Inguinal herniaInguinal hernia

Karen Brasel, MD, MPHKaren Brasel, MD, MPH

Medical College of WisconsinMedical College of Wisconsin

Mr. RobertsMr. Roberts

Your patient in the office is a 28 year-old male Your patient in the office is a 28 year-old male with a several day history of groin and with a several day history of groin and testicular pain.testicular pain.

HistoryHistory

What other points of the history What other points of the history do you want to know?do you want to know?

History, Mr. RobertsHistory, Mr. Roberts

Characterization of symptoms

Temporal sequence Alleviating /

Exacerbating factors:

Pertinent PMH, ROS, MEDS.

Relevant family hx. Associated signs and

symptoms

Consider the Following

History, Mr. RobertsHistory, Mr. Roberts

Characterization of Symptoms: R Characterization of Symptoms: R groin pain began at work after groin pain began at work after lifting 50 lb boxes. Abrupt onset, lifting 50 lb boxes. Abrupt onset, now constant.now constant.

Alleviating / Exacerbating factors: Alleviating / Exacerbating factors: Improved with lying down, worse Improved with lying down, worse with standingwith standing

Associated signs/symptoms: Eating Associated signs/symptoms: Eating normally, no diarrhea or normally, no diarrhea or constipationconstipation

Pertinent PMH: nonePertinent PMH: none ROS: no dysuriaROS: no dysuria MEDS: TylenolMEDS: Tylenol SH: married, single partner. SH: married, single partner.

Construction workerConstruction worker Relevant Family Hx. Relevant Family Hx.

NoncontributoryNoncontributory

What is your Differential What is your Differential Diagnosis?Diagnosis?

Differential DiagnosisDifferential DiagnosisBased on History and PresentationBased on History and Presentation

Inguinal herniaInguinal hernia Testicular torsionTesticular torsion EpididymitisEpididymitis ProstatitisProstatitis Muscle strainMuscle strain

Physical ExaminationPhysical Examination

What would you look for?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 Would you like to revise your Differential Diagnosis?Differential Diagnosis?

Revised DifferentialRevised Differential

Inguinal herniaInguinal hernia EpididymitisEpididymitis

LaboratoryLaboratory

What would you obtain?What would you obtain?

Labs ordered, Mr. RobertsLabs ordered, Mr. Roberts

CBCCBC

Lab Results, DiscussionLab Results, Discussion

• In a young, otherwise healthy patient in whom the In a young, otherwise healthy patient in whom the diagnosis can be made clinically, laboratory diagnosis can be made clinically, laboratory studies are unnecessary.studies are unnecessary.

• An elevated white blood cell count might help you An elevated white blood cell count might help you make the distinction between epididymitis, an make the distinction between epididymitis, an infectious process, and an incarcerated inguinal infectious process, and an incarcerated inguinal hernia. hernia.

• However, it can be normal in epididymitis and However, it can be normal in epididymitis and might be elevated in an incarcerated hernia due to might be elevated in an incarcerated hernia due to compromised or ischemic bowel within the hernia compromised or ischemic bowel within the hernia sacsac

Lab Results, DiscussionLab Results, Discussion

““Routine” preoperative laboratory studies are costly, Routine” preoperative laboratory studies are costly, and false positives occur up to 10% of the time. and false positives occur up to 10% of the time. Selective ordering should be the routine.Selective ordering should be the routine.

History and physical are the best way to screen for History and physical are the best way to screen for coagulation abnormalities.coagulation abnormalities.

Hematocrits should be obtained only forHematocrits should be obtained only for• Patients who are at risk for abnormalities.Patients who are at risk for abnormalities.• Procedures with significant blood loss.Procedures with significant blood loss.• Patients with considerable comorbidity.Patients with considerable comorbidity.

Lab Results, DiscussionLab Results, Discussion

Guidelines for obtaining routine chemistriesGuidelines for obtaining routine chemistries• BUN/Creatinine, potassium BUN/Creatinine, potassium

− Renal diseaseRenal disease− DiabeticsDiabetics− >60 years old >60 years old − CV disease CV disease − Diuretics, digoxinDiuretics, digoxin− corticosteroidscorticosteroids

• Glucose- Glucose- − >60 years old >60 years old − diabetics diabetics − corticosteroidscorticosteroids

What would you do now?What would you do now?

Interventions at this point?Interventions at this point?

Re-examine the patientRe-examine the patient Obtain diagnostic studiesObtain diagnostic studies Schedule patient for surgerySchedule patient for surgery

StudiesStudies

What further studies would you What further studies would you want at this time?want at this time?

Studies, Mr. RobertsStudies, Mr. Roberts

An ultrasound can be helpful if the diagnosis of An ultrasound can be helpful if the diagnosis of a hernia is truly in doubt. However, often a a hernia is truly in doubt. However, often a careful re-examination of the patient with careful re-examination of the patient with specific attention paid to examining the specific attention paid to examining the epididymis separately from the inguinal canal epididymis separately from the inguinal canal will make an ultrasound unnecessary.will make an ultrasound unnecessary.

Revised Differential DiagnosisRevised Differential Diagnosis

Inguinal hernia, incarceratedInguinal hernia, incarcerated

What next?What next?

What next?What next?

1.1. Immediate ORImmediate OR

2.2. Attempt at reductionAttempt at reduction

What next?What next?

Reduction should be attempted in the patient with an Reduction should be attempted in the patient with an incarcerated hernia. This allows an operation to be incarcerated hernia. This allows an operation to be performed electively rather than emergently, and performed electively rather than emergently, and allows choice of anesthesia and operative approach. allows choice of anesthesia and operative approach.

Reduction is best accomplished by elongating the neck Reduction is best accomplished by elongating the neck of the hernia sac while applying pressure to reduce the of the hernia sac while applying pressure to reduce the hernia. The patient should be given adequate sedation hernia. The patient should be given adequate sedation and analgesia, and placed in Trendelenberg position. and analgesia, and placed in Trendelenberg position.

ManagementManagement

Discussion of patient response to management recommendations:

If reduction is unsuccessful, the patient should be prepared for urgent operation.

ManagementManagement

Although symptomatic hernias should all be repaired Although symptomatic hernias should all be repaired operatively, it is not clear that all small, asymptomatic operatively, it is not clear that all small, asymptomatic hernias should be fixed.hernias should be fixed.

Age, comorbid conditions, patient activity and patient Age, comorbid conditions, patient activity and patient preference should be considered.preference should be considered.

Current trials are studying the natural history of these Current trials are studying the natural history of these small hernias.small hernias.

ManagementManagement

Hernias do not always present as a “groin bulge”, and Hernias do not always present as a “groin bulge”, and not all patients will complain of groin pain. Consider not all patients will complain of groin pain. Consider the following:the following:

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

ManagementManagement

This woman likely has an obturator or possibly This woman likely has an obturator or possibly a femoral hernia. a femoral hernia.

Obesity can make examination of the groin Obesity can make examination of the groin difficult.difficult.

Her management is much different than the Her management is much different than the previous case.previous case.

ManagementManagement

Plain films of the abdomen Plain films of the abdomen should also be obtained, as should also be obtained, as the patient may have a bowel the patient may have a bowel obstruction due to small obstruction due to small bowel incarceration in the bowel incarceration in the hernia. hernia.

How might this change How might this change your management?your management?

DiscussionDiscussion

The majority of hernias should be repaired when discovered, as The majority of hernias should be repaired when discovered, as the mortality increases 9 to 10 fold with emergent compared to the mortality increases 9 to 10 fold with emergent compared to elective repair. Elective repair done with an open approach can elective repair. Elective repair done with an open approach can be performed under local, spinal, or general anesthesia. It can be performed under local, spinal, or general anesthesia. It can also be done laparoscopically, which requires general anesthesia. also be done laparoscopically, which requires general anesthesia.

In addition to the elective or urgent/emergent nature or the repair, In addition to the elective or urgent/emergent nature or the repair, anesthetic choice, patient preference, and primary or recurrent anesthetic choice, patient preference, and primary or recurrent nature of the hernia factor into the decision regarding operative nature of the hernia factor into the decision regarding operative approach. A laparoscopic approach, or an open preperitoneal approach. A laparoscopic approach, or an open preperitoneal approach, is best for recurrent or bilateral hernias. For unilateral approach, is best for recurrent or bilateral hernias. For unilateral primary groin hernias, the approaches have similar recurrence primary groin hernias, the approaches have similar recurrence rates, similar disability times, and similar costs. rates, similar disability times, and similar costs.

DiscussionDiscussion

Indirect hernia:Indirect hernia: contents protrude through the indirect inguinal ring contents protrude through the indirect inguinal ring through a patent processus vaginalis into the inguinal canal. In through a patent processus vaginalis into the inguinal canal. In men, they follow the spermatic cord and may present as scrotal men, they follow the spermatic cord and may present as scrotal swelling, while in females they may present as labial swelling. swelling, while in females they may present as labial swelling.

Direct hernia:Direct hernia: contents protrude through Hesselbach’s triangle contents protrude through Hesselbach’s triangle medial to the inferior epigastric vessels.medial to the inferior epigastric vessels.

Femoral hernia:Femoral hernia: contents protrude through the femoral canal, contents protrude through the femoral canal, bounded by the inguinal ligament superiorly, the femoral vein bounded by the inguinal ligament superiorly, the femoral vein laterally, and the pyriformis and pubic ramus medially. Unlike laterally, and the pyriformis and pubic ramus medially. Unlike inguinal hernias, these hernias protrude below, rather than above, inguinal hernias, these hernias protrude below, rather than above, the inguinal ligament.the inguinal ligament.

DiscussionDiscussion

Obturator herniaObturator hernia: Herniation through the obturator canal alongside : Herniation through the obturator canal alongside the obturator vessels and nerves. This hernia occurs mostly in the obturator vessels and nerves. This hernia occurs mostly in women, particularly elderly women with a history of recent weight women, particularly elderly women with a history of recent weight loss. A mass may be palpable in the medial thigh, particularly loss. A mass may be palpable in the medial thigh, particularly with the hip flexed, externally rotated and abducted (Howship-with the hip flexed, externally rotated and abducted (Howship-Romberg sign).Romberg sign).

Sliding herniaSliding hernia: A hernia in which one wall of the hernia is made up : A hernia in which one wall of the hernia is made up of an intraabdominal organ, most commonly sigmoid colon, of an intraabdominal organ, most commonly sigmoid colon, ascending colon, or bladder.ascending colon, or bladder.

Laparoscopic Hernia Reduction

Laparoscopic Repair

QUESTIONS ??????

SummarySummary

Inguinal hernia is primarily a clinical diagnosisInguinal hernia is primarily a clinical diagnosis Ultrasound can be helpful in diagnosing testicular Ultrasound can be helpful in diagnosing testicular

torsion; also if hernia diagnosis uncleartorsion; also if hernia diagnosis unclear Surgical repair, elective or emergentSurgical repair, elective or emergent Various operative and anesthetic approachesVarious operative and anesthetic approaches Obturator and occasionally femoral hernias may Obturator and occasionally femoral hernias may

present as nonspecific abdominal pain, present as nonspecific abdominal pain, nausea/vomitingnausea/vomiting

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