How to distinguish direct inguinal hernias from indirect inguinal hernias on cross sectional imaging

How to distinguish direct inguinal hernias from indirect inguinal hernias on cross sectional imaging?

All inguinal hernias are superiorly located to the inguinal ligament (which extends from the anterior superior iliac spine of the iliac bone to the pubic tubercle of the ipsilateral pubic bone) and are more commonly seen in men than in women.

Direct inguinal hernias occur through Hesselbach’s triangle secondary to acquired weakness of the transversalis fascia and are therefore located inferior and medial to the inferior epigastric vessels in the groin region.

Indirect inguinal hernias occur lateral to Hesselbach’s triangle through the inguinal canal secondary to a patent processus vaginalis or acquired weakness and dilation of the deep inguinal ring and are therefore located lateral to the inferior epigastric vessels in the groin region 

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