Inguinal hernia

Karen Brasel, MD, MPH

Medical College of Wisconsin
 Mr. Roberts

Your patient in the office is a 28 year-old male

with a several day history of groin and
testicular pain.
 History

What other points of the history

do you want to know?
 History, Mr. Roberts
Consider the Following
Characterization of Pertinent PMH, ROS,
symptoms MEDS.
Temporal sequence Relevant family hx.
Alleviating / Associated signs and
Exacerbating factors: symptoms
 History, Mr. Roberts

Characterization of Symptoms: R Pertinent PMH: none

groin pain began at work after ROS: no dysuria
lifting 50 lb boxes. Abrupt onset,
now constant. MEDS: Tylenol
Alleviating / Exacerbating factors: SH: married, single partner.
Improved with lying down, worse Construction worker
with standing Relevant Family Hx.
Associated signs/symptoms: Eating Noncontributory
normally, no diarrhea or
constipation
What is your Differential
Diagnosis?
 Differential Diagnosis
Based on History and Presentation
Inguinal hernia
Testicular torsion
Epididymitis
Prostatitis
Muscle strain
 Physical Examination

What would you look for?

 Physical Examination, Mr. Roberts

Vital Signs: T 98.6, pulse 82, BP 132/76, RR 16

Appearance: healthy, uncomfortable

Chest: clear Rectal: normal tone, prostate

nontender
CV: RRR GU: testes descended,
nontender, normal position.
Abd: soft, nontender, normoactive Epididymis and inguinal canal
bowel sounds tender; bulge in R. inguinal
canal

Remaining Examination findings non-contributory

Would you like to revise your
Differential Diagnosis?
 Revised Differential

Inguinal hernia
Epididymitis
 Laboratory

What would you obtain?

 Labs ordered, Mr. Roberts

CBC
 Lab Results, Discussion

In a young, otherwise healthy patient in whom the

diagnosis can be made clinically, laboratory
studies are unnecessary.
An elevated white blood cell count might help you
make the distinction between epididymitis, an
infectious process, and an incarcerated inguinal
hernia.
However, it can be normal in epididymitis and
might be elevated in an incarcerated hernia due to
compromised or ischemic bowel within the hernia
sac
 Lab Results, Discussion

Routine preoperative laboratory studies are costly,

and false positives occur up to 10% of the time.
Selective ordering should be the routine.
History and physical are the best way to screen for
coagulation abnormalities.
Hematocrits should be obtained only for
Patients who are at risk for abnormalities.
Procedures with significant blood loss.
Patients with considerable comorbidity.
 Lab Results, Discussion
Guidelines for obtaining routine chemistries
BUN/Creatinine, potassium
Renal disease
Diabetics
>60 years old
CV disease
Diuretics, digoxin
corticosteroids
Glucose-
>60 years old
diabetics
corticosteroids
What would you do now?
 Interventions at this point?

Re-examine the patient

Obtain diagnostic studies
Schedule patient for surgery
 Studies

What further studies would you

want at this time?
 Studies, Mr. Roberts

An ultrasound can be helpful if the diagnosis of

a hernia is truly in doubt. However, often a
careful re-examination of the patient with
specific attention paid to examining the
epididymis separately from the inguinal canal
will make an ultrasound unnecessary.
 Revised Differential Diagnosis

Inguinal hernia, incarcerated

What next?
 What next?

1. Immediate OR
2. Attempt at reduction
 What next?

Reduction should be attempted in the patient with an

incarcerated hernia. This allows an operation to be
performed electively rather than emergently, and
allows choice of anesthesia and operative approach.

Reduction is best accomplished by elongating the neck

of the hernia sac while applying pressure to reduce the
hernia. The patient should be given adequate sedation
and analgesia, and placed in Trendelenberg position.
 Management

Discussion of patient response to management

recommendations:

If reduction is unsuccessful, the patient should be

prepared for urgent operation.
 Management

Although symptomatic hernias should all be repaired

operatively, it is not clear that all small, asymptomatic
hernias should be fixed.
Age, comorbid conditions, patient activity and patient
preference should be considered.
Current trials are studying the natural history of these
small hernias.
 Management

Hernias do not always present as a groin bulge, and

not all patients will complain of groin pain. Consider
the following:
An 80-year old woman who resides at a nursing
home has lost several pounds over the last 3 months.
For the last 3 days she has not been able to eat
anything, has been vomiting, and was found in bed
this morning confused and quite ill. Her abdominal
exam is fairly unremarkable without any previous
scars.
 Management

This woman likely has an obturator or possibly

a femoral hernia.
Obesity can make examination of the groin
difficult.
Her management is much different than the
previous case.
 Management

Plain films of the abdomen

should also be obtained, as
the patient may have a bowel
obstruction due to small
bowel incarceration in the
hernia.
How might this change
your management?
 Discussion

The majority of hernias should be repaired when discovered,

as the mortality increases 9 to 10 fold with emergent compared
to elective repair. Elective repair done with an open approach
can be performed under local, spinal, or general anesthesia. It
can also be done laparoscopically, which requires general
anesthesia.
In addition to the elective or urgent/emergent nature or the
repair, anesthetic choice, patient preference, and primary or
recurrent nature of the hernia factor into the decision regarding
operative approach. A laparoscopic approach, or an open
preperitoneal approach, is best for recurrent or bilateral
hernias. For unilateral primary groin hernias, the approaches
have similar recurrence rates, similar disability times, and
similar costs.
 Discussion

Indirect hernia: contents protrude through the indirect inguinal ring

through a patent processus vaginalis into the inguinal canal. In
men, they follow the spermatic cord and may present as scrotal
swelling, while in females they may present as labial swelling.
Direct hernia: contents protrude through Hesselbachs triangle
medial to the inferior epigastric vessels.
Femoral hernia: contents protrude through the femoral canal,
bounded by the inguinal ligament superiorly, the femoral vein
laterally, and the pyriformis and pubic ramus medially. Unlike
inguinal hernias, these hernias protrude below, rather than above,
the inguinal ligament.
 Discussion

Obturator hernia: Herniation through the obturator canal alongside

the obturator vessels and nerves. This hernia occurs mostly in
women, particularly elderly women with a history of recent weight
loss. A mass may be palpable in the medial thigh, particularly with
the hip flexed, externally rotated and abducted (Howship-Romberg
sign).
Sliding hernia: A hernia in which one wall of the hernia is made up
of an intraabdominal organ, most commonly sigmoid colon,
ascending colon, or bladder.
Laparoscopic Hernia Reduction
Laparoscopic Repair
QUESTIONS ??????
 Summary

Inguinal hernia is primarily a clinical diagnosis

Ultrasound can be helpful in diagnosing testicular
torsion; also if hernia diagnosis unclear
Surgical repair, elective or emergent
Various operative and anesthetic approaches
Obturator and occasionally femoral hernias may
present as nonspecific abdominal pain,
nausea/vomiting
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