When the abdominal organs and tissues protrude through the medial Hesselbach's triangle below the inferior epigastric artery to the body surface, it results in a direct inguinal hernia. In elderly or physically weak individuals, the degeneration of abdominal wall muscles, tendon membranes, and fascial membranes reduces the strength of the abdominal wall, leading to the occurrence of a direct hernia under increased intra-abdominal pressure. A large indirect inguinal hernia that significantly weakens or destroys the posterior wall of the inguinal canal can also complicate into a direct hernia.

bubble_chart Clinical Manifestations

Direct hernias are more common in middle-aged and elderly individuals with weaker physiques. Direct hernias typically present no obvious symptoms, causing only mild soreness and swelling when the hernia protrudes. Since the hernia directly emerges through Hesselbach's triangle, the hernial ring—the weakened area of Hesselbach's triangle—is relatively large and lacks a distinct hernial sac neck, making incarceration extremely rare. During physical examination, when the patient stands, the hernia protrudes above and lateral to the pubic tubercle, appearing as a hemispherical bulge. After reduction, applying pressure to Hesselbach's triangle can prevent the hernia from recurring.

bubble_chart Treatment Measures

If there are no surgical contraindications, surgical treatment should be the principle. Given that direct hernias rarely become incarcerated, for elderly or frail patients or those with other chronic conditions who cannot tolerate surgery, a truss can be used to alleviate symptoms.

Since direct hernias lack a distinct hernial sac neck and sac, the procedure only requires the removal of the relaxed and protruding abdominal membrane. Sometimes, it can be converted into an indirect hernia followed by high ligation. Repair can be performed using the Madden method to strengthen the transversus abdominis membrane. Alternatively, the Bassini or Halsted method can be employed to reinforce the posterior wall of the inguinal canal. It must be noted that for large direct hernias, the McVay method is preferred over the Madden method.

Direct hernias do not enter the scrotum, which distinguishes them from indirect hernias. Alternatively, after reducing the hernia, pressing on the internal ring will still result in the hernia protruding. During surgery, the relationship between the hernia ring and the inferior epigastric artery can be used to determine the type; the hernia ring of a direct hernia is located medial to the inferior epigastric artery.