Inguinal Hernia Flashcards
What is an inguinal hernia
The abnormal protrusion of omentum or bowel through inguinal canal
What is the inguinal canal
4-6cm long oblique passage along lower anterior abdominal wall.
Males - spermatic cord, testicular and cremasteric vessels
Deep inguinal ring -2cm above mid point of inguinal ligament and superficial inguinal ring - 1cm superior and medial to pubic tubercle
What are the types of hernias
Indirect - through the deep inguinal ring (lateral to inferior epigastric vessel)
Direct - directly through weak posterior wall of inguinal canal (medial to inferior epigastric vessel)
What are the boundaries of the inguinal canal
Ant: External oblique aponeurosis
Posterior: Transversalis fascia
Roof: Fibers of IO and TA as they merge to form conjoint tendon
Floor: Inguinal ligament
What are the contents of the spermatic cord
Layers: External spermatic fascia
Cremasteric fascia
Internal spermatic fascia
Testicular vein/artery
Vas deferens vein/artery
Cremasteric vein/artery
Nerves: Ilioinguinal nerve - on, not in
Autonomic T10 fibers
Genitofemoral nerve branch (cremasteric nerve)
Others: Vas deferens
Processes vaginalis
Lymphatics
What are the boundaries of Hesselbach’s triangle
Lateral - Inferior epigastric artery
Medial - lateral border of rectus
Inferior - Inguinal ligament
What is the epidemiology of inguinal hernia
Male (27-43%) > female (3-6%)
2/3 indirect inguinal
Bilateral hernia 4x more common in direct over indirect hernia
1/2 of males present with bilateral hernia
10% of inguinal hernia at risk for incarceration
Risk factors of inguinal hernia
High Male Old age Collagen metabolism Obesity Prostatectomy Inheritance
Old, obese man with family history of inguinal hernia, with previous history of prostatectomy and diminished collagen type 1
Moderate
Connective tissue disorders
Increased mettalloproteinase
Low
Constipation
Social factors
Smoking
Very low
Chronic cough
What is the clinical presentation of inguinal hernia
- Intermittent bulge (related to standing/exertion)
- Groin pain without bulge
- Lying flat improves symptoms
- Valsalva manoeuvre can reproduce symptoms/bulge
- Incarcerated inguinal hernia presents with pain+abdominal distension+n/v
What are the investigations to carry out for hernia
Dynamic ultrasound (with valsalva to accentuate small hernia)
AXR for any IO
CT AP if required
What is the progression of hernias
Progression of hernia
Reducible -> Incarcerated -> strangulated
What are the complications and presentation of strangulated hernias
- Ischemic/gangrenous bowel
- Must operated immediately without CT scan
- NBM
- IV drip and abx
- NG tube suction
- Pre op investigations - Suspect if acutely tender with signs of IO
What are the clinical differences of direct vs indirect hernias
- Relation to epigastric artery
- Reduction direction
- Controlling reduction via pressure over deep/superficial ring
- Descend down scrotum
- Likelihood of strangulation
- Reducability on lying down
What is the treatment of hernia
Watchful waiting if asymptomatic with low complication risk +/- hernia truss
Indications for surgery
- Elective surgery for symptomatic hernia repair for physically fit patients
- Emergency surgery for strangulated hernia
What are the surgical options
- Open inguinal hernia repair +/- mesh
- Herniotomy - remove hernia sac
- Herniorrhaphy - remove hernia sac and repair posterior wall of inguinal canal
- Herniplasty - reinforce posterior wall with synthetic mesh eg. Lichtenstein tension free repair
Laparo-endoscopic inguinal hernia repair
- Totally extra-peritoneal
- Trans abdominal perperitoneal
