Inguinal hernia

Urology

Clinicals - History

Fact Explanation
Lump in the groin They most commonly present with a lump in the groin area due to bulging of the abdominal contents. The lump increases in size with standing up, heavy work, coughing, straining or any other instances in which intra abdominal pressure rises. It usually disappears when lying down. Lump in the groin
They most commonly present with a lump in the groin area due to bulging of the abdominal contents. The lump increases in size with standing up, heavy work, coughing, straining or any other instances in which intra abdominal pressure rises. It usually disappears when lying down.
Vague pain in the groin area Sometimes patients present with a vague pain in the groin which again increases with heavy weight lifting, coughing, straining. Vague pain in the groin area
Sometimes patients present with a vague pain in the groin which again increases with heavy weight lifting, coughing, straining.
Acute intermittent abdominal pain A hernia can get obstructed and the patient can present with intestinal obstruction. Abdominal pain can be located according to the part of the intestine that gets obstructed and is classically intermittent. Acute intermittent abdominal pain
A hernia can get obstructed and the patient can present with intestinal obstruction. Abdominal pain can be located according to the part of the intestine that gets obstructed and is classically intermittent.
Nausea, Vomiting This is a feature of acute intestinal obstruction and usually when the part of the intestine which is obstructed is proximal. Nausea, Vomiting
This is a feature of acute intestinal obstruction and usually when the part of the intestine which is obstructed is proximal.
Constipation This is a feature of acute intestinal obstruction and mainly if large bowel gets obstructed. It can be absolute in which the passage of flatus doesn't occur as well. Constipation
This is a feature of acute intestinal obstruction and mainly if large bowel gets obstructed. It can be absolute in which the passage of flatus doesn't occur as well.
Abdominal distension More distal the bowel obstruction is greater the distension. Abdominal distension
More distal the bowel obstruction is greater the distension.
Increased thirst, Reduced level of consciousness These are features of dehydration due to intestinal obstruction. With obstruction of the bowel oedema of the bowel wall occurs and fluid gets sequestered in the bowel lumen. It also causes defective absorption of fluid via the bowel wall. Additionally more fluid is lost due to vomiting. Increased thirst, Reduced level of consciousness
These are features of dehydration due to intestinal obstruction. With obstruction of the bowel oedema of the bowel wall occurs and fluid gets sequestered in the bowel lumen. It also causes defective absorption of fluid via the bowel wall. Additionally more fluid is lost due to vomiting.

Clinicals - Examination

Fact Explanation
Lump in the groin The size of the hernia can increase with lifting of heavy weight, coughing, straining when the intra-abdominal pressure rises. When the patient is examined in the standing position, it appears and maybe apparent with coughing. Manual reduction maybe possible initially but when the hernia increases in size, it can get irreducible due to formation of fibrous adhesions. Direct and indirect hernias can be differentiated clinically only when the hernia is reducible. When the hernia is reduced, the finger is held over the internal ring and the patient is asked to cough. If the lump appears the hernia is direct and if not it's an indirect hernia as indirect hernias enter the inguinal canal through the internal ring. Lump in the groin
The size of the hernia can increase with lifting of heavy weight, coughing, straining when the intra-abdominal pressure rises. When the patient is examined in the standing position, it appears and maybe apparent with coughing. Manual reduction maybe possible initially but when the hernia increases in size, it can get irreducible due to formation of fibrous adhesions. Direct and indirect hernias can be differentiated clinically only when the hernia is reducible. When the hernia is reduced, the finger is held over the internal ring and the patient is asked to cough. If the lump appears the hernia is direct and if not it's an indirect hernia as indirect hernias enter the inguinal canal through the internal ring.
Expansile cough impulse Finger is held over the lump and patient is asked to cough which produces an expansile cough impulse.
Sliding hernias are probable with large scrotal hernias
Expansile cough impulse
Finger is held over the lump and patient is asked to cough which produces an expansile cough impulse.
Sliding hernias are probable with large scrotal hernias
Redness over the lump There can be redness over the lump. This usually indicates strangulation of the hernia with resultant bowel ischemia. Redness over the lump
There can be redness over the lump. This usually indicates strangulation of the hernia with resultant bowel ischemia.
Tenderness over the lump There can be tenderness over the lump. Severe tenderness usually indicates strangulation of the hernia with resultant bowel ischemia. Tenderness over the lump
There can be tenderness over the lump. Severe tenderness usually indicates strangulation of the hernia with resultant bowel ischemia.
Scar at the groin Inguinal hernias are known to recur. Therefore a previous hernia repair scar maybe present. Scar at the groin
Inguinal hernias are known to recur. Therefore a previous hernia repair scar maybe present.
Exaggerated bowel sounds This is a feature of intestinal obstruction and due to increased peristalsis. Exaggerated bowel sounds
This is a feature of intestinal obstruction and due to increased peristalsis.

Investigations - Diagnosis

Fact Explanation
Ultrasound scan of the groin This has nearly 100% specificity and can detect herniae Ultrasound scan of the groin
This has nearly 100% specificity and can detect herniae
CT scan of the groin If the ultrasound scan is negative and clinical suspicion is high further evaluation by CT of the groin may be done. But a negative CT scan will not exclude the possibility of a hernia and valsalva manoeuvre performed at time of the scan can increase the rate of detection. CT scan of the groin
If the ultrasound scan is negative and clinical suspicion is high further evaluation by CT of the groin may be done. But a negative CT scan will not exclude the possibility of a hernia and valsalva manoeuvre performed at time of the scan can increase the rate of detection.
Herniography This is an invasive investigation therefore not commonly done. Herniography
This is an invasive investigation therefore not commonly done.
MRI scan of the groin Even though it's very sensitive and specific not commonly performed because this is an expensive investigation. MRI scan of the groin
Even though it's very sensitive and specific not commonly performed because this is an expensive investigation.
Urine full report This may be done to rule out a urinary tract infection as a urinary tract infection may cause pain in the groin that can be mistaken for hernia pain Urine full report
This may be done to rule out a urinary tract infection as a urinary tract infection may cause pain in the groin that can be mistaken for hernia pain
Full blood count If strangulation is suspected, a full blood count may show high white cell count and high hematocrit due to dehydration. Full blood count
If strangulation is suspected, a full blood count may show high white cell count and high hematocrit due to dehydration.
X-ray abdomen If bowel obstruction is suspected, x-ray abdomen is done which shows multiple air fluid levels and dilated bowel loops. X-ray abdomen
If bowel obstruction is suspected, x-ray abdomen is done which shows multiple air fluid levels and dilated bowel loops.
Chest x-ray If there's any predisposing chronic cough or any features of chronic obstructive pulmonary disease, which causes hernia, this need to investigated prior to management of hernia Chest x-ray
If there's any predisposing chronic cough or any features of chronic obstructive pulmonary disease, which causes hernia, this need to investigated prior to management of hernia
Flexible sigmoidoscopy If there's chronic constipation, this needs to be investigated using a flexible sigmoidoscopy to assess the colon Flexible sigmoidoscopy
If there's chronic constipation, this needs to be investigated using a flexible sigmoidoscopy to assess the colon
Ultrasound kidney, ureters and bladder Straining at micturition can cause hernia as well. Therefore to detect any prostatic enlargement, or any obstruction this is done. Ultrasound kidney, ureters and bladder
Straining at micturition can cause hernia as well. Therefore to detect any prostatic enlargement, or any obstruction this is done.

Investigations - Management

Fact Explanation
Full blood count To exclude anemia prior to surgery Full blood count
To exclude anemia prior to surgery
Coagulation studies To exclude any coagulopathy prior to surgery Coagulation studies
To exclude any coagulopathy prior to surgery
Serum creatinine, Blood urea nitrogen To exclude any renal dysfunction prior to anesthesia Serum creatinine, Blood urea nitrogen
To exclude any renal dysfunction prior to anesthesia

Management - Supportive

Fact Explanation
Patient education If the hernia is small, the patient may only need reassurance and education regarding the etiology, nature and available treatment options. He should be educated on warning signs of intestinal obstruction and when to seek treatment. Patient should also be advised to avoid smoking. Patient education
If the hernia is small, the patient may only need reassurance and education regarding the etiology, nature and available treatment options. He should be educated on warning signs of intestinal obstruction and when to seek treatment. Patient should also be advised to avoid smoking.
Treatment of predisposing factors If there's underlying chronic cough, constipation, straining on micturition, these problems need to be properly addressed and should be treated prior to surgical management. As well as patient should be educated to avoid heavy weight lifting as this may aggravate hernia Treatment of predisposing factors
If there's underlying chronic cough, constipation, straining on micturition, these problems need to be properly addressed and should be treated prior to surgical management. As well as patient should be educated to avoid heavy weight lifting as this may aggravate hernia
Acute management of intestinal obstruction Patient is dehydrated, therefore normal saline intravenously given. Potassium can also be given. Nasogastric tube is placed to decompress the stomach. The patient should be monitored with regard to heart rate, respiratory rate, blood pressure, urine output, temperature and clinical status.
Administration of analgesia is important as patient is in pain and antiemetics are given as there's severe vomiting. Administration of antibiotics are to cover against gram-negative and anaerobic organisms
Acute management of intestinal obstruction
Patient is dehydrated, therefore normal saline intravenously given. Potassium can also be given. Nasogastric tube is placed to decompress the stomach. The patient should be monitored with regard to heart rate, respiratory rate, blood pressure, urine output, temperature and clinical status.
Administration of analgesia is important as patient is in pain and antiemetics are given as there's severe vomiting. Administration of antibiotics are to cover against gram-negative and anaerobic organisms

Management - Specific

Fact Explanation
Emergency management of a strangulated hernia This becomes a surgical emergency through obstruction and incarceration and then emergency surgery is indicated for possible strangulation where the hernial sac is operated. Emergency management of a strangulated hernia
This becomes a surgical emergency through obstruction and incarceration and then emergency surgery is indicated for possible strangulation where the hernial sac is operated.
Open repair of hernia Bassini's operation invloves apposition of the transversus abdominis and transversalis fascia and the lateral rectus sheath to the inguinal ligament. The Shouldice technique is another surgical technique. But now Lichtenstein tension free hernial repair technique is widely used and a polypropylene mesh is used to reinforce the abdominal wall. Possible complications are Recurrence (rate is very low), ischemic orchitis, wound infection, bladder injury, intestinal injury, pain, hematoma formation. Open repair of hernia
Bassini's operation invloves apposition of the transversus abdominis and transversalis fascia and the lateral rectus sheath to the inguinal ligament. The Shouldice technique is another surgical technique. But now Lichtenstein tension free hernial repair technique is widely used and a polypropylene mesh is used to reinforce the abdominal wall. Possible complications are Recurrence (rate is very low), ischemic orchitis, wound infection, bladder injury, intestinal injury, pain, hematoma formation.
Laparoscopic repair of hernia Similar to any laparoscopic surgery, this has less postoperative pain and return to work is faster than in an open surgery. But it is expensive and not widely available. There are two approaches which are the transabdominal preperitoneal (TAPP) or the preperitoneal appraoch (TEP) procedure. In TEP peritoneal cavity is not entered into whereas TAPP needs entry into the peritoneal cavity. Laparoscopic repair of hernia
Similar to any laparoscopic surgery, this has less postoperative pain and return to work is faster than in an open surgery. But it is expensive and not widely available. There are two approaches which are the transabdominal preperitoneal (TAPP) or the preperitoneal appraoch (TEP) procedure. In TEP peritoneal cavity is not entered into whereas TAPP needs entry into the peritoneal cavity.
Conservative management If the patient refuses surgery, a truss may be used. Conservative management
If the patient refuses surgery, a truss may be used.
Management of a congenital inguinal hernia The operation is undertaken as soon as possible either as open or laparoscopically. Management of a congenital inguinal hernia
The operation is undertaken as soon as possible either as open or laparoscopically.

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