Inguinal Hernia Flashcards
What is an inguinal hernia?
Abdominal cavity viscus enters into inguinal canal.
What is an irreducible hernia? Obstructed? Strangulated? Incarcerated?
Irreducible - contents cannot be pushed back into place
Obstructed - bowel contacts cannot pass
Strangulated - ischaemia occurs
Incarcerated - contents of hernia sac are stuck inside by adhesion
What are the types of inguinal hernia?
Direct inguinal hernia - bowel enters the inguinal canal directly through a weakness in the posterior wall of the canal (Hesselback’s traingle)
- Occur more commonly in older patients, often secondary to abdominal wall laxity or increases in intra-abdominal pressure
Indirect inguinal hernia - bowel enters the inguinal canal via the deep inguinal ring
- Arise from an incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, there deemed congenital in origin
Describe direct inguinal hernia
Direct inguinal hernia - bowel enters the inguinal canal directly through a weakness in the posterior wall of the canal (Hesselback’s traingle)
- Occur more commonly in older patients, often secondary to abdominal wall laxity or increases in intra-abdominal pressure
Describe indirect inguinal hernia
Indirect inguinal hernia - bowel enters the inguinal canal via the deep inguinal ring
- Arise from an incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, there deemed congenital in origin
How can direct and indirect hernias be differentiated in surgery?
Inferior epigastric vessels:
Indirect hernias will be lateral to the vessels while direct hernias will be medial
What makes up Heseslbachs triangle?
Medial to the inferior epigastric vessels
Lateral to rectus abdominus
Inguinal ligament inferiorly
What are risk factors for inguinal hernia?
Male Increasing age Raised intra-abdominal pressure: chronic cough constipation heavy lifting ascites Obesity
Where is the deep inguinal ring?
Mid-Point of the inguinal ligament (slightly above the femoral pulse (which crosses the mid-inguinal point)
Midpoint of inguinal ligament between pubic tubercle and ASIS
Mid-inguinal point between the pubic symphysis and ASIS
Where is the superficial inguinal ring?
Split in the eternal oblique aponeurosis just superior and medial to the pubic tubercle - bony prominence forming medial attachment of the inguinal ligament
What are clinical features of inguinal hernia?
Lump in the groin
For reducible hernia, this initially disappears with minimal pressure to when the patient lies down.
If the hernia is irreducible/incarcerated, it can become painful, tender and erythematous.
If bowel lumen becomes blocked, patient may present with bowel obstruction - constipation, vomiting, abdominal distension
How should you examine a groin lump?
Look for previous scars
Feel other side
Examine the external genitalia
Is lump visible
Is lump reducible - on lying down ± minimal pressure
Cough impulse - occlude the deep internal ring with 2 fingers -ask patient to cough, if hernia is restrained it is indirect, if not, it is direct.
Location: Inguinal (superomedial to pubic tubercle) or femoral (inferolateral to pubic tubercle)
If it enters the scrotum, can you get above ti, is it separate from the testis
Where is a inguinal hernia compared to a femoral hernia?
Inguinal - superomedial to pubic tubercle
Femoral - inferolateral to pubic tubercle
How do you differentiate a direct and indirect inguinal hernia clinically?
Reduce the hernia and place pressure over the deep inguinal ring, located at the midpoint of the inguinal ligament before asking patient to cough.
if the hernia protrudes despite occclusion of the deep inguinal ring - indicates direct hernia
IF hernia does not protrude - indirect hernia
What are differentials for groin lump?
Femoral hernia Inguinal lymphadenopathy Lipoma Groin abscess Internal iliac aneurysm If the mass extends into scrotum - hydrocele, varicocele or testicular mass
What is the investigation for hernia?
Clinical diagnosis
Explorative surgery
What is the management for an inguinal hernia?
Surgical open repair (LIchenstein technique)
Laparoscopic repair - total exztraperitoneal (TEP) or trans abdominal pre-peritoneal (TAPP)
When are open repairs preferred?
Primary inguinal hernias
When are laparoscopic approaches preferred?
Bilateral, recurrent inguinal hernias
Female primary hernias
Risk fo chronic pain (young, active, previous chronic pain)
What advice would you give patient pre-op
Lose weight and stop smoking
What are complications of hernia that require urgent intervention?
Irreducible/incarcerated
Obstruction (of bowel lumen)
Strangulation (compression of hernia compromises blood supply leading to ischaemic bowel)
How does a strangulated hernia present?
Irreducible tender tense lump, pain is out of proportion to clinical signs
What are post-operative complications of hernia repair?
Pain, bruising, haematoma, infection, urinary retention
Recurrence
Chronic pain
Damage to vas deferens or testicular vessels
Describe the borders of the inguinal canal?
Floor - inguinal ligament and lacunar ligament medialls
Roof: fibres of transversals, internal oblique
Anterior: External oblique aponeurosis + internal obqlique for lateral 1/2
Posterior - laterally,t transversals fascia
What is the contents of the inguinal canal?
External spermatic fascia from external oblique
Internal spermatic fascia from transversals fascia
These cover the cord
Spermatic cord
- vas deferens, arteries to the vas, cremaster and testis
Genial branch of the genitofemoral nerve and sympathetic nerves
Ilioinguinal nerve
In female, young ligament of the uterus in place of male structures
