Hernias and other groin problems

Question 1

• *Lumps in the groin
• Clinical examination***

Answer 1

Groin and scrotum must be examined to discover the anatomical origin of the swelling. Lumps in the groin are examined as lumps elsewhere but there are some special points to note:

• Examine the patient both standing and lying
• Examine for the presence of a cough impulse and test the reducibility of the lump
• Demonstrate the relationship of the origin of the lump to the inguinal ligament and the pubic tubercle

The patient must first be examined whilst standing, which increases intra-abdominal pressure, making any hernia more visible.

• Ask the patient to cough while palpating the lump: intra-abdominal pressure is thus transmitted through the abdominal wall and an expansile cough impulse is felt in a hernia.
• Small inguinal hernias may reduce on lying down, and a scrotal varicocoele will empty.

Question 2

Summary of groin lumps and swellings and their clinical features

Answer 2

Inguinal hernia Direct:

• ​Simple bulging of abdominal contents resulting from inadequate support by weak or ruptured posterior wall of inguinal canal (transversalis fascia)
• Discomfort; lump usually disappears on lying down; risk of incarceration if large but low risk of strangulation

Indirect:

• Passage of abdominal contents, often including bowel, through inguinal canal towards scrotum or labium majus
• Potential for incarceration and strangulation; much more common in men

Femoral hernia:

• Abdominal contents, often including bowel, migrate into femoral canal
• Rarely has a cough impulse; rarely reducible; high rate of strangulation; more common in women

Inguinal lymphadenopathy:

• Inguinal nodes drain lower limb, abdominal wall below umbilicus, anal canal, scrotal skin, penis (but not testes, which drain to para-aortic and para-iliac nodes)
• Enlarged nodes indicate infection, lymphoma or metastases from primary lesion in drainage area

Saphena varix:

• Dilatation of long saphenous vein superficial to deep fascia before it enters the femoral vein
• Can be mistaken for femoral hernia but empties on pressure and disappears on lying down, unlike femoral hernia; varicose veins present in the leg

Femoral artery aneurysm:

• Dilatation of common femoral artery just below inguinal ligament
• Found in patients over 65 years, mostly male; classic clinical sign is expansile pulsation; could be mistaken for femoral hernia

Psoas abscess

• Classically, a tuberculous abscess of lumbar vertebra tracking down inside sheath of psoas muscle; occasionally a pyogenic abscess originating within the abdomen presents via the same route
• TB presents as swelling or ‘cold abscess’ below inguinal ligament; rare nowadays but may be confused with lymph nodes; pyogenic abscess typically ‘hot’; rarely may be due to abscess from renal stones

Question 3

Strangulated inguinal hernia

Answer 3

• diagnosed by finding an irreducible hernia in the correct anatomical position; the lump is tender and often red
• Conversely, strangulated femoral hernias are usually very small and unimpressive, often no more than the size of a grape, yet have serious consequences.
• Strangulated hernias, particularly femoral hernias, sometimes present with abdominal pain or signs of obstruction but without localised pain in the groin.

Question 4

Direct and indirect inguinal hernias

Answer 4

indirect inguinal hernia

• is one in which the hernial sac lies within the spermatic cord, leaving the abdomen via the deep (internal) inguinal ring to pass along the inguinal canal, exiting through the superficial (external) ring.
• Thus, if the hernia can be completely reduced, finger pressure over the deep ring will prevent it reappearing on coughing (the deep ring is midway between the pubic tubercle and the anterior superior iliac spine, 2.5cm above the femoral pulse;

direct inguinal hernia:

• leaves the abdomen through a weakness or split in the transversalis fascia, the posterior wall of the inguinal canal, emerging directly through the superficial ring and cannot be controlled by digital pressure over the deep ring

Question 5

Inguinal and femoral hernias

Answer 5

• Differentiating an inguinal from a femoral hernia may sometimes be problematic but is important as it will determine the surgical approach and the operation performed.
• The key is the position of the hernia in relation to the inguinal ligament. An inguinal hernia, emerging from the superficial ring, has its origin above the inguinal ligament, often descending over or medial to the pubic tubercle.
• A femoral hernia originates below the inguinal ligament and lies lateral to the pubic tubercle.
• Rarely it becomes large, and tends to be deflected upwards and may seem to arise above the inguinal ligament.
• This explains the importance of careful examination to determine the origin of the neck of any groin hernia.

Question 6

Inguinal hernia

Mechanisms of inguinal hernia formation

Answer 6

Inguinal herniation may be direct or indirect. In either case, the herniated abdominal contents are contained within a sac of peritoneum.

indirect hernia,

the peritoneal sac may represent a patent or reopened processus vaginalis and may extend as far as the tunica vaginalis and surround the testis.

Direct hernias

tend to bulge forwards and rarely enter the scrotum. They are usually found in older patients with deficient muscles and weak transversalis fascia. The neck of a direct sac is broad, in contrast to the narrow neck of an indirect sac, confined as it is by the borders of the deep ring. Consequently, indirect inguinal hernias are more liable to strangulate.

Question 7

Management of inguinal hernias

Answer 7

• Inguinal hernias in adults should ideally be repaired by herniorrhaphy, although there is evidence that small, reducible direct hernias in older men can safely be left alone.
• performed under general anaesthesia, although epidural or spinal or local anaesthesia may be used in patients with poor cardiovascular or respiratory function
• In 1989 Lichtenstein described his mesh implant technique which rapidly became the standard operation

Question 8

Laparoscopic inguinal hernia repair

Answer 8

• Laparoscopic repair of inguinal hernias by a transperitoneal or retroperitoneal route now standard operation for hernia repair in many centres.
• offers less postoperative pain and a quicker return to activities has a slightly higher risk of complications compared to open techniques for primary hernia repair.
• particularly recommended for repair of recurrent hernias, having the advantage of allowing the mesh to be placed in virgin territory, and also for bilateral repair, when both sides can be repaired through the same three small incisions.
• long learning curve for laparoscopic repair and the recurrence rate slightly higher than the Lichtenstein technique.

Question 9

Femoral hernia

Answer 9

• femoral hernia is formed by a protrusion of peritoneum into the potential space of the femoral canal.
• The sac may contain abdominal viscera (usually small bowel) or omentum.
• Around 40% of femoral hernias present with strangulation.
• incidence is higher in women and increases with age (Figs 32.4 and 32.10).
• Increased intra-abdominal pressure and other factors related to pregnancy may be important in females since the incidence of femoral hernia is higher in parous than nulliparous women.

Question 10

Clinical features of femoral hernia

Answer 10

• A femoral hernia is usually small, appearing as a lump immediately below the inguinal ligament and just lateral to its medial attachment to the pubic tubercle.
• Since the femoral canal is narrow, a cough impulse can rarely be detected, and the hernia is usually irreducible.
• Thus, small femoral hernias may be difficult to distinguish from other lumps arising in the femoral canal such as a lipoma or enlarged Cloquet’s lymph node.
• However, a hernia is deeply fixed whereas the others tend to be more mobile.

Question 11

Management of femoral hernia

Answer 11

• The abdominal orifice of the femoral canal is small and indistensible so abdominal contents finding their way into the canal strangulate much more readily than in inguinal hernias.
• Thus, all femoral hernias, even if asymptomatic, should be repaired without delay.
• Elective repair is performed by first isolating, emptying and excising the peritoneal sac
• The femoral canal is then closed with non-absorbable sutures or a plug placed between pectineus fascia and inguinal ligament.

Question 12

Saphena varix

Answer 12

• Saphena varix is a dilatation of the long saphenous vein in the groin, just proximal to its junction with the femoral vein.
• The varix is caused by valvular incompetence at this point; there are usually substantial varicose veins elsewhere in the long saphenous system
• saphena varix is a dilatation of the long saphenous vein in the groin, just proximal to its junction with the femoral vein. The varix is caused by valvular incompetence at this point; there are usually substantial varicose veins elsewhere in the long saphenous system
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