Inguinal Hernia Flashcards
Explain inguinal hernia
When abdo cavity contents enter into the inguinal canal
Most common type of hernia and accounts for 75% of all anterior abdo wall hernias
Types of inguinal hernia
Direct
Indirect
(Management will be the same regardless of type)
Explain direct inguinal hernia
Bowel enters the inguinal canal directly through a weakness in the posterior wall of the canal
Hesselbach’s triangle
Explain Indirect inguinal hernia
Bowel enters the inguinal canal via the deep inguinal ring.
Arise from incomplete closure of the processus vaginalis.
Usually deemed congenital in origin.
How can the two be differentiated?
Indirect = lateral to inferior epigastric vessel
Direct = medial to inferior epigastric vessel
Risk factors
Male
Increasing age
Raised abdo pressure from chronic cough, chronic constipation or heavy lifting
Obesity
Clinical features
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.
Clinical features of incarcerated inguinal hernia
Painful
Tender
Erythematous
Might also have features of bowel obstruction or strangulation
Examinations of inguinal hernia
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?
Examination to differentiate between direct and indirect.
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.
Dx
Femoral hernia
Saphena varix
Inguinal lymphadenopathy
Lipoma
Groin abscess
Internal iliac aneurysm
Hydrocoele
Varicocoele
Testicular mass
Ix
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.
Management of symptomatic inguinal hernia like significant mass or discomfort
Surgical intervention
Risk of strangulation
Approx 3% per year
If there is evidence of strangulation this requires urgent surgical exploration
Surgical approaches
Open mesh repair (Lichtenstein technique) most commonly used
Laparoscopic repair (Total extraperitoneal (TAP) or transabdominal pre-peritoneal (TAPP))