Hernias

Question 1

causes of inguinal hernias

Answer 1

far more common in males

Congenital: patent processus vaginalis
• Processus vaginalis should obliterate following
descent of the testes.
• If it stays patent it may fill with
§ Fluid → hydrocele
§ Bowel/omentum → indirect hernia

Acquired: mainly things which ↑IAP
• Chronic cough: COPD, asthma
• Prostatism
• Constipation
• Severe muscular effort: e.g. heavy lifting
• Previous incision/repair
• Ascites / obesity
• Appendicectomy

Question 2

classify inguinal hernias

Answer 2

Indirect
• 80%: commoner in young
• Congenital patent processus vaginalis
• Emerge through deep ring
• Can strangulate

Direct
• 20%: commoner in elderly
• Acquired
• Emerge through Hesselbach’s triangle
• Rarely descend into scrotum
• Rarely strangulate

Question 3

investigating hernias

Answer 3

clinical exam

ultrasound to confirm

Question 4

children and inguinal hernias hx

Answer 4

• Lump in groin which may descend into scrotum
• Exacerbated by crying
• Commonly obstruct

Question 5

adults and inguinal hernias hx

Answer 5

Lump in groin, exacerbated by straining/cough
• Precipitating event: e.g. heavy lifting
• Dragging pain radiating to groin
• May present ¯c obstruction/strangulation

Question 6

questions to ask of someone with a hernia

Answer 6

Reducible?
• Ever episodes of obstruction / strangulation?
• Predisposing factors: cough, straining, lifting?
• Occupation and social circumstances?

Question 7

management of inguinal hernia

Answer 7

reduce coughing, constipation

Surgical
• Tension-free mesh (e.g. Lichtenstein repair) better
than suture repair (e.g. Shouldice repair)
bilateral repair - lap

• 1O unilateral repairs should be open (NICE)
• Children only require sac excision (herniotomy)

Question 8

complications of inguinal hernia

Answer 8

early: retention, infection, bleed
late: recurrence, ischaemic orchitis (emerg), chronic pain / parasthesiae

Question 9

femoral hernia presentation

Answer 9

more common in females but rarer overall than ing

Painless groin lump
• Neck inferior (and lateral) to the pubic tubercle.
• Cough impulse.
• Often irreducible (tight borders)

Commonly present with obstruction or strangulation
• Tender, red and hot
• Abdo pain, distension, vomiting, constipation

Question 10

management femoral hernia

Answer 10

surgical no question
as strangulation likely

Elective: Lockwood Approach
• Low incision over hernia ¯c herniotomy and
herniorrhaphy (suture ing. ligt. to pectineal ligt.)

Emergency: McEvedy Approach
• High approach in inguinal region to allow inspection
and resection of non-viable bowel.
• Then herniotomy and herniorrhaphy

Question 11

incisional hernia risk factors

Answer 11

6% surgical incisions

pre op - old, obese, sig comorbid, ISupp drugs

intra-op = technique+skill, incision type, drains, wrong suture, stitches too small

post-op - chronic cough / straining, infection, bleeds

Question 12

management of incisional hernia

Answer 12

mostly conservative as low risk of strangulation

Conservative - reduce IAP risk factors, lose weight, elasticated truss

Surgical - optimise function, reduce weight, then mesh repair

Question 13

other reasonably common hernias

Answer 13

umbilical - if not closed by 3 yrs, surgery

paraumbilicial - from straining, surg repair

epigastric - surg repair

Question 14

rarer hernias just FYI

Answer 14

spigelian - within abdo wall layers

obturator - pain on inner aspect of thigh or knee

lumbar - following loin incision

sciatic or gluteal - presents as SBO and gluteal mass