Femoral + inguinal hernias

Question 1

What is the definition of a hernia?

Answer 1

A protrusion, bulge or projection of an organ or part of an organ through the body wall that normally contains it

Question 2

Are inguinal or femoral hernias more common?

Answer 2

Inguinal

Question 3

Which of femoral or inguinal hernias present with complications more frequently?

Answer 3

Femoral

Question 4

What is the prevalence of groin hernias in the US?

Answer 4

5-10 percent of the population

Question 5

What is the classical demographic/ethnic patient for hernias?

Answer 5

Old white male

Question 6

What is the lifetime risk of developing a groin hernia for men vs women?

Answer 6

25% vs 5%

Question 7

What is the peak age of presentation for groin hernias?

Answer 7

50-69 years for men

40-60 years for women

Question 8

Of groin hernias, what percentage are inguinal vs femoral?

Answer 8

96% are inguinal, 4% femoral

Question 9

Are direct or indirect hernias more common, and in women vs men?

Answer 9

Indirect are most common in both sexes

Question 10

What are some risk factors for the development of hernias?

Answer 10

Previous hernia

Older age, caucasian, male

Chronic cough

Chronic constipation

Abdominal wall injury

FHx

Smoking

Question 11

Is obesity a risk factor for developing hernias?

Answer 11

No

Large observational study from a Swedish hernia register involving 50,000 patients found lower incidence of hernia in obese patients

Question 12

What causes a congenital hernia in the male?

Answer 12

The processus vaginalus not closing correctly, as well as the internal ring not closing correctly

Question 13

When does a congenital hernia present?

Answer 13

Can be anywhere from early childhood to adulthood

Question 14

What is the aetiology of an acquired hernia?

Answer 14

Weakening or disruption of the fibromuscular tissues of the body wall allowing intra-abdominal contents to protrude through the acquired defect

Question 15

Is there any preference between left and right in indirect inguinal hernias?

Answer 15

Yes

Right is more common in both males and females

Thought to be due to the later descent of the right testicle, and in females by asymmetry of the female pelvis

Question 16

What is the origin of the hernia sac in relation to the inferior epigastric artery in indirect inguinal hernias?

Answer 16

Lateral to the artery

Question 17

What is the origin of the hernia sac in relation to the inferior epigastric artery in direct inguinal hernias?

Answer 17

Medial to the artery

Question 18

What is the name of the triangle of anatomical structures that are important in the consideration of hernias?

Answer 18

Hesselbach’s triangle

Question 19

What forms Hesselbach’s triangle?

Answer 19

Inguinal ligament inferiorly

Inferior epigastric vessels laterally

Rectus abdominus muscle medially

Question 20

Why do direct inguinal hernias occur?

Answer 20

Weakness in the floor of the inguinal canal

Secondary to connective tissue abnormalities in many cases, or weakness in abdo muscles due to chronic overstretching or injury

Question 21

Where do femoral hernias arise from?

Answer 21

Inferior to the inguinal ligament

Protrude through the femoral ring which is medial to the femoral sheath and lateral to the lacunar ligament

Question 22

What can cause a congenital femoral hernia?

Answer 22

There is no such thing, they are all acquired

Question 23

Are femoral hernias also more common in men?

Answer 23

No

More common in women

Question 24

What percentage of femoral hernias present as emergency cases with complications?

Answer 24

40%

Question 25

Which population is most likely to present with a hernia complication to ED?

Answer 25

Women Higher incidence of femoral hernias, and with inguinal the rings are smaller and everything is tighter in general

Question 26

What is the normal symptom that hernias will present with?

Answer 26

A heaviness or dull discomfort in the groin May or may not be associated with a visible bulge

Question 27

How does the groin discomfort associated with hernias change with time?

Answer 27

Becomes worse when intra-abdominal pressure is increased, such as with straining, lifting heavy weights, coughing, prolonged standing, etc Discomfort will be worse at the end of the day Resolves when the patient stops straining or lies down

Question 28

Can hernias present with moderate to severe pain?

Answer 28

Yes Indicates a complicated hernia however, and demands urgent investigation

Question 29

What is the most common finding on physical examination with hernias?

Answer 29

A bulge

Question 30

How can you detect a hernia on physical exam that is not grossly obvious?

Answer 30

Place the tip of the finger into the external inguinal ring and ask the patient to cough, the contents may come down to touch the fingertip

Question 31

How should you position the patient to best see a hernia?

Answer 31

Erect

Question 32

Can you assess for a cough impulse in a hernia with the patient standing?

Answer 32

Yes -- this is the correct technique Can be done supine as well though

Question 33

What can you do to identify a hernia on physical exam, when the hernia is not obvious (often won't be)?

Answer 33

Nothing Can't palpate into the inguinal canal, can't usually feel a cough impulse

Question 34

Which of the groin hernias are medial to the pubic tubercle, and which are lateral?

Answer 34

Femoral is lateral Inguinal is medial

Question 35

What is the approx sensitivity and specificity of the physical exam and history together for diagnosing groin hernias?

Answer 35

Sensitivity 75% Specificity 96%

Question 36

When do you perform imaging in diagnosing hernias?

Answer 36

When the type is not clear Identify an occult hernia To distinguish a hernia from another clinical entity And to identify complicated hernias

Question 37

What is peritoneography/herniography?

Answer 37

Contrast is injected into the peritoneum and radiographic imaging is performed Slightly more accurate but hardly ever done because ultrasound is very good and non-invasive and inexpensive

Question 38

Why is it particularly important to distinguish between inguinal and femoral hernias?

Answer 38

Because you can use watchful waiting for inguinal hernias, but femoral hernias pretty much always need to be operated on soon because they have a much higher chance of developing complications

Question 39

How do patients typically present when they have a complicated hernia?

Answer 39

Nausea/vomiting Abdominal distension Groin pain or mass Bowel obstruction

Question 40

What is the definitive management for any type of hernia?

Answer 40

Surgical repair

Question 41

Why do we use watchful waiting in the case of inguinal hernias, rather than just treat them before they become symptomatic?

Answer 41

Because two studies showed that there was no penalty in morbidity or mortality for delaying repair until symptoms develop

Question 42

What are the contraindications to mesh hernia repair?

Answer 42

Mainly stems from standard contraindications to anaesthetics Active infection prohibits the placement of foreign material into the body however

Question 43

What is an important complication of mesh hernia repair surgery?

Answer 43

Neuralgia

Question 44

What are some things you can do pre-operatively in mesh hernia repair to limit post-operative neuralgia?

Answer 44

Reduce post-operative pain with intensive pre and peri-op analgesia Choice and placement of mesh -- lighter mesh may have less inflammation Prophylactic neurectomy -- division of ilioinguinal nerve if it becomes entangled in the mesh Careful approach to the surgery