0:01

Okay, so we've seen an umbilical hernia, and that

0:03

was quite nice and very easy to diagnose.

0:05

But there are number of other types of

0:06

hernias throughout the abdominal cavity,

0:09

many of which have dead white guy names

0:11

again, and you have to know many of them.

0:13

But we're gonna talk about the groin hernias.

0:16

So the overarching umbrella here is groin hernias,

0:19

and here are three patients with groin hernias.

0:22

Can you decide which one has the

0:24

greatest risk for bowel strangulation?

0:26

Take a moment and look at all three.

0:30

Okay, so let's look at how we analyze groin hernias.

0:34

The first thing I do when I see a groin

0:36

hernia is I draw a horizontal line from

0:38

the lateral aspect of the symphysis pubis,

0:41

that's referred to as the pubic tubercle.

0:43

Once I draw that horizontal line,

0:45

I decide if the hernia comes out anterior

0:47

or posterior to that horizontal line.

0:51

If the patient has a hernia that comes out

0:54

anterior, it is going to be an inguinal hernia.

0:57

You have both your indirect

0:58

and direct inguinal hernias.

1:00

The posterior to this horizontal line

1:03

are your femoral hernia and your obturator hernia.

1:06

The femoral hernia will be anterior to the

1:08

pectineus muscle, but don't worry, we're gonna

1:10

go through this again, and the obturator hernia

1:12

here will be posterior to the pectineus muscle.

1:15

So let's go into the groin

1:19

inguinal hernias — so groin hernia, inguinal

1:21

hernias — both your direct and your indirect hernias.

1:24

So your indirect hernia,

1:25

this is the classic image of Hesselbach’s

1:28

triangle that you may have learned during

1:30

your surgical rotation in medical school.

1:31

But guess what?

1:32

It all comes back to you.

1:33

You don't get to forget anything besides renal

1:36

homeostasis, which you don't have to know anymore.

1:38

Lucky you.

1:39

I condoed that personally. Anyway, so I digress.

1:43

So if the bowel comes out lateral, the landmark here

1:46

is the inferior epigastric vasculature, the lateral

1:50

margin of the rectus muscle, and the inguinal ligament.

1:53

If the hernia comes out lateral to the

1:55

epigastric vasculature and goes down the

1:57

inguinal ligament, that is an indirect hernia,

2:00

as opposed to a direct hernia, which will be

2:02

medial to the epigastric vasculature

2:05

and come anterior to that.

2:07

So this would be the indirect,

2:08

and this would be the direct hernia.