Hernia

Question 1

What is a hernia?

Answer 1

condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it

Question 2

What types of hernias can you have?

Answer 2

1. Inguinal hernia:(most common)
   - abdominal or pelvic contents protrudes thorugh the inguinal canal (also have femoral hernia but less common).
   - Inguinal = supermedial to the pubic tubercle
   Two sub- types:
   a. Direct Inguinal → protrusion directly through the posterior wall of the inguinal canal.
   b. Indirect Inguinal → protrusion into the inguinal canal through the deep inguinal ring.
2. Femoral hernia= inferolateral to the pubic tubercle
3. pantaloon hernia = if indirect and direct inguinal hernias coexist

Question 3

What is a direct inguinal hernia?

Answer 3

• protrusion directly through the posterior wall of the inguinal canal.
• Develop over time due to straining and is caused by weakness in the abdominal muscles.
• Usually occurs in older men, rare in children.
• Medial to inferior epigastric vessels.

Question 4

What is an indirect inguinal hernia?

Answer 4

• protrusion into the inguinal canal through the deep inguinal ring.
• Caused by defect in abdominal wall that will have typically been present since birth.
• May occur in infants.
• Lateral to inferior epigastric vessels.
• When reduced and pressure is applied to the deep inguinal ring, indirect hernia will remain reduced (direct hernia reappears).

Question 5

What is meant by the “Hesselbach’s Triangle”?

Answer 5

a.k.a inguinal triangle=
- It describes a potential area of weakness in the abdominal wall, through which a hernia can protrude.
- borders: inferior epigastric artery, rectus border, inguinal ligament

Question 6

What are the risk factors for developing a hernia?

Answer 6

• Male
• prematurity
• age, obesity, raised intra-abdominal pressure (Chronic cough), constipation, family history, AAA, Marfan syndrome, Ehlers-Danlos syndrome

Question 7

What are the presenting symptoms/ signs of an inguinal hernia?

Answer 7

1. Experience pain (dull, heaviness, dragging) in association with a bulging hernia
2. Visible + Palpable groin mass (may also enlarge with standing or coughing) → inguinal hernias are superior and medial to the pubic tubercle
3. N&V, Constipation

Question 8

What are the presenting symptoms/ signs of a femoral hernia?

Answer 8

• Typically non-reducible
• Cough impulse often absent (If the swelling expands upon coughing, it is said to have a ‘cough’ impulse= clinical sign)

Question 9

What investigations are used to diagnose/ manage hernias?

Answer 9

Clinical Diagnosis → via observation and palpation
1. Ultrasound scan of groin → useful when there is diagnostic uncertainty
2. CT Scan → useful in very obese patients
3. Strangulated Hernia → leukocytosis and raised lactate

Question 10

How are hernia’s managed?

Answer 10

1. Treat medically fit patients even if they are asymptomatic, typically with surgical repair (mesh repair)
   - Inguinal Hernias can be left if patient not fit for surgery. Can use Truss support belt if unfit for surgery.
   - Femoral hernias must undergo surgical repair due to risk of strangulation
2. If obstructed/strangulated → emergency laparotomy
   - Incarceration ⇒ herniated tissue can’t be reduced. May cause pain with no systemic features.
   - Strangulation ⇒ blood supply cut off, leading to ischaemia of the hernia. More common with femoral hernias. May present as tender, distended abdomen with absent bowel sounds and systemic features.