Femoral and inguinal hernia. Flashcards
How common is it?
Approximately 75% of all hernias are inguinal; of these, 50% are indirect (male-to-female ratio, 7:1), with a right-side predominance, and 25% are direct; 3% of inguinal hernias have a sliding component, most often on the left side (left-to-right ratio, 4.5:1)
Only 3-5% of hernias are femoral
Who does it affect?
Anyone
What causes it?
Inguinal:
- internal ring musculature tenses during abdominal muscular straining, prohibits protrusion of the intestine into a patent processus.
- muscle paralysis or injury can disable the shutter effect. - in addition, the transversus abdominis aponeurosis flattens during tensing, thus reinforcing the inguinal floor. - congenitally high position of aponeurotic arch may preclude the buttressing effect.
Femoral:
- follows the tract below the inguinal ligament through the femoral canal.
- canal lies medial to the femoral vein and lateral to the lacunar ligament.
- because femoral hernias protrude through such a small defined space, they frequently become incarcerated or strangulated.
What risk factors are there (and how can they be reduced)?
Straining that increases intra-abdominal pressure (manual work etc) Chronic cough Ascites Increased peritoneal fluid from biliary atresia Peritoneal dialysis Ventriculoperitoneal shunts Intraperitoneal masses Organomegaly Obstipation Male sex (inguinal)
How does it present? What symptoms should you look out for?
Asymptomatic:
- swelling or fullness at the hernia site
- aching sensation (radiating into the area of the hernia)
- no true pain or tenderness upon examination
- enlargement with increasing intra-abdominal pressure or standing
Incarcerated:
- painful enlargement of a previous hernia or defect
- inability to manipulate the hernia (either spontaneously or manually) through the fascial defect
- nausea, vomiting, and symptoms of bowel obstruction (possible)
Strangulated:
- symptoms of an incarcerated hernia, combined with a toxic appearance
- possibility of systemic toxicity secondary to ischemic bowel
- probability of strangulation if pain and tenderness of an incarcerated hernia persist after reduction
what signs may the patient have on examination?
Swelling/mass in the area of the fascial defect
Provocative cough may be required
The following signs suggest strangulation (over incarceration)
- pain out of proportion to examination findings
- fever or toxic appearance
- pain that persists after reduction of hernia
Which other conditions might present similarly?
Groin abscess Hematoma Lipoma Lymphadenitis Obstructive uropathy Pseudoaneurysm Spermatocele Tumor Undescended or retracted testes Varicocele
How would you investigate this patient?
USS
What would you tell the patient and how would you explain the condition to them?
A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall.
The lump can often be pushed back in or disappears when you lie down. Coughing or straining may make the lump appear.
Inguinal hernias occur when fatty tissue or a part of your bowel pokes through into your groin at the top of your inner thigh.
Femoral hernias also occur when fatty tissue or a part of your bowel pokes through into your groin at the top of your inner thigh. They’re much less common than inguinal hernias and tend to affect more women than men.
How do you think the patient and/or family might be affected by the diagnosis? Will it affect their
ability to work/care for themselves?
Hernia’s are a common cause of morbidity, disability and sick days.
What questions are they likely to have?
Can it be removed?
Will it come back if removed?
How can I avoid it happening again.
What treatment/s (surgical, pharmacological and non-pharmacological) would you discuss with
them? What risks and benefits of treatment are there?
Manual hernia reduction and support clothing
- Few risks but not a permanent solution
Surgical repair
- Risks of surgery and reccurance
- More permanent solution
