Inguinal Hernia

Question 1

Define

Answer 1

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

Indirect (80%)→ pass through the internal inguinal ring and (in large) out through the external, runs lateral to inferior epigastric vessels
Commonly children, failure of closure of inguinal canal during development

Direct → push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdomen wall, runs medial to inferior epigastric vessels More common in elderly, rare in children

Question 2

Risk factors

Answer 2

Predisposing conditions (↑intra-abdominal pressure) such as:  Chronic cough

 Constipation
 Urinary obstruction
 Heavy lifting
 Ascites
 Past abdominal surgery
 In infants: prematurity, male sex

Question 3

Causes

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

Epidemiology

Answer 4

COMMON

Peak age in adults: 55-85 yrs

9 x more common in MALES

Question 5

Symptoms

Answer 5

• 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 6

Signs

Answer 6

• Groin lump that extends to the scrotum (males) or labia (women)
• Distinguishing inguinal and femoral hernias:

1. Inguinal - superior and medial to the pubic tubercle
2. 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
• Bowel obstruction and systemic upset (pyrexia, tachycardia etc.)

Question 7

Investigations

Answer 7

If ACUTE with painful irreducible hernia

Bloods

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

Imaging

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

Question 8

Management

Answer 8

Surgical

• Usually elective repair of uncomplicated hernias
• Mesh Repair
  
  • The hernia is surgically reduced and a mesh is inserted to reinforce the defect in the transversalis fascia

Laparoscopic Mesh Repair

EMERGENCY

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

Question 9

Complications

Answer 9

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

Surgery Complications

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

Question 10

Prognosis

Answer 10

Slowly enlarge if left alone

Surgical mesh repair has a GOOD outcome