Hernias - femoral and inguinal

Question 1

Anatomy of direct vs indirect inguinal hernia - vessels

Answer 1

INDIRECT = lateral = lateral thinking is indirect thinking

Question 2

Anatomy of inguinal canal

Answer 2

Question 3

What is a hernia?

Answer 3

• Internal part of the body pushes through weakness in muscle/surrounding tissue
• This muscle and tissue usually creates the wall of the cavity where these contents usually reside

Question 4

How does hiatus hernia present?

Answer 4

• Reflux
• Dysphagia
• Belching
• Chest pain
• N+V

These last symptoms come later if obstruction is caused

Question 5

Presentation of hernias in general

Answer 5

• Visible bulge - bulges when coughing, straining, dissapears when lay down
• Heaviness/pressure
• Pain
• Burning/aching
• Swollen scrotum
• Difficulty with activities - raised IAP worsens pain
• Strangulation - severe pain, N+V

Question 6

Natural history of hernias

Answer 6

• Stable
• Then increase in size, esp when in areas caused by increased IAP
• Become irreducible and incarcerated
• Then strangulated
• Can cause bowel obstruction

Question 7

Surgical options (general) for hernias and material options

Answer 7

• Open or laparascopic with mesh repair
• Reduce hernia and suture femoral ring narrower
• Mesh options inc polypropylene, polyester, composite, biological, absorbable, titanium

Question 8

Differentials for groin lump

Answer 8

• Inguinal hernia
• Femoral hernia
• Inguinal lymphadenopathy
• Femoral artery aneurysm
• Femoral artery pseudoaneurysm
• Ectopic/undescended testes
• Saphena varix - dilation of saphenous vein at junction of femoral vein
• Psoas abscess

Question 9

Neck of swelling location for inguinal vs femoral hernia

Answer 9

• Superior and medial to pubic tubercle - inguinal
• Inferior and lateral - femoral

Femoral makes you IL - more likely to be strangulated

Question 10

Direct vs indirect hernia

Answer 10

• Direct - passes into inguinal canal directly through weakness in posterior canal known as Hesselbachs triangle
• Indirect - enters canal via deep inguinal ring

Question 11

Hesselbachs triangle

Answer 11

DRAW THIS

Question 12

RF inguinal hernia

Answer 12

• Male
• Increasing age
• Obesity
• Raised intra-abdominal pressure - coughing, heavy lifting, chronic constipation

Question 13

When examining groin lump, what to check?

Answer 13

• Size
• Cough impulse
• Location - inguinal vs femoral
• Reducible?
• Enters scrotum - distinguishable from testes?

Question 14

Examining direct vs indirect inguinal hernia

Answer 14

• Theoretically, if reduce hernia and cover deep inguinal ring
• If comes back out - direct
• If does not - indirect

BUT often this is unreliable, need surgery to assess

Question 15

Investigations for inguinal hernia

Answer 15

• Only needed if uncertain and need to rule out other pathology using USS
• If sure, don’t need imaging
• CT needed if strangulation/obstructive features

Question 16

Management inguinal hernias

Answer 16

• Any symptomatic patient should be offered surgery
• If strangulation - need urgent surgical exploration

Question 17

Emergency presentation of hernia

Answer 17

• Irreducible/incarcerated
• Bowel obstruction
• Strangulation -> bowel ischaemic

Question 18

Surgical options inguinal hernia

Answer 18

• Open mesh repair
• Laparascopic mesh repair - total extraperitoneal (TEP) or transabdominal pre-peritoneal (TAPP)

Question 19

Open mesh repair

Answer 19

• Preferred for primary inguinal hernias
• Under general, local or spinal anaesthesia
• Lichtenstein technique using mesh most commonly used (Bassini/Shouldice= no mesh)

Question 20

Laparascopic mesh repair

Answer 20

• Preferred in bilateral/recurrent hernias
• Also in primary unilateral for those at risk of chronic pain (young and active, previous chronic pain, predominant symptom of pain) or females (increased risk of femoral hernia)

Question 21

TEP vs TAPP laparascopic repair

Answer 21

• TAPP - pneumoperitoneum before accessing pre-peritoneal space by incising parietal peritoneum from inside
• TEP - Entire op within pre-peritoneal space, no entering peritoneal cavity, balloon dissector used to expand room

Question 22

Complications inguinal hernias

Answer 22

• Incarceration
• Strangulation
• Obstruction
• Haematoma/seroma formation post op
• Recurrence
• Damage to vas deferens or testicular vessels (affect fertilty)

Question 23

Femoral canal borders

Answer 23

Question 24

RF femoral hernia

Answer 24

• Female
• Pregnancy
• Raised intra-abdominal pressure
• Increasing age

Question 25

Femoral hernia investiagtions

Answer 25

• USS
• CT scan abdo pelvis

Question 26

Management femoral hernias

Answer 26

• All should be surgical ideally within 2 weeks of presentation due to risk of strangulation
• Reduce hernia and narrow femoral ring

Question 27

3 different surgical approaches to femoral hernia

Answer 27

• Low approach (Lockwood)
• High approach (McEvedy)
• Inguinal approach (Lotheissen)

Question 28

Low approach

Answer 28

• Incision is made below the inguinal ligament
• Advantage of not interfering with the inguinal structures
• But does result in limited space for access to the intraperitoneal space or the removal of any compromised small bowel

Question 29

High approach

Answer 29

• Incision is made above the inguinal ligament
• Allows access to the preperitoneal and intraperitoneal space via the lateral edge of the rectus sheath
• The main benefit is that the integrity of the posterior wall of the inguinal canal is not compromised
• Preferred technique in an emergency due to the easy access to compromised small bowel for any resection

Question 30

Inguinal approach

Answer 30

• Incision is similar to that for an open inguinal hernia repair
• Canal is entered via incising the external oblique aponeurosis
• Preperitoneal and intraperitoneal space can then be accessed via incising the transversalis fascia