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2025 Part Twos > Groin hernias > Flashcards

Groin hernias Flashcards

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1
Q

Give a differential diagnosis for “groin lump” under the following subheadings:
- subcutaneous lesions/soft tissue
- above the inguinal ligament
- below the inguinal ligament

A

Subcutaneous lesions/ Soft Tissue
- Sebaceous cyst
- Lipoma
- Sarcoma

Above the Inguinal Ligament
- Infectious/Inflammatory
- Lymph node/ Adenitis
- Psoas abscess
- Urological
- Undescended testes
- Hydrocele (congenital, infantile)
- Renal transplant
- Hernia
- Cord lipoma
- Inguinal (indirect, direct)

Below the inguinal Ligament
- Hernia - Femoral
- Vascular - Femoral aneurysm/ pseudoaneurysm
- Saphena-varix

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2
Q

What classification system can be used for groin hernias?

A

Nyhus classification

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3
Q

What are the components of the nyhus classification?

A

Type I = indirect hernia without dilatation of the deep ring (& posterior inguinal wall intact) ® e.g. paediatric hernia

Type II = indirect hernia with dilatation of the deep ring (& posterior inguinal wall intact)

Type III = posterior wall defects

  • Type IIIa – Direct hernia with post wall defect
  • Type IIIb – Indirect hernia with post wall defect (massive scrotal, sliding)
  • Type IIIc – Femoral hernia

Type IV = recurrent hernias

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4
Q

What is the male to female ratio for inguinal hernias?

A

10:1

Males are more commonly affected than females.

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5
Q

What is the prevalence of inguinal hernias in men?

A

3%

This statistic indicates how common inguinal hernias are among the male population.

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6
Q

Which type of hernia is more common, indirect or direct?

A

Indirect hernias are more common than direct hernias at a ratio of 2:1

This highlights the frequency of indirect hernias compared to direct ones.

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7
Q

Are direct hernias common in women?

A

No, direct hernias are rare in women

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8
Q

Do direct hernias occur in children?

A

No, direct hernias do not occur in children

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9
Q

On which side are inguinal hernias more common?

A

Right side

This is attributed to the slower descent of the testis and the blocking effect of the sigmoid colon.

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10
Q

What causes the higher prevalence of right-sided inguinal hernias?

A

Slower descent of the testis and delayed obliteration of processus vaginalis, and the blocking effect of the sigmoid colon on the left side

These anatomical factors contribute to the greater incidence of hernias on the right side.

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11
Q

Describe the aetiology of inguinal hernias under the subgroups “congenital causes” and “acquired causes”.

A

Congenital
- Male – Patent processus vaginalis
- Connective tissue disorders (Marfan’s, Ehler-Danlos syndr, Down’s syndr)

Acquired
- ↑ IAP – Obesity, cough, pregnancy, constipation, ascites, BPH
- Systemic – ­ Age, smoker, malnutrition, steroids

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12
Q

Describe Bubonocele and Funicular inguinal hernia sacs

A

Classified according to the length of the hernia

Bubonocele – Sac confined to inguinal ligament

Funicular – Sac extends through the superficial ring but not into the scrotum/ labia majora

ا
Complete/ scrotal/ inguinoscrotal – Sac extends into the scrotum/ labia

 

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13
Q

Give six sub-classifications of inguinal hernias

A

Direct inguinal hernias
- bubonoceles
- funicular inguinal hernias
-complete inguinoscrotal hernias
Indirect
Mixed

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14
Q
A
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15
Q

What is the inguinal canal?

A

The inguinal canal passes through the abdominal wall between the deep/internal and superficial/external rings.

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16
Q

What structures pass through the inguinal canal?

A

The inguinal canal is the passage for:
* ilioinguinal nerve
* spermatic cord (in males) or round ligament of the uterus (in females)

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17
Q

What causes the weakness in the inguinal canal leading to hernias?

A

Causes of weakness include:
* Patent processus vaginalis
* Failure of normal mechanisms that maintain integrity of the inguinal canal

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18
Q

What are the shutter mechanisms in the context of the inguinal canal?

A

Shutter mechanisms refer to the obliquity of the canal and the narrowing of the deep ring upon straining.

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19
Q

What happens when the rings of the inguinal canal are stretched?

A

Stretching of the rings can lead to reduced obliquity, allowing the rings to almost overlie each other.

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20
Q

What is an Indirect Inguinal Hernia (IIH)?

A

An Indirect Inguinal Hernia (IIH) is characterized by a hernia sac that is a patent processus vaginalis.

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21
Q

Where does the hernia sac in an Indirect Inguinal Hernia lie?

A

The hernia sac lies in front of the spermatic cord and is enclosed by the coverings of the cord.

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22
Q

What leads to the formation of a hernia sac in Indirect Inguinal Hernia?

A

The failure of the processus vaginalis to become completely obliterated leads to the formation of a hernia sac.

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23
Q

What is the neck of the Indirect Inguinal Hernia?

A

The neck of the Indirect Inguinal Hernia is the deep inguinal ring, which is lateral to the inferior epigastric vessels.

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24
Q

True or False: An Indirect Inguinal Hernia is always congenital.

A

False. Although the sac is congenital, herniation may not occur until later in life.

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25
What is a 'Lipoma of the cord'?
A 'Lipoma of the cord' is the protrusion of preperitoneal fat through the inguinal ring into the spermatic cord.
26
What is a Direct Inguinal Hernia (DIH)?
Protrudes directly through posterior wall of inguinal canal, medial to inferior epigastrics and deep ring.
27
Where does a Direct Inguinal Hernia occur?
At Hesselbach’s triangle, where transversalis fascia is not supported by conjoint tendon.
28
What causes a Direct Inguinal Hernia?
Acquired structural weakness of transversalis fascia and inguinal canal, associated with poor abdominal musculature.
29
On which side is a Direct Inguinal Hernia more common after an open appendicectomy?
Right side.
30
What nerve damage is associated with Direct Inguinal Hernia post-appendicectomy?
Damage to iliohypogastric and ilioinguinal nerves.
31
What is the typical neck size of a Direct Inguinal Hernia compared to its body?
Neck is usually larger than the body.
32
Is strangulation common in Direct Inguinal Hernia?
Rare.
33
What is a pantaloon hernia?
A 'double' hernia where inferior epigastric vessels straddle the hernia.
34
What is a Sliding Hernia?
A hernia that can contain retroperitoneal organs forming part of the wall of the hernia sac.
35
In which gender are Sliding Hernias nearly always found?
Males.
36
What types of organs can be contained in a Sliding Hernia?
* Bladder * Adnexa * Sigmoid colon * Caecum
37
On which side is a Sliding Hernia more common?
Left side (containing sigmoid).
38
How may inguinal hernias present?
Inguinal hernias may present as: * Asymptomatic * Symptomatic
39
What are common symptoms of symptomatic inguinal hernias?
Common symptoms include: * Groin pain * Groin lump
40
What is the typical onset of groin pain in inguinal hernias?
Typical onset occurs upon ↑ IAP (due to stretching of tissues of the inguinal canal)
41
What is a potential radiation of pain associated with inguinal hernias?
Pain may radiate into the scrotum due to pressure on the spermatic cord
42
How does groin pain vary throughout the day?
Pain ↑ during the day and decreases at night when supine
43
What may precipitate a groin lump in inguinal hernias?
A groin lump may be precipitated by ↑ IAP
44
What happens to a groin lump when lying down or resting?
The lump may reduce upon lying down/rest
45
What are the complications associated with inguinal hernias?
Complications include incarceration or strangulation
46
What factors suggest bowel compromise in inguinal hernias?
Factors suggesting bowel compromise include: * ↑ WCC * Peritonism * Sac containing dark/bloody fluid
47
What should be included in the examination of the groin area?
Prostate history, abdominal exam, testicular exam, PR
48
What characterizes direct hernias?
A diffuse bulge at the medial end of the inguinal canal, often disappears when the patient lies down (reducible)
49
What are the characteristics of indirect hernias?
Protrudes along the inguinal canal towards the scrotum/labia, may not reduce easily ## Footnote Indirect hernias are the most common type of inguinal hernia.
50
How can inguinoscrotal hernias be classified?
Almost always indirect ## Footnote Iinguinoscrotal hernias extend into the scrotum in males or labia in females.
51
What is the method to distinguish between direct and indirect hernias?
Reduce hernia with gentle upward and lateral pushing, apply firm pressure over deep ring with two fingers, ask patient to cough ## Footnote The response to coughing can indicate the type of hernia based on how it behaves under pressure.
52
What happens to an indirect inguinal hernia during the cough test?
Hernia is controlled ## Footnote This indicates that the hernia is reducible and does not push against the fingers applied to the deep ring.
53
What happens to a direct inguinal hernia during the cough test?
Hernia felt medial to finger pressure ## Footnote This suggests that the hernia is not easily reducible and is located in a different area compared to an indirect hernia.
54
Is it clinically possible to reliably distinguish between direct and indirect hernias?
No ## Footnote Clinically, it is often challenging to differentiate between the two types of hernias based solely on physical examination.
55
What imaging study can be indicated for groin pain with clinically insignificant hernia?
Ultrasound, but beware false positives based on cord lipomas within the inguinal canal
56
When is a CT scan indicated in the context of inguinal hernias?
Post hernia surgery groin pain, for recurrence, missed hernia, or other pathology
57
What is the definition of a femoral hernia?
Abnormal protrusion of intra-abdominal contents through the femoral ring, into the femoral canal
58
How common are femoral hernias compared to inguinal hernias?
Less common than inguinal hernia (1:20) and is the 3rd commonest type of primary hernia ## Footnote This means that for every 20 inguinal hernias, there is approximately 1 femoral hernia.
59
What is the male to female ratio for femoral hernias?
F > M - 3:1
60
Which side is femoral hernia more common on?
More common on the right-hand side (2:1)
61
What is the commonest site of Richter’s hernia?
Commonest site of Richter’s hernia is the femoral canal
62
What is the rate of emergency presentations for femoral hernias?
High rate of emergency presentations with incarceration or strangulation ## Footnote This indicates that femoral hernias often present with complications that require urgent medical attention.
63
What are the predisposing factors for acquiring a femoral hernia?
Localised weakness at femoral ring and increased intra-abdominal pressure ## Footnote Factors include age, female gender, pregnancy, chronic cough, straining/constipation, weight loss, and ascites.
64
What does the femoral canal contain?
Contains fat, lymphatics, and lymph nodes of Cloquet ## Footnote The femoral canal is a key anatomical area in the groin where femoral hernias occur.
65
What structures define the femoral ring? (ant/post/med/lat)
Ant = Inguinal ligament; Post = Pectineal ligament; Med = Lacunar ligament; Lat = Femoral vein ## Footnote These ligaments and vein surround the femoral ring and are important anatomical landmarks.
66
What happens to the transversalis fascia in femoral hernias?
It is disrupted, allowing the peritoneal sac and contents to pass through the femoral ring into the femoral canal ## Footnote This disruption is a key pathological event in the formation of a femoral hernia.
67
In which direction does the fundus of a femoral hernia typically move?
Downward through the femoral canal, then forward through the fossa ovalis, and then upwards in the loose areolar tissue of the upper thigh ## Footnote This movement pattern is important for understanding the progression of a femoral hernia.
68
How is a femoral hernia reduced?
Apply pressure in the reverse order of its movement ## Footnote This technique is important in the management of a femoral hernia.
69
Why is the femoral ring wider in women?
Because the iliopubic tract inserts into Cooper’s ligament ## Footnote This anatomical difference may contribute to the higher prevalence of femoral hernias in females.
70
What are the two subtypes/classifications of femoral hernias
Classical type: Protrudes through the femoral canal Prevascular type: Protrudes under the inguinal lig in front of the femoral a & v, Have a wide neck and a flattened wide sac which buldges downwards, Difficult to repair.
71
72
What are common symptoms of femoral hernias?
Groin pain and groin lump
73
Where is the neck of a femoral hernia located?
Below the medial end of the inguinal ligament ## Footnote This is in contrast to inguinal hernias, which have their neck above the inguinal ligament.
74
What is the fundus location in a femoral hernia?
In the region of the saphenous opening ## Footnote This anatomical detail can help differentiate it from other conditions.
75
What are the potential complications of femoral hernias?
Pain, incarceration, obstruction, strangulation
76
How do femoral hernias and inguinal hernias differ in presentation?
Femoral hernias bulge the groin crease out, while inguinal hernias accentuate the groin crease
77
What is a notable characteristic of femoral hernias regarding symptoms?
They may be asymptomatic until incarcerated or strangulated ## Footnote Even then, pain may be felt more in the abdomen than the femoral area.
78
What is the primary method for diagnosing femoral hernias?
Clinical diagnosis ## Footnote Radiology can be used when the diagnosis is unclear.
79
What imaging techniques can be used for further investigation of femoral hernias?
Ultrasound (US) and Computed Tomography (CT)
80
True or False: Femoral hernias can be fully reduced with manipulation.
Rarely true ## Footnote Most femoral hernias are not reducible, especially if incarcerated.

2025 Part Twos (23 decks)

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