URO - Hernias Flashcards
Differential Diagnoses for Groin Lumps
Hernias
Infection
Vascular
Testicular
Other
1.) Hernias
- direct/indirect, inguinal/femoral
- reducible/incarcerated/strangulated
2.) Infection - lymphadenopathy, psoas/groin abscess
- painful/tender, warm, overlying erythema
- show rapid changes in size
- swollen lymph nodes are solid whilst other differentials are generally softer and fluctuant
3.) Vascular
- femoral artery pseudoaneurysm
- saphena varix (rare)
4.) Testicular
- varicocoele, hydrocoele, testicular mass
- cryptorchidism: never changes in size
5.) Other
- lipoma: smooth, mobile painless lump, lies in subcutaneous tissue
Vascular Causes of Groin Lumps
Femoral Artery Pseudoaneurysm
Saphena Varix
1.) Femoral Artery Pseudoaneurysm - collection of blood outside vessel lumen following angiography
- pulsatile (only true pulsatile groin lump)
- can become infected so becomes warm, tender etc…
2.) Saphena Varix - dilation of the saphenous vein, usually over the sapheno-femoral junction
- only seen when standing and can increase in size if standing for long periods of time (blood pooling)
- palpable thrill when coughing w/ the presence
of varicose veins elsewhere
- only other reducible groin lump
Classification of Inguinal Hernias
Indirect
Direct
Theoretical Distinction
Practical Differentiation
Distinction of Type
Prevalence
1.) Indirect - go through deep ring and superficial ring
- caused by failure of processus vaginalis to regress
- can extend into scrotum (can get above it)
- reduces superolaterally and posteriorly
- more likely to become strangulated than direct
2.) Direct - doesn’t go through deep ring but goes straight through the posterior wall
- caused by weakening of the abdominal musculature
- reduces superiorly and posteriorly
3.) Distinction - the point the hernia leaves its containing cavity describes if its indirect or direct
- neck of the swelling is superior and medial to the pubic tubercle (femoral hernia is inferior and lateral)
- indirect: lies lateral to the inferior epigastric vessels
- direct: lies medial to the inferior epigastric vessels
4.) Differentiation
- reduce the hernia
- apply pressure over the deep inguinal ring (midpoint of the inguinal ligament, ASIS–> pubic tubercle)
- then ask the patient to cough
- direct hernia protrudes whilst indirect does not as you’re covering its exit point
5.) Prevalence - approx 75% of all abdominal hernias
- 50% indirect (mainly right sided), 25% Direct
- 20% are bilateral
Clinical Features of Inguinal Hernias
Reducible
Incarcerated
Strangulated
1.) Reducible - swellings and aches
- generally painless but can be tender to palpation
- can disappear with minimal pressure or lying down
- cough impulse: expands during coughing (↑pressure) due to pushing contents through wall defect
2.) Incarcerated - contents of the hernia are unable to return to the original cavity (not reducible)
- painful, tender, and erythematous
- no cough impulse
- at increased risk of strangulation
3.) Strangulated - compromised blood supply causing ischaemic bowel, surgical emergency
- very painful, irreducible, tender, tense lump
- there may be signs of peritonitis, bowel obstruction or ischaemia (blood stools)
- no cough impulse
- DO NOT attempt to manually reduce
- the annual probability of strangulation is up to 3%
Management of Inguinal Hernias
Investigations
Conservative
Surgical Intervention
1.) Investigations - clinical diagnosis
- USS if necessary, CT for features of obstruction
2.) Conservative - if asymptomatic (1/3 of patients)
- safety net sx of strangulation
- if incarcerated/strangulated will need IV fluids + NBM, a draining NG tube, and sufficient analgesia
- strangulation: abdo CT/X-ray + eCXR, FBC (↑WCC), ABG (lactate), NBM + IVI, NG tube, analgesia
3.) Surgical Intervention - symptomatic (discomfort) or congenital
- open mesh repair: for primary inguinal hernias, can be done under general, spinal, or local anaesthesia
- laparoscopic repair: for bilateral or recurrent hernias or those are risk of chronic pain or females
- asymptomatic patients should still have a routine referral for an open mesh repair to prevent potential strangulation
- congenital hernias should be immediately referred to paediatric surgery, if <6wks, operate in 2 days, <6mths operate in 2 weeks, <6yrs, operate in 2 months
General Features of Femoral Hernias
Femoral Canal Borders
Prevalence
Risk Factors
1.) Femoral Canal Borders
- superior border: femoral ring (covered by septum)
- anterior: inguinal ligament, posterior: pectineal ligament, pectineus, superior ramus of pubic bone
- lateral: femoral vein, medial: lacunar ligament
- rigid borders ↑complications of femoral hernias
2.) Prevalence - relatively uncommon but important due to high rate of strangulation (due to narrow neck)
- more common in women (3:1) due to having a wider bony pelvis, it is very rare in children
3.) Risk Factors
- female, pregnancy, ↑age, ↑intra-abdominal pressure
Management of Femoral Hernias
Clinical Features
Investigations
Surgical Interventions
1.) Clinical Features - small lump in groin
- usually asymptomatic but 30% of cases present as an emergency (obstruction or strangulation)
- unlikely to be reducible (tightness of femoral ring)
- infero-lateral to pubic tubercle
- may have a cough impulse
2.) Investigations
- routine pre-op investigations: all need surgery
- imaging: USS or CT abdo-pelvo
- can be surgical explored if any doubt
3.) Surgical Intervention - reduce the hernia and narrow the femoral ring with sutures or a mesh plug
- low approach: incision below inguinal ligament (safer but less room to manoeuvre)
- high approach: incision above is preferred in emergencies due to easy access to small bowel
Incisional Hernia
What is it?
Risk Factors
Clinical Features
Investigations
Management
1.) What is it? - protrusion of contents of a cavity through a previously made incision in the compartment’s wall
- layers of abdominal wall are structurally weakened so contents can herniate through the weakness
2.) Risk Factors
- ↑age, BMI >25, pregnancy, emergency surgery
- midline incision, wound type, wound infection
- pre-op chemo, intra-op blood transfusion
3.) Clinical Features - swelling at or near the site of a previous surgical wound
- non-pulsatile, reducible, soft and non-tender
- can become incarcerated/obstructed/strangulated
4.) Investigations - clinical diagnosis
- USS or CT if unclear: shows fascial gap with protruding abdominal contents
5.) Management - majority managed conservatively
- surgical: suture repair, open/laparoscopic mesh repair
- recurrence rates are high and chronic pain is common
Hiatal Hernia
What is it?
Classification
Clinical Features
Investigations
Management
1.) What is it? - protrusion of an organ from abdominal cavity into the thorax via oesophageal hiatus
- usually the stomach but can also be bowel or colon
- risk factors: age, pregnancy, obesity, ascites
2.) Classification
- sliding (95%): contents slides upwards through hiatus (Z line above diaphragm)
- rolling: ‘bubble’ of stomach in thorax (true hernia), higher risk of strangulation and ischaemia
3.) Clinical Features
- GORDs sx, hiccups, palpitations, dysphagia
- N/V, weight loss, bleeding/anaemia
4.) Investigations - OGD (gold), CT/MRI (incidentally)
- OGD: upwards displacement of the gastro-oesophageal junction (GOJ)
- barium swallow
5.) Management
- conservative: PPI, lifestyle modification (weight loss)
- surgery is rarely indicated (fundoplication): nutritional failure (gastric outlet obstruction), ‘rolling’ hernias, risk of volvulus/strangulation
- complications of surgery: bloating, recurrence, fundal necrosis, dysphagia, dumping syndrome
