Inguinal Hernias

Question 1

Define Inguinal Hernia?

Answer 1

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

Question 2

What are the two types of Inguinal Hernias?

Answer 2

Direct Inguinal Hernia

Indirect Inguinal Hernia

Question 3

What are the characteristics of Direct Inguinal Hernias?

Answer 3

Protrusion of the hernial sac directly through a weakness in the transversalis fascia and posterior wall of the inguinal canal
Arises medial to the inferior epigastric vessels
Appear through Hesselbach’s triangle

Question 4

What are the borders of Hesselbach’s Triangle?

Answer 4

Lateral border of rectus abdominiis
Inferior epigastric veseels
Inguinal ligament

Question 5

What are the characteristics of Indirect Inguinal Hernias?

Answer 5

Protrusion of the hernial sac through the deep inguinal ring, following the path of the inguinal canal

Question 6

What do you call it if indirect and direct Inguinal Hernia coexist?

Answer 6

Pantaloon hernia

Question 7

What is the congenital aetiology of Inguinal Hernias?

Answer 7

Abdominal contents enter the inguinal canal through a patent processus vaginalis

Question 8

What is the acquired aetiology of Inguinal Hernias?

Answer 8

Due to increased intra-abdominal pressure along with muscle and transversalis fasica weakness

Question 9

What are the risk factors for Inguinal Hernias?

Answer 9

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

Question 10

What is the epidemiology of Inguinal Hernias?

Answer 10

COMMON
Peak age in adults: 55-85 yrs
9x more common in males

Question 11

What are the presenting symptoms of Inguinal Hernias?

Answer 11

May be 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 12

What are the signs of Inguinal Hernias on physical examination?

Answer 12

Groin lumps that extends to the scrotum (males) or labia (women)
Check for cough impulse
Indirect hernias can be reduced and controlled by applying pressure over the deep inguinal ring
Herenia may be irreducible
Tenderness if strangulated
Signs of complications
Bowel obstruction and systemic upset (pyrexia, tachycardia etc. )

Question 13

How do you distinguish between inguinal and femoral hernias?

Answer 13

Inguinal - superior and medial to the pubic tubercle

Femoral - inferior and lateral to the pubic tubercle

Question 14

What can you hear upon auscultation of Inguinal Hernias?

Answer 14

There may be bowel sounds over the hernia

Question 15

When do we investigate Inguinal Hernias?

Answer 15

If acute with painful irreducible hernia

Question 16

What bloods do you do for Inguinal Hernias?

Answer 16

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

Question 17

What imaging would you do for Inguinal Hernias?

Answer 17

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

Question 18

What is the surgical management plan for Inguinal Hernias?

Answer 18

Usually elective repair of uncomplicated hernias
Mesh Repair
Laparoscopic Mesh Repair

Question 19

What’s involved in Mesh Repair treatment of Inguinal Hernias?

Answer 19

The hernias is surgically reduced and a mesh is inserted to reinforce the defect in the transversalis fascia

Question 20

What do you do in an emergency to manage Inguinal Hernias?

Answer 20

If obstructed or strangulated

Laparotomy with bowel resection may be indicated if the bowel is gangrenous

Question 21

What are the complications of Inguinal Hernias?

Answer 21

Incarceration
Strangulation 
Bowel Obstruction
Maydl's hernia
Richter's Hernia

Question 22

What is Maydl’s Hernia?

Answer 22

Strangulated W-shaped loop of small bowel

Question 23

What is Richter’s Hernia?

Answer 23

Strangulation of only part of the bowel circumference

Question 24

What are the complications of Surgery for Inguinal Hernias?

Answer 24

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

Question 25

What is the prognosis for patients with Inguinal Hernias?

Answer 25

Slowly enlarge if left alone

Surgical mesh repair has a GOOD outcome