Inguinal hernias

Question 1

Define:

Answer 1

This is the most common type of hernia

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

Both go through the superficial ring.

Direct - protrusion directly through weakness in the posterior wall of the inguinal canal . Emerge medial to the deep ring and to inferior epigastric artery @ Hesselbach’s triangle.

Indirect - protrusion through both deep and superficial ring. (usually found in the scrotum inferiolateral to the inferior epigastric artery.)

Question 2

Aetiology:

Answer 2

Congenital - patent processus vaginalis

Acquired due to an increase in intrabdominal pressure (chronic coughing, smoking, weight lifting, constipation, pregnancy)

Question 3

Risk factors:

Answer 3

Male 
Prematurity
Age 
Obesity 
Raised intra-abdominal pressure (e.g. chronic cough) 
Constipation 
Bladder outflow obstruction 
Intraperitoneal fluid (e.g. ascites)

Question 4

Epidemiology:

Answer 4

Peak ages - 55-85 years

Common

9x 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

• Look for previous scars and check both sides – more common on R side
• Groin lump that extends to the scrotum (males) or labia (women)
• If lump visible, ask patient to reduce it. If he cannot, make sure it is not a scrotal lump. If no lump visible, go straight to cough impulse.
• Distinguishing inguinal and femoral hernias:
o Inguinal - superior and medial to the pubic tubercle
o Femoral - inferior and lateral to the pubic tubercle
• Check for cough impulse
• Auscultation - there may be bowel sounds over the hernia
• Hernia may be irreducible
• Tenderness if strangulated
• Check for signs of complications
o Bowel obstruction and systemic upset (pyrexia, tachycardia etc.)
• Repeat examination with patient standing
• Distinguishing direct and indirect hernias
o Reduce the hernia and occlude the deep internal ring with two fingers. Ask patient to cough/stand. If hernia is restrained, it is indirect. If not, it is direct
o Gold standard: surgery – direct hernias are medial to inferior epigastric vessels, indirect are lateral

Question 7

Investigations:

Answer 7

o Bloods
• FBC
• U&Es
• CRP
• Clotting
• Group and save (if operation is likely)
• ABGs - may show lactic acidosis from bowel ischaemia
o Imaging
• Erect CXR - check for perforation
• USS - exclude other causes of groin lump
• AXR - check for obstruction

Question 8

Management:

Answer 8

o Usually elective repair of uncomplicated hernias
o Mesh Repair

• The hernia is surgically reduced and a mesh is inserted to reinforce the defect in the transversalis fascia
• Advise diet, if over weight, and to stop smoking before pre-op
o Laparoscopic Mesh Repair
o 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 (image on the right - strangulated W-shaped loop of small bowel) 
•	Richter's hernia (strangulation of only part of the bowel circumference) 
•	Surgery Complications
o	Pain 
o	Wound infection 
o	Haematoma 
o	Penile/scrotal oedema 
o	Mesh infection 
o	Testicular ischaemia

Question 10

Prognosis:

Answer 10

• Slowly enlarge if left alone