“so, you’ve got a lump?”: a guide to inguinal hernias
TRANSCRIPT
Disclaimer…I have checked all my information thoroughly, but if you think there is anything inaccurate, please say!I am also a student, not an expert, please bear this in mind!We are all learning, anything you would like to add please say/ help people in the chat if you feel inclined!Feel free to throw out any questions, no such thing as a stupid one!If I can I will answer questions as I go, if not I will get to it in a break/at the end.
Enjoy!!
Contents
What is a hernia?
Whos at Risk?
Direct Vs Indirect Inguinal Canal Anatomy
Hesselbachs Triangle
Patient Presentation Red Flags!!! Ix & Mx
Session ObjectivesüBe able to explain what an inguinal hernia is including the anatomyüTo recognise a hernia presentation and identify risk factorsüTo know red flag symptoms of an inguinal hernia
What is a hernia?“Protrusion of part of/whole organ/tissue through the wall of the cavity that normally contains it”
• Not all hernias are a lump!
Knowing it now…but remembering it tomorrow…
M = muscles ROOFA = aponeurosis ANTERIOR WALLL = ligament FLOORT = Transversalis fascia POSTERIOR WALL
An important distinction…ØMid-inguinal point = Halfway between the Pubic
symphysis and Anterior superior iliac spine. Femoral pulse palpated here.
ØMidpoint of the inguinal ligament = Halfway between the pubic tubercle and Anterior superior iliac spine. Deep inguinal ring palpated here.
https://teachmeanatomy.info/abdomen/areas/inguinal-triangle/
Hesselbachs TriangleØAn area of abdominal wall typically
weak where a hernia can occur
ØDistinguishes between a direct and indirect inguinal hernia
Direct Vs IndirectUsing that anatomy…
Direct IndirectThrough Hesselbach triangle Through deep inguinal ring, canal and superficial
ringMedial to inferior epigastric vessels Lateral to inferior epigastric vessels
Will still protrude on compression of deep ring Will not protrude on compression of deep ring
Due to muscle weakening/increased intra-abdominal pressure
Congenital in origin
! Won’t know for sure until identifying which side of the inferior epigastric vessels the hernia is
Who is at risk?ØInguinal hernias make up 75% of all abdominal herniasØOf those, 80% indirect 20% direct
Ø MaleØ Increasing age Ø Raised Intra-abdominal pressure Ø Obesity
Patient PresentationØSwelling/lump in groinØPainlessØGets bigger when coughing Ø“goes in” on laying downØAching in groinØDevelop over time/suddenlyØAsymptomatic - ?incidental finding
ØWhat else may you want to ask the patient?
Patient Presentation cont.Ø Where will a patient with a hernia present?General practiceA&EClinicLook out on inpatient wards!
Ø Differentials?LymphadenopathyLymphomaSaphina varixHydrocoele Abscess
Red Flags!!!!!!
ØReducible = Able to return the hernia to the usual anatomical site through the defect
ØIncarcerated = Fixed hernia that is compressed by the defect and cant be reducedØObstructed = Incarcerated and bowel is compressed Bowel obstructionØStrangulated = Compromised blood supply, incarceration causing ischaemia
Bit of Terminology…
Red Flags!!!!!!
ØPain – worse on coughing/bending, may be out of proportionØChange in bowel habitØSkin changes – erythemaØTender on palpationØTense
ØAs a junior, Identify – Emergency/Not?
Signs & Symptoms…
Investigations & Management Ø Clinical examination (another Webinar??)Ø USS if uncertaintyØ If features of obstruction or strangulation, CT scan
Ø Obstruction/Strangulation = Urgent surgical explorationØ Asymptomatic = conservative managementØ Open mesh repair = primary inguinal herniaØ Laparoscopic approach = Pts deemed high risk or history of recurrence
SurgeryConsiderations for open vs laproscopic
Ø Pts suitability for general anesthesiaØ Nature of the presenting herniaØ Suitability of the hernia for each optionØ Experience of the surgeon in each
technique
Ø British hernia society advises open for primary single-sided hernia
Summary1 2
AnatomyLearn in context. How will this help me with a
patient?
Direct vs IndirectDirect = through
Hesselbach triangle
Indirect = Through the canal
Red FlagsPain out of proportion
Skin changesTender
Change in bowel habit
1 2 3
Additional Resources
TeachMeAnatomy Series
Local guidelines NICE in UK
Guidelines “Conditions and diseases”
PassMedicine
Armando HasudunganYouTube videos
References1. https://www.drrpadmakumar.com/blog/hiatal-hernia/
2. https://teachmeanatomy.info/abdomen/areas/inguinal-canal/
3. https://teachmeanatomy.info/abdomen/areas/inguinal-triangle/
4. https://teachmesurgery.com/general/small-bowel/inguinal-hernia/
5. https://www.medicalisland.net/health-guide/natural-treatment-for-hiatal-hernia
6. https://www.dailymail.co.uk/health/article-4639024/NHS-hernia-mesh-repairs-leave-thousands-agony.html
7. https://www.nice.org.uk/guidance/ta83/chapter/4-Evidence-and-interpretation
8. https://pubmed.ncbi.nlm.nih.gov/22729252/
9. https://www.nhs.uk/conditions/inguinal-hernia-repair/