Hernias / Groin swelling Flashcards
Direct (inguinal) hernia
- direct penetrate the abdominal wall
- indirect pass through the deep and superficial inguinal rings
Caused by a defect or weakness in the transversalis fascia area of the Hesselbach triangle (degeneration in the changes of the structure of the aponeurosis of trsnversalis fascia). Usually seen in adults, more common in males.
always acquired- degeneration and fatty changes. do not contain bowel- mainly preperitoneal fat, ocassionally blader.
posterior wall > inguinal canal > superficial ring.
Protrudes through the Hasselback triangle. Passes medial to the inferior epigastric artery, inferior to mesenteric artery.
Low risk of strangulation
Indirect (inguinal) hernia
Caused by failure of the processus vaginalis to close leads to formation of an empty peritoneal sac lying in the inguinal canal- usually occurs in infants, more common in males. enter the inguinal canal lateral to the inferior epigastric vessels.
Passes through the deep inguinal ring along the inguinal cnaal into the scrotum, defect in fascia transversalis (posterior wall of the inguinal canal)
Protrudes through the inguinal ring and passes lateral to the inferior epigastric artery, laterally to the inferior mesenteric artery.
Femoral hernia aetiology and pathophysiology
A section of the bowel / any part of the abdominal viscera passes into the femoral canal. The femoral canal is a potential space which can be occupied by herniated contents via the femoral ring.
Protrudes below the inguinal ligament, lateral to the pubic tubercle. more common in adult females. (more common in multiparous women- increased abdominal pressure in pregnancy)
High risk of strangulation.
Femoral hernia clinical features
Lump within the groin Mildly painful Inferolateral to the pubic tubercle (inguinal hernias are superlateral to the pubic tubercle) Non-reducible Cough impulse is absent.
Femoral hernia diagnosis
Ultrasound
differentials to exclude lymphadenopathy abscess femoral artery aneurysm hydrocele / varicocele lipoma inguinal hernia.
management:
surgical repair (risk of strangulation)
hernia support belts/trusses
laparotomy in an emergency.
Inguinal hernia clinical features
Protrusion of abdominal or pelvic content through a dilated inguinal ring
Groin lump
Disappears on pressure / when the patient lies down
Discomfort and ache, worse with activity
Strangulation is rare.
Inguinal hernia management
Treat medically fit pt even if asymptomatic
Hernia truss if not fit for surgery
Mesh repair
Do not return to work for 2-3 weeks following open repair
1-2 weeks after laparoscopic
complications
(early) bruising wound infection
(late) chronic pain, recurrence
Inguinal hernia pathophysiology
A protrusion of all or part of the viscus through the wall of the abdominal or pelvic cavity, causing a visible or easily palpable bulge.
*male, elderly, family history, Ehler-Danlos
right-sided hernias are more common than left due to the descent of testis/ previous appendectomy.?
Strangulated hernias
Acute onset of symptoms
Irreducible groin mass
Pain on groin/abdomen
Nausea and vomiting
Inguinal hernia management
Conservative - weight loss, smoking cessation
Classification of inguinal hernia
- Direct
- Indirect
- Reducible (manual pressure allows the content to be returned to original compartment)
- Irreducible- bowel is incarcerated, hernia content cannot be reduced to the peritoneal cavity. blood supply not compromised.
- stagnated- blood supply to the hernia has been compromised- ischaemia, gangrene, perforation.
Why are indirect hernias more prone to strangulation than direct hernias?
Direct hernia is usually due to widespread weakness of inguinal floor tissues.
Indirect hernias pass through a tight internal ring. Sequestration of fluid in the lumen with herniated bowel. Impairment of lymphatic and venous drainage- aggreates= impaired arterial supply.
How to test for an indirect hernia
Apply finger pressure over the deep inguinal ring (just above midpoint of the inguinal ligament) here you can control an indirect hernia as it has been reduced.
if when you press thedeep inguinal ring the hernia still protrudes, this means the hernia is emerging via a defect in the posterior wall, medial to this point and is, therefore, a direct hernia.
How to test for direct hernia
Instruct the patient to cough = a buldge should appear medial to the point of finger pressure.
Investigation for hernias
If doubt / complex case:
USS groin
CT/MRI groin
Herniography of groin
Strangulated hernia: FBC, U+E’s, LFT, CRP, lactate, urinalysis, group and save, CT, USS
Clinical presentation of strangulated hernias
Acute and require immediate treatment- what?
Pain groin discomfort irreducible groin mass tender distended abdomen with lack of bowel sounds abdominal pain nausea/vomiting constipation.
Hernia managemenet
Mild/asymptomatic= conservative
Symtomatic= referral for 2’ care
watchful waiting if the risk of bowel obstruction and strangulation is low= 6 months regular clinical follow up.
weight loss
stop smoking
surgical : mesh
differential diagnosis of inguinal hernia
- femoral hernia (anatomically inferior and lateral to pubic tubercle)
- saphena varix (protrusion of saphenous vein, always reducible, disappears when patient lies down)
- femoral aneurysm (pulsatile, continous murmur, weak peripheral pulse)
- lymphadenopathy (firm and round in texture, lower limb infection, abrasion)
Inguinal hernia- congenital / acquired.
- increased intra abdominal pressure (chronic cough, constipation, heavy lifting, advanced age, obesity)
- weakenss in abdominal muscles.
Congenital: processus vaginalis fails to undergo regression
Acquired: degeneration / fatty changes in the tissue of inguinal floor. (usually direct)
Define the following terms: Reducible Irreducible Obstructed Strangulated
Reducible – when the contents of the hernia can be manipulated back into its original position through the defect from which it emerges
Incarcerated hernia (irreducible) – the hernia is compressed by the defect causing it to be irreducible (i.e. unable to be pushed back into its original position)
Obstructed hernia – refers mainly to hernias containing bowel, where the contents of the hernia are compressed to the extent that the bowel lumen is no longer patent and causes bowel obstruction
Strangulated hernia – the compression around the hernia prevents blood flow into the hernial contents causing ischaemia to the tissues and pain
Anatomy of the inguinal canal
https://geekymedics.com/wp-content/uploads/2016/02/IMG_0045.jpg
This functions to provide a passageway for abdominal content to exit the abdomen.
- males= spermatic cord to facilitate ejaculation
- females= round ligament
the canal carries the sensory ilioinguinal nerve.
entry point is the deep inguinal ring
exit point is the superificial inguinal ring.
Deep inguinal ring: just above the midpoint of the inguinal ligament
Superficial inguinal ring: just above and medial to the pubic tubercle
direct inguinal hernia
direct: weakness in the posterior wall of the inguinal canal. fatty tissue/bowel is forced through and enters the inguinal canal.
* does not go through the deep ring
protrudes via a defect in the posterior wall, through the superficial ring.
https://geekymedics.com/wp-content/uploads/2016/02/IMG_0047.jpg
indirect inguinal hernia
does not pierce the posterior wall
abdominal content passes through the deep inguinal ring
through the inguinal canal
exits via the superficial ring.
NAVY VAN
Passes beneath the inguinal ligament, travelling to upper leg.
Femoral artery, femoral vein, femoral nerve.
NAVY VAN
Nerve, artery, vein groin crease, vein, artery, nerve.
Femoral canal
The femoral canal lies medial to the femoral vein.
Allows expansion of the femoral vein to increase venous return.
The femoral canal can contain a small amount of fatty tissue. // lymph node (Cloquet)
can be a defect through which Abdo content protrudes.
high risk of strangulation and obstruction
https://geekymedics.com/hernias-explained/
incarcerated hernia
obstructed hernia
strangulated hernia
incarcerated- irreducible but not necessarily strangulated or obstructed. (adult urgent repair, infant repair within 2 weeks)
obstructed- narrow lumen, preventing the passage of faeces
strangulated- ischaemic, cut off the blood supply. will be obstructed if contain bowel.
borders of the inguinal canal
floor- inguinal ligamnet, lacunar ligament
celing- transversusabdominus, internal oblique
anterior wall- external oblique
posterior wall- transversalis fascia
medial opening- superfiical ring
lateral opening- deep inguinal ring
content of the inguinal canal
vas arteries- testicular, artery to vas, cremasteric
veins- pampiniform plexus
lymphatic vessels- testis drain into the para-aortic lymph nodes
nerves- genital branch of genitofemoral, sympathetic nerves accomponying arteries, ilioinguinal cnerve
clinical presentation of hernia
lump/fullness in groin or scrotum
aching
lump which increases in size when abdominal pressure increases
if incarcerated= cannot be reduced, increase in size
obstructed= relative/absoloute constipation, nausea, vomiting
strangulation= unwell patient, firm, painful and tender, erythema overlying skin
the differential diagnosis for hernia
constipation tumor lipoma groin haematoma speramtocele undescended testes varicocele
hernia investigations
symptoms- clinical
groin ultrasound if diagnostic uncertainty
CT if an obese patient
hernia management
if no features of strangulation, obstruction or incarceration
- infant/young boy: refer urgently to paeds surgeon within 2 week
- older boy/men: routine surgery
features of incarceration but no strangulation or obstruction
- infant/young boy refer urgently to paeds surgeon
- older boys/men urgent surgical repair
if features of strangulation or obstruction
admit immediately.
prophylactic antibiotics
DIRECT vs INDIRECT
DIRECT hernia protrudes through the hesselback triangle due to a weakness in the transversals fascia
(goes straight through the abdominal wall)
INDIRECT hernia protrudes through the inguinal ring (through the deep and superficial ring) due to a failure of the processes vaginalis to close
DIRECT passess medial to the inferior epigastric artery and INDIRECT possess lateral to the epigastric artery.
both are a low risk of strangulation and more common in males.
femoral
section of bowel/part of the abdominal viscera possess into the femoral canal via femoral ring
lump, mildly painful
inferolateral to pubic tubercle
non reducible
cough impulse is absent
ultrasound
! incarceration
! strangulation
! bowel obstruction
! bowel ischaemia
inguinal
goin lump superior and medial to pubic tubercle reduccible on pressure or lying down worse with activity discomfort
treat even if asymptomatic
mesh repair
