Inguinal Hernias

Question 1

What is an inguinal hernia?

Answer 1

It defined as an abnormal protrusion of abdominopelvic contents through the superficial ring into the groin

Question 2

What is the most common abdominal hernia classification?

Answer 2

Inguinal hernias

Question 3

Where is the inguinal ligament located?

Answer 3

It extends between the anterior superior iliac spine (ASIS) and the pubic tubercle (PT)

Question 4

Where is the inguinal canal located?

Answer 4

It runs above the inguinal ligament

Question 5

What is the function of the inguinal canal?

Answer 5

It provides a passageway between the peritoneal cavity and the external genitalia

Question 6

Where is the deep ring of the inguinal canal located?

Answer 6

It is located just above the mid-point of the inguinal ligament

Question 7

Where is the superficial ring of the inguinal canal located?

Answer 7

It is located just above and lateral to the pubic tubercle

Question 8

What are the two classifications of inguinal hernias?

Answer 8

Direct Inguinal Hernia

Indirect Inguinal Hernia

Question 9

What are direct inguinal hernias?

Answer 9

They are defined as the abnormal protrusion of abdominal contents direct through the Hesselbach’s triangle, due to a weakness in the posterior wall of the inguinal canal

The hernia enters the inguinal canal medial to the deep ring and exits via the superficial ring

Question 10

What are indirect inguinal hernias?

Answer 10

They are defined as the abnormal protrusion of abdominal contents, which enter the deep ring, pass along the length of the inguinal canal and exit via the superficial ring

Question 11

How do we differentiate between direct and indirect inguinal hernias?

Answer 11

We can reduce the hernia and then press on the deep inguinal ring

Question 12

What is the feature of indirect inguinal hernias on clinical examination? Explain

Answer 12

The groin lump will not reappear

This is due to the fact that its entry point is the deep inguinal ring

Question 13

What is the feature of direct inguinal hernias on clinical examination? Explain

Answer 13

The groin lump will reappear

This due to the fact that its entry point is Hesselbach’s triangle – not the deep inguinal ring

Question 14

What are the three risk factors of inguinal hernias?

Answer 14

Older Age > 70 Years Old

Male Gender

Low BMI

Question 15

What are the two clincial features of inguinal hernias?

Answer 15

Groin Lump

Dull Groin Pain

Question 16

Where are groin lumps associated with inguinal hernias located?

Answer 16

They are located superior and medial to the pubic tubercle

Question 17

In which two circumstances, are inguinal hernias reducible?

Answer 17

Pressure Application

Lying Down

Question 18

What are the four characteristic features of the groin pain associated with inguinal hernias?

Answer 18

Exacerbated by exercise

Exacerbated by coughing

Exacerbated by bending over

Exacertbated by standing for extended period

Question 19

How are inguinal hernias diagnosed?

Answer 19

Clinically

In most cases, there is not a requirement of futher investigations

Question 20

What investigation is used to diagnose inguinal hernias?

Answer 20

Ultrasound Scan

Question 21

How are ultrasound scans used to investigate inguinal hernias?

Answer 21

In cases of diagnostic uncertainty in order to exclude differential diagnoses of inguinal hernias – including enlarged lymph nodes, fatty lumps or vascular pathology

Question 22

When do we conduct management of inguinal hernias?

Answer 22

It is recommended that all medically fit patients should undergo surgical management, even in cases where individuals are asymptomatic

Question 23

What are the two surgical management options of inguinal hernias?

Answer 23

Open Mesh Repair

Laparoscopic Mesh Repair

Question 24

When is an open mesh repair used to manage inguinal hernias?

Answer 24

It is the first line management option used to treat unilateral inguinal hernias

Question 25

What is an open mesh repair?

Answer 25

It involves direct exploration of the inguinal canal via a groin incision, in which the hernia contents are reduced back into the abdominal cavity and a mesh is placed to strengthen the deep inguinal ring and posterior wall

Question 26

When should individuals return to non-mannual work following open mash repair?

Answer 26

> 2 - 3 weeks

Question 27

When is a laparoscopic mesh repair used to manage inguinal hernias?

Answer 27

It is the first line management option used to treat bilateral or recurrent inguinal hernias

Question 28

What is laparoscopic mesh repair?

Answer 28

It It involves laparoscopic exploration of the inguinal canal via a small abdominal incision, in which the hernia contents are reduced back into the abdominal cavity and a mesh is placed to strengthen the deep inguinal ring and posterior wall

Question 29

When should individuals return to non-mannual work following laproscopic mash repair?

Answer 29

> 1 - 2 weeks

Question 30

What are the five complications of inguinal hernias?

Answer 30

Incarcerated Inguinal Hernias

Strangulated Inguinal Hernias

Recurrent Inguinal Hernias

Groin Bruising

Chronic Groin Pain

Question 31

What are incancerated inguinal hernias?

Answer 31

They are defined as those that are irreducible, which means that their hernia content cannot be pushed back into their original position

Question 32

What are strangulated inguinal hernias?

Answer 32

They are defined as those that are irreducible, in which the hernia contents become compressed

This reduces blood flow to the herniated tissues – eventually leading to ischaemia and necrosis

Question 33

Strangulated inguinal hernias are deemed as a surgical emergency. Why?

Answer 33

Inguinal hernias are most commonly composed of small bowel

Therefore, strangulation can lead to bowel obstruction, perforation and necrosis

Question 34

Incarcerated and strangulated inguinal hernias are both irreducible. How do we differentiate between them?

Answer 34

Incarcerated hernias are painless

Strangulated hernias are painful

Question 35

What are the two signs that inguinal hernias are at risk of strangulation?

Answer 35

Inguinal hernias which become painful when previously asymptomatic

Inguinal hernias which are incarcerated

Question 36

What are the nine clinical features of strangulated inguinal hernias?

Answer 36

Fever > 38C

Nausea & Vomiting

Severe Groin Pain

Increased Groin Lump Size

Erythema of Groin Lump

Peritonitic Features

Abdominal Distension

Rectal Bleeding

Tachycardia

Question 37

What are the three investigations used to diagnose strangulated inguinal hernias?

Answer 37

Blood Tests

Erect Chest X-Ray (CXR)

Abdominal CT Scan

Question 38

What two blood test results indicate strangulated inguinal hernias?

Answer 38

Increased WCC Levels

Increased Lactate Levels

Question 39

How are erect CXRs used to investigate strangulated inguianl hernias?

Answer 39

They are used to identify bowel perforation, which is a complication of strangulated inguinal hernias

Question 40

How are abdominal CT scans used to investigate strangulated inguianl hernias?

Answer 40

They are used to identify bowel obstruction, which is a complication of strangulated inguinal hernias

Question 41

What is the management of strangulated inguinal hernias?

Answer 41

We call for an ambulance and arrange urgent secondary care assessment

In secondary care, the same surgical procedures used for elective inguinal hernias are used in an emergency setting - except there is an additional step of removing dead bowel contents

Question 42

Do we manually reduce strangulated inguinal hernias whilst waiting for surgery? Why?

Answer 42

No

This increases the risk of peritonitis