Inguinal Hernia

Question 1

def

Answer 1

abnormal protrusion of a peritoneal sac through a weakness in the inguinal region

Question 2

what types of inguinal hernias are there

Answer 2

indirect (60%)
direct (35%)
‘pantaloon’ (5%)

Question 3

where do direct hernias emerge from

Answer 3

emerge through hesselbachs triangle

• medially the lateral border of the rectus
• laterally the inferior epigastric vessels
• inferiorly the inguinal ligament

Question 4

how can hernias be described

Answer 4

reducible
irreducible (incarcerated)
strangulated

Question 5

def of direct inguinal hernia

Answer 5

protrusion of the hernial sac occurring directly through the transversalis fascia + posterior wall of the inguinal canal, medial to the inferior epigastric vessels

Question 6

def of indirect inguinal hernia

Answer 6

protrusion of the hernial sac, through a deep inguinal ring with coverings of the spermatic cord, following the path of the inguinal canal

Question 7

aetiology

Answer 7

1 congenital
-persistant processus vaginalis
2 acquired
-increased intra-abdominal pressure + muscle + transversalis fascia weakness

Question 8

associations/risk factors

Answer 8

1 male
2 increasing age
3 raised intra-abdominal pressure
-cough
-constipation
-bladder outflow obstruction

Question 9

epi

Answer 9

common
1 congenital indirect inguinal hernias - 4% of male births
2 acquired
-55-85yrs
-men:women is 9:1

Question 10

history

Answer 10

1 asymptomatic
2 lump or swelling in groin
3 pain or discomfort

Question 11

examination

Answer 11

1 groin lump which may extend to scrotum
2 may be cough impulse associated with hernia when standing
3 auscultation may reveal bowel sounds from within the hernia
4 irreducible if incarcerated
5 tender if strangulated

Question 12

how would inguinal + femoral hernias be distinguished

Answer 12

inguinal hernias emerge above + medial to the pubic tubercle

Question 13

investigations

Answer 13

if acute with painful irreducible hernia
1 bloods 
-FBC, UEs, CRP, clotting
-ABG may show bowel ischaemia within hernia (metabolic acidosis + high lactate)
2 imaging
-erect CXR + AXR in emergency
-USS for diagnosis + exclusion

Question 14

management

Answer 14

1 conservative
-if patient unfit for surgery, managed with an inguinal truss (a belt which stops the hernia protruding)
2 surgery
-elective repair for uncomplicated hernias
-mesh (lichtenstein) repair - most common
-laparoscopic mesh repair

Question 15

when is laparoscopic mesh repair commonly used

Answer 15

bilateral + recurrent hernias

Question 16

management of an emergency hernia

Answer 16

obstructed + strangulated hernia

laparotomy with bowel resection if gangrenous bowel present within hernia

Question 17

complications

Answer 17

incarceration
strangulation
bowel obstruction

Question 18

prognosis

Answer 18

slowly enlarge if not treated
strangulation risk of 0.3-3%PA
good prognosis with surgical mesh repair