Introduction
Hernia examination is a core surgical OSCE station. You must identify the hernia type, assess its characteristics, and recognise surgical emergencies (irreducibility, obstruction, strangulation). Differentiating direct from indirect inguinal hernia and identifying femoral hernias are consistent examiner favourites.
💎 Clinical Pearl
Examine the patient standing first — hernias are more apparent on standing and Valsalva. Offer to examine both sides.
Inguinal Canal Anatomy
| Structure | Location |
|---|---|
| Deep (internal) inguinal ring | Midinguinal point (midpoint of inguinal ligament) |
| Superficial (external) inguinal ring | Above and medial to pubic tubercle |
| Inguinal ligament | Anterior superior iliac spine to pubic tubercle |
| Hesselbach's triangle | Bounded by: inguinal ligament (inferior), inferior epigastric vessels (lateral), rectus abdominis (medial) — site of direct hernia |
Direct vs Indirect Inguinal Hernia
| Feature | Indirect | Direct |
|---|---|---|
| Origin | Lateral to inferior epigastric vessels, through deep ring | Medial to epigastric vessels, through Hesselbach's triangle |
| Path | Traverses full inguinal canal; may enter scrotum | Pushes directly forward; rarely scrotal |
| Age group | Young men | Older men |
| Strangulation risk | Higher (narrower neck) | Lower |
| Controlled by deep ring pressure | Yes | No |
🧠 Mnemonic
"MDs have Indirect hernias" — the Midpoint (midinguinal point) = the Deep ring = site of Indirect hernias.
Alternative: "Indirect = Impulsive young man (lateral, through the ring). Direct = Directly out in the Old man (medial, through the wall)."
Examination Framework
Standing: Look and Cough
- Inspect groin for swelling, skin changes (erythema = strangulation concern)
- Ask patient to cough — observe for visible impulse
- Ask patient to perform Valsalva — increases hernia prominence
Palpation
- Locate the pubic tubercle: inguinal hernia = above and medial to pubic tubercle
- Femoral hernia = below and lateral to pubic tubercle
- Assess: reducibility, consistency, tenderness
Cough Impulse
Hand over the swelling: a palpable impulse on coughing confirms peritoneal communication.
Reducibility
Gently press swelling toward the abdomen. Reduces = reducible. Does not reduce = irreducible (incarcerated).
Deep Ring Occlusion Test
- 1Reduce the hernia fully
- 2Occlude the deep ring: press firmly at the midinguinal point (midpoint between ASIS and pubic symphysis)
- 3Ask patient to cough
- 4Hernia does NOT reappear = indirect (controlled by deep ring)
- 5Hernia DOES reappear medially = direct (not controlled by deep ring)
Hernia Types and Key Features
| Type | Site | Key features |
|---|---|---|
| Indirect inguinal | Above and medial to pubic tubercle | Lateral, can descend to scrotum, higher strangulation risk |
| Direct inguinal | Above and medial to pubic tubercle | Medial (Hesselbach's), rarely scrotal, lower strangulation risk |
| Femoral | Below and lateral to pubic tubercle | More common in women, high strangulation risk, rigid neck |
| Umbilical | Umbilicus | True umbilical (congenital) vs paraumbilical (adult) |
| Incisional | Previous scar | Common in obese patients post-laparotomy |
| Epigastric | Midline above umbilicus | Through linea alba, small, often irreducible |
Strangulation — Surgical Emergency
⚠️ Red Flag
Strangulation = compromised blood supply to hernial contents.
Signs: hard, tense, exquisitely tender, non-reducible swelling; overlying skin erythema and warmth; systemically unwell with nausea, vomiting, fever, tachycardia.
Femoral hernias carry the highest strangulation risk due to their rigid, inelastic neck.
Management: emergency surgical repair.
How to Present
"On examination there was a right groin swelling arising above and medial to the pubic tubercle with a positive cough impulse. The swelling reduced fully on gentle pressure. Deep ring occlusion controlled the hernia on coughing, consistent with an indirect inguinal hernia. There was no tenderness or skin change to suggest strangulation. I would refer for elective repair given the risk of strangulation."
"How do you differentiate an inguinal from a femoral hernia?"
Locate the pubic tubercle. An inguinal hernia emerges above and medial to the pubic tubercle. A femoral hernia emerges below and lateral to the pubic tubercle, through the femoral canal. A useful mnemonic for the femoral triangle contents (lateral to medial) is NAVY: Nerve, Artery, Vein, Y-fronts (femoral canal = most medial).
"How do you perform the deep ring occlusion test?"
Reduce the hernia, then apply firm pressure at the midinguinal point (halfway between the anterior superior iliac spine and the pubic symphysis) to occlude the deep inguinal ring. Ask the patient to cough. If the hernia is controlled (does not reappear), it is indirect. If it re-emerges medially despite deep ring pressure, it is direct.
"Why does a femoral hernia carry a higher strangulation risk than an inguinal hernia?"
The femoral canal has a rigid inelastic neck formed by the inguinal ligament anteriorly, the lacunar ligament medially, the pectineal ligament posteriorly, and the femoral vein laterally. This narrow, non-compliant ring means even a small amount of herniated bowel can become tightly constricted with rapid vascular compromise.
"What is the difference between irreducible, obstructed, and strangulated hernias?"
An irreducible (incarcerated) hernia cannot be returned to the abdomen but has intact blood supply. An obstructed hernia contains kinked bowel causing intestinal obstruction with the blood supply possibly still intact. A strangulated hernia has compromised blood supply to its contents, causing ischaemia and potential perforation — this is a surgical emergency.
Related guides: [Abdominal Examination OSCE](/blog/abdominal-examination-osce) | [Testicular and Scrotal Examination OSCE](/blog/testicular-scrotal-examination-osce) | [Urology History OSCE](/blog/urology-history-osce)