haemorrhoids

Question 1

define an inguinal hernia?

Answer 1

the abnormal protrusion of a peritoneal sac through a weakness of the abdominal wall in the inguinal region

Question 2

what is a direct inguinal hernia?

Answer 2

• Protrusion of the hernial sac directly through a weakness in the transversalis fascia
- appears through hesselbachs triangle

Question 3

what is an inguinal inguinal hernia?

Answer 3

• Protrusion of the hernial sac through the deep inguinal ring, following the path of the inguinal canal

Question 4

what is a combination of both indirect inguinal hernias?

Answer 4

if indirect and direct inguinal hernias coexist = pantaloon hernia

Question 5

which hernias are congenital?

Answer 5

indirect hernia

Question 6

which hernias are acquired?

Answer 6

direct inguinal hernia

Question 7

what are the risk factors of getting a hernia?

Answer 7

o	Male  
o	Prematurity 
o	Age  
o	Obesity  
o	Raised intra-abdominal pressure (e.g. chronic cough)  
o	Constipation  
o	Bladder outflow obstruction  
o	Intraperitoneal fluid (e.g. ascites

Question 8

what is the epidemiology of an inguinal hernia?

Answer 8

• common

- more likely in males

Question 9

what are the presenting symptoms of inguinal hernias?

Answer 9

• Asymptomatic
• Patient notices a ‘lump in the groin’
• May cause discomfort and ache worse with activity
• Disappears on pressure or when the patient lies down

Question 10

signs of inguinal hernias on physical examination

Answer 10

• Groin lump that extends to the scrotum or labia
• Check for cough impulse
• Auscultation - there may be bowel sounds over the hernia
• Check for signs of complications

Question 11

what is the position of inguinal hernias?

Answer 11

superior and medial to the pubic tubercle

Question 12

what is the position of femoral hernias?

Answer 12

inferior and lateral to the pubic tubercle

Question 13

what investigations should be done for acute hernias?

Answer 13

o	Bloods 
•	FBC  (leukocytosis) 
•	U&Es  
•	CRP 
•	Clotting  
•	Lactate (raised)
•	Group and save (if operation is likely)  
•	ABGs - may show lactic acidosis from bowel ischaemia  

o	Imaging 
•	Erect CXR - check for perforation  
•	USS - exclude other causes of groin lump  
•	AXR - check for obstruction 
•	Herniogram – for unclear cases

Question 14

management plan for inguinal hernias?

Answer 14

• Asymptomatic hernias can be managed conservatively
• Symptomatic or risky hernias are treated surgically
• First time hernias can be treated with open inguinal hernia repair and a mesh
• Recurrent / bilateral hernias can be treated with a laparoscopic approach with a mesh.

Question 15

possible complications of inguinal hernias?

Answer 15

• Incarceration
• Bowel obstruction
• Maydl’s hernia (strangulated W-shaped loop of small bowel)
• Richter’s hernia
• Strangulation

Question 16

what are the features of richters?

Answer 16

o Characterised by lack of symptoms of obstruction when strangulated
o VBG – low PH, low pCO2, low bicarbonate
o Due to metabolic acidosis and partial respiratory compensation
o Presents with firm mass and necrosed skin

Question 17

what are the features of strangulation?

Answer 17

Indications:
o	new onset episodes of pain
o	 irreducible hernias 
Symptoms: 
o	Pain 
o	Fever 
o	Increase in size of hernia 
o	Peritonitis 
o	bowel obstruction 
o	bowel ischaemia 
Management: 
o	Immediate surgery 
o	Open/laparoscopic with a mesh
o	Dead bowel to be removed 
o	No manual reduction

Question 18

what is the prognosis for patients with inguinal hernias.?

Answer 18

• Slowly enlarge if left alone

* Surgical mesh repair has a GOOD outcome