Hernias (inguinal)

Question 1

Definition

Answer 1

The abnormal protrusion of a peritoneal sac through a weakness of the abdominal wall
in the inguinal region

Question 2

Types

Answer 2

o Direct Inguinal Hernia
• Protrusion of the hernial sac directly through a weakness in the
transversalis fascia and posterior wall of the inguinal canal
• Arises medial to the inferior epigastric vessels
• Appear through Hesselbach’s triangle (BORDERS: lateral border of rectus
abdominis, inferior epigastric vessels, inguinal ligament)

o Indirect Inguinal Hernia
• Protrusion of the hernial sac through the deep inguinal ring, following the
path of the inguinal canal

o NOTE: if indirect and direct inguinal hernias coexist = pantaloon hernia

Question 3

Aetiology

Answer 3

• Congenital - abdominal contents enter the inguinal canal through a patent processus
vaginalis

• Acquired - due to increased intra-abdominal pressure along with muscle and
transversalis fascia weakness

Question 4

Risk factors

Answer 4

o Male
o Prematurity
o Age
o Obesity
o Raised intra-abdominal pressure (e.g. chronic cough)
o Constipation
o Bladder outflow obstruction
o Intraperitoneal fluid (e.g. ascites)

Question 5

Epidemiology

Answer 5

• COMMON
• Peak age in adults: 55-85 yrs
• 9 x more common in MALES

Question 6

Presenting symptoms

Answer 6

• Asymptomatic
• Patient notices a ‘lump in the groin’
• May cause discomfort and pain
• May be irreducible
• May present because it has increased in size
• May present because of complications (e.g. bowel obstruction)

Question 7

Signs on physical examination

Answer 7

• Groin lump that extends to the scrotum (males) or labia (women)

• Distinguishing inguinal and femoral hernias:
o Inguinal - superior and medial to the pubic tubercle
o Femoral - inferior and lateral to the pubic tubercle

• Check for cough impulse

• Indirect hernias can be reduced and controlled by applying pressure over the deep
inguinal ring

• Auscultation - there may be bowel sounds over the hernia
• Hernia may be irreducible
• Tenderness if strangulated

• Check for signs of complications
o Bowel obstruction and systemic upset (pyrexia, tachycardia etc.)

Question 8

Investigations

Answer 8

• If ACUTE with painful irreducible hernia

o Bloods
• FBC
• U&Es
• CRP
• Clotting
• Group and save (if operation is likely)
• ABGs - may show lactic acidosis from bowel ischaemia

o Imaging
• Erect CXR - check for perforation
• USS - exclude other causes of groin lump
• AXR - check for obstruction

Question 9

Management plan

Answer 9

• Surgical

o Usually elective repair of uncomplicated hernias

o Mesh Repair
• The hernia is surgically reduced and a mesh is inserted to reinforce the
defect in the transversalis fascia

o Laparoscopic Mesh Repair

o EMERGENCY
• If obstructed or strangulated
• Laparotomy with bowel resection may be indicated if the bowel is
gangrenous

Question 10

Possible complications

Answer 10

• Incarceration
• Strangulation
• Bowel obstruction
• Maydl’s hernia (image on the right -
strangulated W-shaped loop of small bowel)
• Richter’s hernia (strangulation of only part of
the bowel circumference)

Question 11

Surgery complications

Answer 11

o Pain
o Wound infection
o Haematoma 
o Penile/scrotal oedema
o Mesh infection
o Testicular ischaemia

Question 12

Prognosis

Answer 12

• Slowly enlarge if left alone

* Surgical mesh repair has a GOOD outcome