Hernias - femoral and inguinal Flashcards
Anatomy of direct vs indirect inguinal hernia - vessels
Anatomy of inguinal canal
What is a hernia?
- Internal part of the body pushes through weakness in muscle/surrounding tissue
- This muscle and tissue usually creates the wall of the cavity where these contents usually reside
How does hiatus hernia present?
- Reflux
- Dysphagia
- Belching
- Chest pain
- N+V
These last symptoms come later if obstruction is caused
Presentation of hernias in general
- Visible bulge - bulges when coughing, straining, dissapears when lay down
- Heaviness/pressure
- Pain
- Burning/aching
- Swollen scrotum
- Difficulty with activities - raised IAP worsens pain
- Strangulation - severe pain, N+V
Natural history of hernias
- Stable
- Then increase in size, esp when in areas caused by increased IAP
- Become irreducible and incarcerated
- Then strangulated
- Can cause bowel obstruction
Surgical options (general) for hernias and material options
- Open or laparascopic with mesh repair
- Reduce hernia and suture femoral ring narrower
- Mesh options inc polypropylene, polyester, composite, biological, absorbable, titanium
Differentials for groin lump
- Inguinal hernia
- Femoral hernia
- Inguinal lymphadenopathy
- Femoral artery aneurysm
- Femoral artery pseudoaneurysm
- Ectopic/undescended testes
- Saphena varix - dilation of saphenous vein at junction of femoral vein
- Psoas abscess
Neck of swelling location for inguinal vs femoral hernia
- Superior and medial to pubic tubercle - inguinal
- Inferior and lateral - femoral
Femoral makes you IL - more likely to be strangulated
Direct vs indirect hernia
- Direct - passes into inguinal canal directly through weakness in posterior canal known as Hesselbachs triangle
- Indirect - enters canal via deep inguinal ring
Hesselbachs triangle
RF inguinal hernia
- Male
- Increasing age
- Obesity
- Raised intra-abdominal pressure - coughing, heavy lifting, chronic constipation
When examining groin lump, what to check?
- Size
- Cough impulse
- Location - inguinal vs femoral
- Reducible?
- Enters scrotum - distinguishable from testes?
Examining direct vs indirect inguinal hernia
- Theoretically, if reduce hernia and cover deep inguinal ring
- If comes back out - direct
- If does not - indirect
BUT often this is unreliable, need surgery to assess
Investigations for inguinal hernia
- Only needed if uncertain and need to rule out other pathology using USS
- If sure, don’t need imaging
- CT needed if strangulation/obstructive features
Management inguinal hernias
- Any symptomatic patient should be offered surgery
- If strangulation - need urgent surgical exploration
Emergency presentation of hernia
- Irreducible/incarcerated
- Bowel obstruction
- Strangulation -> bowel ischaemic
Surgical options inguinal hernia
- Open mesh repair
- Laparascopic mesh repair - total extraperitoneal (TEP) or transabdominal pre-peritoneal (TAPP)
Open mesh repair
- Preferred for primary inguinal hernias
- Under general, local or spinal anaesthesia
- Lichtenstein technique using mesh most commonly used (Bassini/Shouldice= no mesh)
Laparascopic mesh repair
- Preferred in bilateral/recurrent hernias
- Also in primary unilateral for those at risk of chronic pain (young and active, previous chronic pain, predominant symptom of pain) or females (increased risk of femoral hernia)
TEP vs TAPP laparascopic repair
- TAPP - pneumoperitoneum before accessing pre-peritoneal space by incising parietal peritoneum from inside
- TEP - Entire op within pre-peritoneal space, no entering peritoneal cavity, balloon dissector used to expand room
Complications inguinal hernias
- Incarceration
- Strangulation
- Obstruction
- Haematoma/seroma formation post op
- Recurrence
- Damage to vas deferens or testicular vessels (affect fertilty)
Femoral canal borders
RF femoral hernia
- Female
- Pregnancy
- Raised intra-abdominal pressure
- Increasing age
Femoral hernia investiagtions
- USS
- CT scan abdo pelvis
Management femoral hernias
- All should be surgical ideally within 2 weeks of presentation due to risk of strangulation
- Reduce hernia and narrow femoral ring
3 different surgical approaches to femoral hernia
- Low approach (Lockwood)
- High approach (McEvedy)
- Inguinal approach (Lotheissen)
Low approach
- Incision is made below the inguinal ligament
- Advantage of not interfering with the inguinal structures
- But does result in limited space for access to the intraperitoneal space or the removal of any compromised small bowel
High approach
- Incision is made above the inguinal ligament
- Allows access to the preperitoneal and intraperitoneal space via the lateral edge of the rectus sheath
- The main benefit is that the integrity of the posterior wall of the inguinal canal is not compromised
- Preferred technique in an emergency due to the easy access to compromised small bowel for any resection
Inguinal approach
- Incision is similar to that for an open inguinal hernia repair
- Canal is entered via incising the external oblique aponeurosis
- Preperitoneal and intraperitoneal space can then be accessed via incising the transversalis fascia
