inguinal hernia , there is nyhus classification depend on the integrity of posterior wall and the deep inguinal ring and grouped them into four types
type 1 : indirect inguinal hernia with normal inguinal ring , peritoneal sac is in the inguinal canal
type 2 : indirect inguinal hernia with enlarged deep inguinal ring with posterior wall intact , sac not in scrotum
types 3 : posterior wall (inguinal floor ) defect :
3a: direct hernia with posterior floor defect only
3b : indirect hernia with enlragement of deep inguinal ring and posterior floor defect
3c:femoral hernia
type 4: recurrent hernia
A:direct B:indirect C:femoral d:comorbidities of A-B and C
HOW TO EXAM inguinal hernia and identify its type ?
by three finger test /zieman's technique
use your index finger (deep inguinal ring)= indirect hernia
middle finger (superficial inguinal ring)=direct hernia
ring finger (saphenous opening)= femoral hernia
ask the patient to cough and feel the the site of hernia
deep(internal ring) ring occlusion test :
deep ring located half inch above the mid inguinal point (center point between anterior superior iliac spine and pubic sympthysis)
reduce the hernia content , patient on lying down position , use your thumb to close the deep ring , ask patient to cough
if swelling does not appear and on releasing the thumb swelling appears during cough then it is indirect hernia
if swelling appear medial to thumb while you pressing on deep inguinal ring , then it is direct (from superficial ring )
*note : direct inguinal hernia bulge from the posterior wall of inguinal canal , whereas indirect inguinal hernia passes through inguinal canal or groin
*direct hernia mean posterior wall defect