Direct Hernia or Posterior wall laxity

[Diane]

Hi Steve,

I scanned this guy a while back which I thought was a direct hernia from the long orientation but when I turned into trans, I thought it looked like that case that you mentioned in the webinar where it looks like its pushing onto the psoterior wall of the inguinal canal but doesn’t exactly spill into it?

Thoughts?

Thanks!

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[Stephen Bird]

Oh yes, I feel your pain !

It depends on who you believe really,

The posterior wall (Hesselbachs triangle) in your case is very weak and “spinnakers” forward during valsalva.

I would call this a case of significant posterior wall weakness, but the posterior wall is intact and there is no passage of peritoneal fat into the canal.

There is no physical defect (hole) in the posterior wall, but it is lax and bulges forward.

Some people still call this a direct hernia however personally;y I reserve this term for when there is a hole in the posterior wall and fat flows into the canal itself.

This is certainly a precursor for a direct hernia as the posterior wall must be very weal to allow this bulging.

It all depends on your fundamental definition of a “hernia”

For me it is a defect in a fascial plane allowing material to pass through the defect.

Others include an intact fascial plane that is weak and bulges into another area.

The simplest way to think of this is the lineal alba.

I call it “divarication” when the rectus sheath is weak and bulges forward as the patient tries to sit up.
I reserve the term “ventral hernia” for when there is a hole in the linea alba allowing peritoneal fat to pass into the subcutaneous space.

I use the same logic for inguinal hernias.

Doesn’t mean I am right! but that is my way of thinking.

Steve

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