mobile colon segments (sigmoid, caecum, appendix).

Many are longstanding and asymptomatic, although the shear size can become burdensome.

Complications include:

  • incarceration
    • the most common complication associated with inguinal hernias, the incidence could be as high as 30% for infants younger than 2 months
  • strangulation with bowel ischaemia and perforation
  • intestinal obstruction

On imaging, consider:

  • direct inguinal hernia
    • emerges medially to the to the inferior epigastric vessels and above the inguinal ligament
    • inguinal canal is usually compressed/displaced ("lateral crescent sign")
  • femoral hernia
    • exit below the inguinal ligament and caudal to the emergence of the inferior epigastric vessels

On testicular ultrasound, one could consider spermatic cord lipoma on the differential if an inguinal hernia contains only omental fat. Movement of the fat with the Valsalva manoeuvre is more likely an indirect hernia.

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Article information

rID: 1499
Tag: refs
Synonyms or Alternate Spellings:
  • Indirect inguinal hernias
  • Indirect inguinal herniation

Cases and figures

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    Case 1
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    Coronal CT

    Case 2
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    Case 3: incarcerated inguinal hernia in an infant
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    Coronal Reformat
    Case 4: complicated by small bowel obstruction
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    Indirect Inguinal...
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    Inguinal hernia
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    Inguino scrotal h...
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    Case 8
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