Femoral + inguinal hernias Flashcards
What is the definition of a hernia?
A protrusion, bulge or projection of an organ or part of an organ through the body wall that normally contains it
Are inguinal or femoral hernias more common?
Inguinal
Which of femoral or inguinal hernias present with complications more frequently?
Femoral
What is the prevalence of groin hernias in the US?
5-10 percent of the population
What is the classical demographic/ethnic patient for hernias?
Old white male
What is the lifetime risk of developing a groin hernia for men vs women?
25% vs 5%
What is the peak age of presentation for groin hernias?
50-69 years for men
40-60 years for women
Of groin hernias, what percentage are inguinal vs femoral?
96% are inguinal, 4% femoral
Are direct or indirect hernias more common, and in women vs men?
Indirect are most common in both sexes
What are some risk factors for the development of hernias?
Previous hernia
Older age, caucasian, male
Chronic cough
Chronic constipation
Abdominal wall injury
FHx
Smoking
Is obesity a risk factor for developing hernias?
No
Large observational study from a Swedish hernia register involving 50,000 patients found lower incidence of hernia in obese patients
What causes a congenital hernia in the male?
The processus vaginalus not closing correctly, as well as the internal ring not closing correctly
When does a congenital hernia present?
Can be anywhere from early childhood to adulthood
What is the aetiology of an acquired hernia?
Weakening or disruption of the fibromuscular tissues of the body wall allowing intra-abdominal contents to protrude through the acquired defect
Is there any preference between left and right in indirect inguinal hernias?
Yes
Right is more common in both males and females
Thought to be due to the later descent of the right testicle, and in females by asymmetry of the female pelvis
What is the origin of the hernia sac in relation to the inferior epigastric artery in indirect inguinal hernias?
Lateral to the artery
What is the origin of the hernia sac in relation to the inferior epigastric artery in direct inguinal hernias?
Medial to the artery
What is the name of the triangle of anatomical structures that are important in the consideration of hernias?
Hesselbach’s triangle
What forms Hesselbach’s triangle?
Inguinal ligament inferiorly
Inferior epigastric vessels laterally
Rectus abdominus muscle medially
Why do direct inguinal hernias occur?
Weakness in the floor of the inguinal canal
Secondary to connective tissue abnormalities in many cases, or weakness in abdo muscles due to chronic overstretching or injury
Where do femoral hernias arise from?
Inferior to the inguinal ligament
Protrude through the femoral ring which is medial to the femoral sheath and lateral to the lacunar ligament
What can cause a congenital femoral hernia?
There is no such thing, they are all acquired
Are femoral hernias also more common in men?
No
More common in women
What percentage of femoral hernias present as emergency cases with complications?
40%
Which population is most likely to present with a hernia complication to ED?
Women
Higher incidence of femoral hernias, and with inguinal the rings are smaller and everything is tighter in general
What is the normal symptom that hernias will present with?
A heaviness or dull discomfort in the groin
May or may not be associated with a visible bulge
How does the groin discomfort associated with hernias change with time?
Becomes worse when intra-abdominal pressure is increased, such as with straining, lifting heavy weights, coughing, prolonged standing, etc
Discomfort will be worse at the end of the day
Resolves when the patient stops straining or lies down
Can hernias present with moderate to severe pain?
Yes
Indicates a complicated hernia however, and demands urgent investigation
What is the most common finding on physical examination with hernias?
A bulge
How can you detect a hernia on physical exam that is not grossly obvious?
Place the tip of the finger into the external inguinal ring and ask the patient to cough, the contents may come down to touch the fingertip
How should you position the patient to best see a hernia?
Erect
Can you assess for a cough impulse in a hernia with the patient standing?
Yes – this is the correct technique
Can be done supine as well though
What can you do to identify a hernia on physical exam, when the hernia is not obvious (often won’t be)?
Nothing
Can’t palpate into the inguinal canal, can’t usually feel a cough impulse
Which of the groin hernias are medial to the pubic tubercle, and which are lateral?
Femoral is lateral
Inguinal is medial
What is the approx sensitivity and specificity of the physical exam and history together for diagnosing groin hernias?
Sensitivity 75%
Specificity 96%
When do you perform imaging in diagnosing hernias?
When the type is not clear
Identify an occult hernia
To distinguish a hernia from another clinical entity
And to identify complicated hernias
What is peritoneography/herniography?
Contrast is injected into the peritoneum and radiographic imaging is performed
Slightly more accurate but hardly ever done because ultrasound is very good and non-invasive and inexpensive
Why is it particularly important to distinguish between inguinal and femoral hernias?
Because you can use watchful waiting for inguinal hernias, but femoral hernias pretty much always need to be operated on soon because they have a much higher chance of developing complications
How do patients typically present when they have a complicated hernia?
Nausea/vomiting
Abdominal distension
Groin pain or mass
Bowel obstruction
What is the definitive management for any type of hernia?
Surgical repair
Why do we use watchful waiting in the case of inguinal hernias, rather than just treat them before they become symptomatic?
Because two studies showed that there was no penalty in morbidity or mortality for delaying repair until symptoms develop
What are the contraindications to mesh hernia repair?
Mainly stems from standard contraindications to anaesthetics
Active infection prohibits the placement of foreign material into the body however
What is an important complication of mesh hernia repair surgery?
Neuralgia
What are some things you can do pre-operatively in mesh hernia repair to limit post-operative neuralgia?
Reduce post-operative pain with intensive pre and peri-op analgesia
Choice and placement of mesh – lighter mesh may have less inflammation
Prophylactic neurectomy – division of ilioinguinal nerve if it becomes entangled in the mesh
Careful approach to the surgery
