Hernias / Groin swelling

Question 1

Direct (inguinal) hernia

Answer 1

• direct penetrate the abdominal wall
• indirect pass through the deep and superficial inguinal rings

Caused by a defect or weakness in the transversalis fascia area of the Hesselbach triangle (degeneration in the changes of the structure of the aponeurosis of trsnversalis fascia). Usually seen in adults, more common in males.

always acquired- degeneration and fatty changes. do not contain bowel- mainly preperitoneal fat, ocassionally blader.

posterior wall > inguinal canal > superficial ring.

Protrudes through the Hasselback triangle. Passes medial to the inferior epigastric artery, inferior to mesenteric artery.

Low risk of strangulation

Question 2

Indirect (inguinal) hernia

Answer 2

Caused by failure of the processus vaginalis to close leads to formation of an empty peritoneal sac lying in the inguinal canal- usually occurs in infants, more common in males. enter the inguinal canal lateral to the inferior epigastric vessels.

Passes through the deep inguinal ring along the inguinal cnaal into the scrotum, defect in fascia transversalis (posterior wall of the inguinal canal)

Protrudes through the inguinal ring and passes lateral to the inferior epigastric artery, laterally to the inferior mesenteric artery.

Question 3

Femoral hernia aetiology and pathophysiology

Answer 3

A section of the bowel / any part of the abdominal viscera passes into the femoral canal. The femoral canal is a potential space which can be occupied by herniated contents via the femoral ring.

Protrudes below the inguinal ligament, lateral to the pubic tubercle. more common in adult females. (more common in multiparous women- increased abdominal pressure in pregnancy)

High risk of strangulation.

Question 4

Femoral hernia clinical features

Answer 4

Lump within the groin
Mildly painful
Inferolateral to the pubic tubercle (inguinal hernias are superlateral to the pubic tubercle)
Non-reducible
Cough impulse is absent.

Question 5

Femoral hernia diagnosis

Answer 5

Ultrasound

differentials to exclude
lymphadenopathy
abscess
femoral artery aneurysm
hydrocele / varicocele
lipoma
inguinal hernia.

management:
surgical repair (risk of strangulation)
hernia support belts/trusses
laparotomy in an emergency.

Question 6

Inguinal hernia clinical features

Answer 6

Protrusion of abdominal or pelvic content through a dilated inguinal ring

Groin lump
Disappears on pressure / when the patient lies down
Discomfort and ache, worse with activity
Strangulation is rare.

Question 7

Inguinal hernia management

Answer 7

Treat medically fit pt even if asymptomatic
Hernia truss if not fit for surgery
Mesh repair

Do not return to work for 2-3 weeks following open repair
1-2 weeks after laparoscopic

complications

(early) bruising wound infection
(late) chronic pain, recurrence

Question 8

Inguinal hernia pathophysiology

Answer 8

A protrusion of all or part of the viscus through the wall of the abdominal or pelvic cavity, causing a visible or easily palpable bulge.

*male, elderly, family history, Ehler-Danlos

right-sided hernias are more common than left due to the descent of testis/ previous appendectomy.?

Question 9

Strangulated hernias

Answer 9

Acute onset of symptoms
Irreducible groin mass
Pain on groin/abdomen
Nausea and vomiting

Question 10

Inguinal hernia management

Answer 10

Conservative - weight loss, smoking cessation

Question 11

Classification of inguinal hernia

Answer 11

1. Direct
2. Indirect
3. Reducible (manual pressure allows the content to be returned to original compartment)
4. Irreducible- bowel is incarcerated, hernia content cannot be reduced to the peritoneal cavity. blood supply not compromised.
5. stagnated- blood supply to the hernia has been compromised- ischaemia, gangrene, perforation.

Question 12

Why are indirect hernias more prone to strangulation than direct hernias?

Answer 12

Direct hernia is usually due to widespread weakness of inguinal floor tissues.

Indirect hernias pass through a tight internal ring. Sequestration of fluid in the lumen with herniated bowel. Impairment of lymphatic and venous drainage- aggreates= impaired arterial supply.

Question 13

How to test for an indirect hernia

Answer 13

Apply finger pressure over the deep inguinal ring (just above midpoint of the inguinal ligament) here you can control an indirect hernia as it has been reduced.

if when you press thedeep inguinal ring the hernia still protrudes, this means the hernia is emerging via a defect in the posterior wall, medial to this point and is, therefore, a direct hernia.

Question 14

How to test for direct hernia

Answer 14

Instruct the patient to cough = a buldge should appear medial to the point of finger pressure.

Question 15

Investigation for hernias

Answer 15

If doubt / complex case:
USS groin
CT/MRI groin
Herniography of groin

Strangulated hernia: FBC, U+E’s, LFT, CRP, lactate, urinalysis, group and save, CT, USS

Question 16

Clinical presentation of strangulated hernias

Answer 16

Acute and require immediate treatment- what?

Pain 
groin discomfort
irreducible groin mass
tender distended abdomen with lack of bowel sounds
abdominal pain
nausea/vomiting
constipation.

Question 17

Hernia managemenet

Answer 17

Mild/asymptomatic= conservative

Symtomatic= referral for 2’ care

watchful waiting if the risk of bowel obstruction and strangulation is low= 6 months regular clinical follow up.

weight loss
stop smoking

surgical : mesh

Question 18

differential diagnosis of inguinal hernia

Answer 18

1. femoral hernia (anatomically inferior and lateral to pubic tubercle)
2. saphena varix (protrusion of saphenous vein, always reducible, disappears when patient lies down)
3. femoral aneurysm (pulsatile, continous murmur, weak peripheral pulse)
4. lymphadenopathy (firm and round in texture, lower limb infection, abrasion)

Question 19

Inguinal hernia- congenital / acquired.

Answer 19

1. increased intra abdominal pressure (chronic cough, constipation, heavy lifting, advanced age, obesity)
2. weakenss in abdominal muscles.

Congenital: processus vaginalis fails to undergo regression

Acquired: degeneration / fatty changes in the tissue of inguinal floor. (usually direct)

Question 20

Define the following terms:
Reducible
Irreducible
Obstructed
Strangulated

Answer 20

Reducible – when the contents of the hernia can be manipulated back into its original position through the defect from which it emerges

Incarcerated hernia (irreducible) – the hernia is compressed by the defect causing it to be irreducible (i.e. unable to be pushed back into its original position)

Obstructed hernia – refers mainly to hernias containing bowel, where the contents of the hernia are compressed to the extent that the bowel lumen is no longer patent and causes bowel obstruction

Strangulated hernia – the compression around the hernia prevents blood flow into the hernial contents causing ischaemia to the tissues and pain

Question 21

Anatomy of the inguinal canal

Answer 21

https://geekymedics.com/wp-content/uploads/2016/02/IMG_0045.jpg

This functions to provide a passageway for abdominal content to exit the abdomen.

• males= spermatic cord to facilitate ejaculation
• females= round ligament

the canal carries the sensory ilioinguinal nerve.

entry point is the deep inguinal ring
exit point is the superificial inguinal ring.

Deep inguinal ring: just above the midpoint of the inguinal ligament
Superficial inguinal ring: just above and medial to the pubic tubercle

Question 22

direct inguinal hernia

Answer 22

direct: weakness in the posterior wall of the inguinal canal. fatty tissue/bowel is forced through and enters the inguinal canal.
* does not go through the deep ring

protrudes via a defect in the posterior wall, through the superficial ring.

https://geekymedics.com/wp-content/uploads/2016/02/IMG_0047.jpg

Question 23

indirect inguinal hernia

Answer 23

does not pierce the posterior wall
abdominal content passes through the deep inguinal ring
through the inguinal canal
exits via the superficial ring.

Question 24

NAVY VAN

Answer 24

Passes beneath the inguinal ligament, travelling to upper leg.

Femoral artery, femoral vein, femoral nerve.

NAVY VAN
Nerve, artery, vein groin crease, vein, artery, nerve.

Question 25

Femoral canal

Answer 25

The femoral canal lies medial to the femoral vein.

Allows expansion of the femoral vein to increase venous return.

The femoral canal can contain a small amount of fatty tissue. // lymph node (Cloquet)

can be a defect through which Abdo content protrudes.

high risk of strangulation and obstruction

https://geekymedics.com/hernias-explained/

Question 26

incarcerated hernia
obstructed hernia
strangulated hernia

Answer 26

incarcerated- irreducible but not necessarily strangulated or obstructed. (adult urgent repair, infant repair within 2 weeks)

obstructed- narrow lumen, preventing the passage of faeces

strangulated- ischaemic, cut off the blood supply. will be obstructed if contain bowel.

Question 27

borders of the inguinal canal

Answer 27

floor- inguinal ligamnet, lacunar ligament

celing- transversusabdominus, internal oblique

anterior wall- external oblique

posterior wall- transversalis fascia

medial opening- superfiical ring

lateral opening- deep inguinal ring

Question 28

content of the inguinal canal

Answer 28

vas arteries- testicular, artery to vas, cremasteric

veins- pampiniform plexus

lymphatic vessels- testis drain into the para-aortic lymph nodes

nerves- genital branch of genitofemoral, sympathetic nerves accomponying arteries, ilioinguinal cnerve

Question 29

clinical presentation of hernia

Answer 29

lump/fullness in groin or scrotum
aching
lump which increases in size when abdominal pressure increases

if incarcerated= cannot be reduced, increase in size

obstructed= relative/absoloute constipation, nausea, vomiting

strangulation= unwell patient, firm, painful and tender, erythema overlying skin

Question 30

the differential diagnosis for hernia

Answer 30

constipation
tumor
lipoma
groin haematoma
speramtocele
undescended testes
varicocele

Question 31

hernia investigations

Answer 31

symptoms- clinical
groin ultrasound if diagnostic uncertainty
CT if an obese patient

Question 32

hernia management

Answer 32

if no features of strangulation, obstruction or incarceration

• infant/young boy: refer urgently to paeds surgeon within 2 week
• older boy/men: routine surgery

features of incarceration but no strangulation or obstruction

• infant/young boy refer urgently to paeds surgeon
• older boys/men urgent surgical repair

if features of strangulation or obstruction
admit immediately.

prophylactic antibiotics

Question 33

DIRECT vs INDIRECT

Answer 33

DIRECT hernia protrudes through the hesselback triangle due to a weakness in the transversals fascia
(goes straight through the abdominal wall)

INDIRECT hernia protrudes through the inguinal ring (through the deep and superficial ring) due to a failure of the processes vaginalis to close

DIRECT passess medial to the inferior epigastric artery and INDIRECT possess lateral to the epigastric artery.

both are a low risk of strangulation and more common in males.

Question 34

femoral

Answer 34

section of bowel/part of the abdominal viscera possess into the femoral canal via femoral ring

lump, mildly painful
inferolateral to pubic tubercle
non reducible
cough impulse is absent

ultrasound

! incarceration
! strangulation
! bowel obstruction
! bowel ischaemia

Question 35

inguinal

Answer 35

goin lump
superior and medial to pubic tubercle
reduccible on pressure or lying down
worse with activity
discomfort

treat even if asymptomatic
mesh repair