Body Wall Hernias (1)

Question 1

How does it present?

What are it 3 complications?

What needs to be examined?

What are its differentials?

Answer 1

➊ • Soft lump on abdominal wall
• Lump may be reducible or irreducible
• Lump may protrude on coughing or bending over
• Aching, pulling or dragging sensation

➋ • Incarceration - hernia becomes irreducible as bowel is trapped in a herniated position
• Obstruction - Hernia causes bowel obstruction, presenting with abdominal pain, vomiting, and absolute constipation
• Strangulated - Bowel ischaemia, presenting with severe abdominal pain and tenderness (surgical emergency)

➌ • Is it visible? - If not, ask to cough
• Is it reducible? - If not, ask to cough
• Can you get above it? - If yes, it’s a scrotal swelling instead of an inguinal swelling
• Is it solid or cystic?

➍ • Femoral hernia
• Cryptorchidism
• Hydrocoele
• Lymph node
• Abscess

Question 2

Indirect inguinal hernia: (80%)
Who does it typically occur in?

What’s it caused by?

How is it differentiated from a direct inguinal hernia?

What is this type at a much higher risk of?

Answer 2

➊ Younger pts

➋ Congenital (by a patent processus vaginalis)

➌ Following its reduction, pressure over the deep ring prevents reappearance on coughing

➍ Stangulation

Question 3

Direct inguinal hernia: (20%)
Who does it typically occur in?

What’s it caused by?

What are its risk factors?

Answer 3

➊ Older pts

➋ Weakness in abdominal wall at Hesselbach’s Triangle

➌ • Heavy lifting
• Chronic cough in smokers
• Constipation

N.B. Boundaries of Hesselbach’s Triangle are the rectus abdominis (medial), inferior epigastric vessels (superior/lateral), and inguinal ligament (inferior)

Question 4

How is it managed?

Answer 4

• If large and symptomatic - surgical repair (typically open/laparoscopic mesh repair)
• If small and/or asymptomatic - watchful waiting and advice on risk factor management

N.B. Mesh repairs carry a low rate of recurrence, but a higher risk of infection