Hernias

Question 1

Name 7 differences between direct and indirect inguinal hernia

Answer 1

• Neck lies medial to inferior epigastric artery within Hesselbach’s triangle vs lateral and outside
• reduces upwards and straight backwards vs up, lateral and back
• controlled after reduction by pressure over superficial ring (go through superficial only) vs deep ring (go through deep then superficial)
• less commonly in scrotum vs more commonly
• rarely strangulate due to wide hernia neck vs may strangulate at superficial ring (narrow)
• readily reduces on lying down vs not
• more common in old men vs young adults and infants

Question 2

Inguinal vs femoral hernia location

Answer 2

• inguinal above and medial to pubic tubercle
• Femoral inferior and lateral

Question 3

Most common cause indirect inguinal hernia?

Answer 3

Congenital -patent processus vaginalis and weakened fascia at deep ring

Question 4

Where does indirect inguinal hernia enter the inguinal canal?

Answer 4

Deep inguinal ring (and commonly through superficial ring into scrotum)

Question 5

Most common cause direct inguinal hernia?

Answer 5

Weak abdominal muscles and comorbid conditions causing raised intra-abdominal pressure

Question 6

Where does direct inguinal hernia herniate?

Answer 6

Through posterior wall of inguinal canal through Hesselbach’s triangle then through superficial ring

Question 7

Name 5 types external hernias in order of how common they are

Answer 7

• Inguinal 80%
• Incisional 10%
• femoral 5%
• umbilical
• epigastric

Question 8

Name the borders of Hesselbach’s triangle

Answer 8

• Lateral: inferior epigastric artery
• medial: lateral border rectus abdominis
• inferior: inguinal ligament

Question 9

Name symptoms inguinal hernia (2)

Answer 9

• Heavy discomfort around gut
• constipation

Question 10

Name clinical presentation inguinal hernia (3)

Answer 10

• Intermittent bulge in groin related to exertion or long standing periods
• valsalva maneuver or cough can reproduce symptoms of discomfort and lump enlargement
• may be uncomfortable on examination

Question 11

Name 8 risk factors inguinal hernia

Answer 11

• History hernia
• elderly
• male
• Caucasian
• chronic cough
• chronic constipation
• smoking
• abdominal wall trauma
4 CS : cirrhosis, cardiac failure, cancer, catheter (dialysis)

Question 12

Surface anatomy of deep inguinal ring?

Answer 12

2 cm above midpoint of inguinal ligament

Question 13

Surface anatomy of superficial inguinal ring?

Answer 13

Above and medial to pubic tubercle

Question 14

Differential diagnosis for groin lump? (10)

Answer 14

• Hernia: femoral, inguinal
• Vascular: femoral artery aneurysm, saphenous varix, varicocele
• lymph: inguinal lymphadenopathy, lymphoma
• soft tissue/bone: lipoma, groin abscess, rhabdomyosarcoma, bone tumour
• nerves: neuroma
• other: undescended testes, hydrocele of spermatic cord undescended

Question 15

Define richter’s hernia

Answer 15

Segment of bowel wall is trapped and ischaemic but lumen is patent

Question 16

Treatment inguinal hernia? (7)

Answer 16

• To prevent recurrence: decrease intra-abdominal pressure by weight loss, avoid heavy lifting., treat chronic cough and constipation
• surgically reduce bowel, excise hernia sac and reinforce posterior wall by:
- open herniotomy: remove hernia sac only. Do in kids
-Open herniorrhaphy: herniotomy and repair of posterior wall of inguinal canal ie shouldice repair (non- mesh technique- a continuous back and forth sutures with permanent sutures)
-Open hernioplasty: re-inforce posterior inguinal canal wall with synthetic mesh ie Lichtenstein tension free mesh repair
- laparoscopic Tapp (trans-abdominal pre-peritoneal) repair
- laparoscopic totally extra-peritoneal repair tep

Always open , laparoscopic only if recurrent or bilateral.

Question 17

Name 5 immediate post op complications of surgical treatment of inguinal hernia

Answer 17

• Bruise
• wound haematoma
• scrotal haematoma
• acute retention of urine,
• pain

Question 18

Name 4 late post op complications of surgical treatment of inguinal hernia

Answer 18

• Mesh infection
• recurrence 10% in 10 years
• nerve injury
• ischaemic orchitis

Question 19

Approach to examination inguinal hernia? (7)

Answer 19

• Patient standing
• patient squatting:
Inspect - lump above or below inguinal lig, scrotal lump, estimate dimensions, skin changes, previous scars, other side, abdominal distension or mass
Palpate - tender, can get above lump, can palpate testes, consistency, fluctuant, size, tender, landmark for pubic tubercle to show its above and medial, deep inguinal ring, palpable cough impulse, try to reduce, describe point of reduction
• supine: reduce, locate deep inguinal. ring and hold, then ask patient to sit, swing over bed and stand
• standing; do cough impulse. If remains reduced, indirect. If not, direct. Not very accurate
Remove pressure and watch if comes out oblique (indirect) or forward (direct)
Percuss and auscultale for bowel sounds

Question 20

Name 5 differences between inguinal and femoral hernia

Answer 20

• Appear through superficial ring vs femoral canal
• superior and medial to pubic tubercle vs inferior and lateral
• usually reducible vs not
• expansive cough impulse usually present vs absent
• low risk strangulation vs high

Question 21

Name 10 risk factors incisional hernia

Answer 21

Pre-operation
• elderly
• malnutrition
• diabetes
• morbid obesity
• increased abdominal pressure secondary to chronic bronchitis, Ascites
• chronic disease (ESRF, CLD, malignancy) ; steroids

Intra-op
• wrong suture material
• wrong technique

Post-op
• wound breakdown/haematoma
• ischaemic wound due to excessive tension
• complications: anastomotic leaks, infection, post-op alelectasis and chest infection

Question 22

Treatment umbilical hernia?

Answer 22

Mayo’s “vest over pants” operation