Define ‘hernia’
Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position
Define reducible hernia
Sac can return to the abdominal cavity either spontaneously or with manipulation
Define irreducible
Sac cannot be reduced despite pressure or manipulation
Define strangulated
Blood supply of contents is compromised due to pressure at the neck of the hernia
Define sliding hernia
Part of the sac is formed by bowel (e.g. caecum or sigmoid): take care when excising the sac
Define Mayday’s hernia
Herniating double loop of bowel - strangulated portion may reside as a single loop inside the abdomen
Define Littre’s hernia
Hernial sac containing strangulated Meckel’s diverticulum
Define Amyand’s hernia
Inguinal hernia containing strangulated appendix
Define Richter’s hernia
Only part of circumference of bowel is within sack - most commonly seen with femoral hernias and can strangulate without obstructing
Define a pantaloon hernia
Simultaneous direct and indirect hernia
Define herniotomy
Excision of hernial sac
Define herniorrhaphy
Suture repair of hernial defect
Define hernioplasty
Mesh repair of hernial defect
What is the epidemiology of inguinal hernias?
- 3% adults will need hernioplasty
- ~4% male neonates have hernia (increased in prems)
- M>F 9:1 (due to descent of testes)
- Majority present in 50s
Which side is more common for inguinal hernias?
Commoner on R (?damage to ilioinguinal nerve at appendicectomy leading to muscle weakness) but 5% are bilateral
How commonly do inguinal hernias present as an obstruction/strangulation?
8-15%
What are the aetiological factors in inguinal hernia?
- Congenital: patent processus vaginalis
- Should obliterate after descent of the testes
- If it doesn’t can fill with fluid (hydrocele) or bowel/omentum (indirect hernia)
- Acquired: things which increased IAP:
- Chronic cough: COPD, asthma
- Prostatism
- Constipation
- Severe muscular effort e.g. heavy lifting
- Previous incision/reapir
- Ascites/obesity
- Appendicectomy
What are the defining features of direct and indirect inguinal hernias?
- Indirect
- 80% - commoner in the young
- Congenital patent processus vaginalis
- Emerge through the deep ring
- Same 3 coverings as cord and descend into the scrotum
- Can strangulate
- Direct
- 20% - commoner in the elderly
- Acquired
- Emerge through Hesselbach’s triangle
- Can acquire internal and external spermatic fascia
- Rarely descend into scrotum
- Rarely strangulate
What investigations should be done for an inguinal hernia?
Just an ultrasound, if in doubt
What are the clinical features of inguinal hernias in children?
- Lump in groin which may descend into scrotum
- Exacerbated by crying
- Commonly obstruct
What are the clinical features of inguinal hernias in adults?
- Lump in groin, exacerbated by straining/coughing
- May be clear precipitating event e.g. heavy lifting
- Dragging pain radiating to groin
- May present with obstruction/strangulation
What are the non surgical management options for inguinal hernias?
- Reduce risk factors e.g. cough, constipation
- Lose weight
- Truss
What are the surgical management options for inguinal hernias?
- Tension free mesh (e.g. Lichtenstein repair) between than suture repair (e.g. Shouldice repair)
- Recurrence <2% vs 10%
- Open approach can be under LA or GA
- Lap approach allows bilateral repair and improved cosmesis - also preferred if recurrent
- Primary unilateral repairs should be open (NICE)
- Children only require sac excision (herniotomy)
What are the complications of an inguinal hernia repair?
- Early
- Haematoma/seroma formation (10%)
- Intra-abdominal injury (lap)
- Infection: 1%
- Urinary retention
- Late
- Recurrence (<2%)
- Ischaemic orchitis: 0.5%
- Chronic groin pain/paraesthesia 5%
