Inguinal Hernias Flashcards
What is an inguinal hernia?
It defined as an abnormal protrusion of abdominopelvic contents through the superficial ring into the groin
What is the most common abdominal hernia classification?
Inguinal hernias
Where is the inguinal ligament located?
It extends between the anterior superior iliac spine (ASIS) and the pubic tubercle (PT)
Where is the inguinal canal located?
It runs above the inguinal ligament
What is the function of the inguinal canal?
It provides a passageway between the peritoneal cavity and the external genitalia
Where is the deep ring of the inguinal canal located?
It is located just above the mid-point of the inguinal ligament
Where is the superficial ring of the inguinal canal located?
It is located just above and lateral to the pubic tubercle
What are the two classifications of inguinal hernias?
Direct Inguinal Hernia
Indirect Inguinal Hernia
What are direct inguinal hernias?
They are defined as the abnormal protrusion of abdominal contents direct through the Hesselbach’s triangle, due to a weakness in the posterior wall of the inguinal canal
The hernia enters the inguinal canal medial to the deep ring and exits via the superficial ring
What are indirect inguinal hernias?
They are defined as the abnormal protrusion of abdominal contents, which enter the deep ring, pass along the length of the inguinal canal and exit via the superficial ring
How do we differentiate between direct and indirect inguinal hernias?
We can reduce the hernia and then press on the deep inguinal ring
What is the feature of indirect inguinal hernias on clinical examination? Explain
The groin lump will not reappear
This is due to the fact that its entry point is the deep inguinal ring
What is the feature of direct inguinal hernias on clinical examination? Explain
The groin lump will reappear
This due to the fact that its entry point is Hesselbach’s triangle – not the deep inguinal ring
What are the three risk factors of inguinal hernias?
Older Age > 70 Years Old
Male Gender
Low BMI
What are the two clincial features of inguinal hernias?
Groin Lump
Dull Groin Pain
Where are groin lumps associated with inguinal hernias located?
They are located superior and medial to the pubic tubercle
In which two circumstances, are inguinal hernias reducible?
Pressure Application
Lying Down
What are the four characteristic features of the groin pain associated with inguinal hernias?
Exacerbated by exercise
Exacerbated by coughing
Exacerbated by bending over
Exacertbated by standing for extended period
How are inguinal hernias diagnosed?
Clinically
In most cases, there is not a requirement of futher investigations
What investigation is used to diagnose inguinal hernias?
Ultrasound Scan
How are ultrasound scans used to investigate inguinal hernias?
In cases of diagnostic uncertainty in order to exclude differential diagnoses of inguinal hernias – including enlarged lymph nodes, fatty lumps or vascular pathology
When do we conduct management of inguinal hernias?
It is recommended that all medically fit patients should undergo surgical management, even in cases where individuals are asymptomatic
What are the two surgical management options of inguinal hernias?
Open Mesh Repair
Laparoscopic Mesh Repair
When is an open mesh repair used to manage inguinal hernias?
It is the first line management option used to treat unilateral inguinal hernias
What is an open mesh repair?
It involves direct exploration of the inguinal canal via a groin incision, in which the hernia contents are reduced back into the abdominal cavity and a mesh is placed to strengthen the deep inguinal ring and posterior wall
When should individuals return to non-mannual work following open mash repair?
> 2 - 3 weeks
When is a laparoscopic mesh repair used to manage inguinal hernias?
It is the first line management option used to treat bilateral or recurrent inguinal hernias
What is laparoscopic mesh repair?
It It involves laparoscopic exploration of the inguinal canal via a small abdominal incision, in which the hernia contents are reduced back into the abdominal cavity and a mesh is placed to strengthen the deep inguinal ring and posterior wall
When should individuals return to non-mannual work following laproscopic mash repair?
> 1 - 2 weeks
What are the five complications of inguinal hernias?
Incarcerated Inguinal Hernias
Strangulated Inguinal Hernias
Recurrent Inguinal Hernias
Groin Bruising
Chronic Groin Pain
What are incancerated inguinal hernias?
They are defined as those that are irreducible, which means that their hernia content cannot be pushed back into their original position
What are strangulated inguinal hernias?
They are defined as those that are irreducible, in which the hernia contents become compressed
This reduces blood flow to the herniated tissues – eventually leading to ischaemia and necrosis
Strangulated inguinal hernias are deemed as a surgical emergency. Why?
Inguinal hernias are most commonly composed of small bowel
Therefore, strangulation can lead to bowel obstruction, perforation and necrosis
Incarcerated and strangulated inguinal hernias are both irreducible. How do we differentiate between them?
Incarcerated hernias are painless
Strangulated hernias are painful
What are the two signs that inguinal hernias are at risk of strangulation?
Inguinal hernias which become painful when previously asymptomatic
Inguinal hernias which are incarcerated
What are the nine clinical features of strangulated inguinal hernias?
Fever > 38C
Nausea & Vomiting
Severe Groin Pain
Increased Groin Lump Size
Erythema of Groin Lump
Peritonitic Features
Abdominal Distension
Rectal Bleeding
Tachycardia
What are the three investigations used to diagnose strangulated inguinal hernias?
Blood Tests
Erect Chest X-Ray (CXR)
Abdominal CT Scan
What two blood test results indicate strangulated inguinal hernias?
Increased WCC Levels
Increased Lactate Levels
How are erect CXRs used to investigate strangulated inguianl hernias?
They are used to identify bowel perforation, which is a complication of strangulated inguinal hernias
How are abdominal CT scans used to investigate strangulated inguianl hernias?
They are used to identify bowel obstruction, which is a complication of strangulated inguinal hernias
What is the management of strangulated inguinal hernias?
We call for an ambulance and arrange urgent secondary care assessment
In secondary care, the same surgical procedures used for elective inguinal hernias are used in an emergency setting - except there is an additional step of removing dead bowel contents
Do we manually reduce strangulated inguinal hernias whilst waiting for surgery? Why?
No
This increases the risk of peritonitis
