Inguinal Hernia

Question 1

Explain inguinal hernia

Answer 1

When abdo cavity contents enter into the inguinal canal

Most common type of hernia and accounts for 75% of all anterior abdo wall hernias

Question 2

Types of inguinal hernia

Answer 2

Direct

Indirect

(Management will be the same regardless of type)

Question 3

Explain direct inguinal hernia

Answer 3

Bowel enters the inguinal canal directly through a weakness in the posterior wall of the canal

Hesselbach’s triangle

Question 4

Explain Indirect inguinal hernia

Answer 4

Bowel enters the inguinal canal via the deep inguinal ring.

Arise from incomplete closure of the processus vaginalis.

Usually deemed congenital in origin.

Question 5

How can the two be differentiated?

Answer 5

Indirect = lateral to inferior epigastric vessel

Direct = medial to inferior epigastric vessel

Question 6

Risk factors

Answer 6

Male

Increasing age

Raised abdo pressure from chronic cough, chronic constipation or heavy lifting

Obesity

Question 7

Clinical features

Answer 7

Lump in the groin that will initially disappear with minimal pressure or when the patient lies down

Can be mild-moderate discomfort on activity or standing.

Question 8

Clinical features of incarcerated inguinal hernia

Answer 8

Painful

Tender

Erythematous

Might also have features of bowel obstruction or strangulation

Question 9

Examinations of inguinal hernia

Answer 9

Cough impulse (irreducible hernia may not have cough impulse)

Location - superiomedial to the pubic tubercle

Reducible - only lying down +/- minimal pressure

If it enters the scrotum -> can you get above it / is it separate from the testis?

Question 10

Examination to differentiate between direct and indirect.

Answer 10

Reduce the hernia

Place pressure on the deep inguinal ring and ask the patient to cough.

If the hernia protrudes -> direct hernia

If it does not protrude -> indirect

This assessment is often unreliable.

Question 11

Dx

Answer 11

Femoral hernia

Saphena varix

Inguinal lymphadenopathy

Lipoma

Groin abscess

Internal iliac aneurysm

Hydrocoele

Varicocoele

Testicular mass

Question 12

Ix

Answer 12

Clinical diagnosis

Imaging should only be considered if there is diagnostic uncertainty or to exclude other pathology.

First line imaging is ultrasound scan

Features of obstruction or strangulation requires CT scan.

Question 13

Management of symptomatic inguinal hernia like significant mass or discomfort

Answer 13

Surgical intervention

Question 14

Risk of strangulation

Answer 14

Approx 3% per year

If there is evidence of strangulation this requires urgent surgical exploration

Question 15

Surgical approaches

Answer 15

Open mesh repair (Lichtenstein technique) most commonly used

Laparoscopic repair (Total extraperitoneal (TAP) or transabdominal pre-peritoneal (TAPP))

Question 16

Explain open mesh repai

Answer 16

Preferred for those with primary inguinal hernias and deemed most cost-effective in this patient group.

Can be performed under general, spinal or local anaesthesia.

Question 17

Explain laparoscopic repair

Answer 17

Preferred in bilateral or recurrent inguinal hernias

Also in primary unilateral hernia in high risk of chronic pain (young active, previous chronic pain) or in females.

Longer operating times but quicker post-op recovery, fewer complications and less post-op pain.

Question 18

Complications

Answer 18

Incarceration

Strangulation

Obstruction

Question 19

Post-op complications

Answer 19

Pain, bruising, haematoma

Infection or urinary retention

Recurrence

Chronic pain

Damage to vas def or testicular vessels leading to ischaemic orchitis