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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
symptoms
Temporal sequence
Alleviating /
Exacerbating factors:

Pertinent PMH, ROS,


MEDS.
Relevant family hx.
Associated signs and
symptoms

History, Mr. Roberts

Characterization of Symptoms: R
groin pain began at work after
lifting 50 lb boxes. Abrupt onset,
now constant.
Alleviating / Exacerbating factors:
Improved with lying down, worse
with standing
Associated signs/symptoms: Eating
normally, no diarrhea or
constipation

Pertinent PMH: none

ROS: no dysuria

MEDS: Tylenol
SH: married, single partner.
Construction worker
Relevant Family Hx.
Noncontributory

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.
Epididymis and inguinal canal
tender; bulge in R. inguinal
canal

Abd: soft, nontender, normoactive


bowel sounds

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

Acknowledgment
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