Hernia examination

Question 1

Hernia definition

Answer 1

The protrusion of whole or part of a viscus through an opening in the wall of its containing cavity into a place where it is not normally found.

Question 2

Indirect inguinal hernia features (80%)

Answer 2

Commoner in young (congenital patent processus vaginalis)

Route: through internal inguinal (deep) ring, down inguinal canal and out of external (superficial) ring.

Superior to pubic tubercle

Extension to scrotum common

Can be large

usually reducible

Held by pressure on deep ring palpation

Low risk of incarceration

Usually repaired

Question 3

Direct inguinal hernia features (20%)

Answer 3

Commoner in elderly

Route: through weak point in posterior wall of inguinal canal (hasselbach’s triangle)

Superior to pubic tubercle

Rarely extends to scrotum

Almost always reducible

Not held by pressure on deep ring palpation

Moderate risk of incarceration

Surgical repair necessary

Question 4

Femoral hernia features

Answer 4

Route: through femoral canal underneath inguinal ligament

Inferior to pubic tubercle

Never extends to scrotum

Normally 3-5cm

Rarely reducible (usually incarcerated with absent cough impulse)

Not held by pressure on deep ring palpation

High risk of strangulation

Urgent surgical repair needed

Question 5

Hesselbach’s triangle borders

Answer 5

Inferior epigastric artery
Inguinal ligament
Linea semilunaris (lateral rectus muscle)

Question 6

Risk factors hernia

Answer 6

FH
Weakness of abdominal musculature - increasing age, surgery (incisional)

Increased IAP - obesity, pregnancy, organomegaly, COPD, constipation, heavy lifting

Question 7

Hernia complications

Answer 7

Incarceration (irreducible):

1. obstruction (colic, constipation, vomiting, distension)
2. Strangulation (ischaemia, necrosis, peritonitis)

Question 8

Borders of inguinal canal

Answer 8

Anterior: external oblique and internal oblique (lateral 1/3)

Posterior: transversalis fascia and conjoint tendon (medial 1/3)

Floor: inguinal ligament

Roof: internal oblique and transversus

Question 9

Inguinal canal contents

Answer 9

M: spermatic cord and ilioinguinal nerve

F: round ligament, ilioinguinla nerve

Question 10

Spermatic cord contents

Answer 10

3 layers of fascia

3 arteries: testicular, deferential, cremasteric

3 nerves: genital branch of genitofemoral, cremasteric nerve, sympathetic fibres

3 other other things: ductus deferens, pampiniform plexus, lymph vessels

Question 11

operative distinction of indirect and direct inguinal hernia

Answer 11

Indirect: lateral to inferior epigastric vessels

Direct: medial to inguinal ligament

Question 12

Inguinal hernia Mx

Answer 12

Conservative: manage RFs eg. constipation, cough
weight loss
elasticated corset

Surgical:

Open (GA or LA):
Mesh repair tension free (Lichtenstein)
Suture repair (babinski/shouldice)

Mesh is favoured due to less recurrence rates

Laparoscopic (better for bilateral herniae):
Total extraperitoneal procedure (TEP)

Trans-Abdominal Pre-Peritoneal (TAPP)

Question 13

Complications hernia surgery

Answer 13

Early: urinary retention, haematoma, infection, intra-abdominal injury (lap)

Late: recurrence <2%, ischaemic orchitis (thrombosis of pampiniform plexus), chronic groin pain

Question 14

Post op recovery of hernia steps

Answer 14

Urinate before leaving
Early mobilisation
Good analgesia
avoid constipation - lactulose
Wash carefully
Work in 1-2wks