Hernia

Umbilical Hernia

Para-Umbilical hernia

Incisional Hernia

Inguinal hernia

Femoral hernia

Hernia Overview

hernia

  • Sac is peritoneum.
  • Narrow neck is a risk factor for obstruction.
  • Obstructed hernia are irreducible and no cough impulse is present

hernia

Inguinal hernia

History

Remember these 3 parameters in the history (You’ll tend to forget)

  1. Age
  2. Side
  3. Duration
  • Age and Occupation
  • Duration
  • Progression
  • Reduced when lying down?
  • Other lumps?
  • Surgeries – Incisional hernia, Recurrent hernia
  • Symptoms – pain, discomfort
  • Complications – ios (incarceration, Obstruction, Strangulation)
  • Aetiology – Heavy manual labour, straining when bowel opening and urine; BPH, Smoking

Incarceration – adhesions between sac and contents.

Obstruction – specially small bowel, blood supply is intact.

Strangulation. Blood supply compromised. Risk of gangrene.

Examination

5 Coughs

Hernia –> Inguinal or femoral –> Direct or Indirect

1. Ask to cough and look for the lump

2. Demonstrate it’s a hernia by feeling cough impulse

3. Palpate pubic tubercle and ask to cough to show its a inguinal hernia and not a femoral hernia (Come down along the midline and locate symphysis pubis. Go laterally and locate pubic tubercle. Push the cord up. Keep index finger 45 degrees to pubic tubercle and demonstrate the lump is coming out above and medial)

4. Palpate for deep inguinal ring and ask to cough (Right hand index finger on pubic tubercle. Come along the iliac crest and locate ASIS and palpate it with left index finger. Keep left thumb above midline so that only the deep ring is covered. Rotate hand so that thumb is pointing towards you and other fingers above the deep ring and ask to cough)

5. Release thumb and as to cough

Examine scrotum
Never forget to stand up

Presentation

I examined a 70 yr old lady presented with a lump in right side inguinal region. It is reducible and expansile cough impulse is present.

The lump cannot be controlled by applying pressure over the deep inguinal ring.

Shes doesn’t give a history of any symptoms or complications of this lump and I couldn’t identify any aetiology. Other hernial orifices are normal.

My clinical diagnosis is Right sided direct inguinal hernia.

I’d manage this with [herniotomy – only for indirect hernia] and mesh repair under spinal anaesthesia after assessing the fitness for surgery.

Questions

What are the borders of inguinal canal?

Contents of inguinal canal?

How to surface mark deep inguinal ring?

Situated 2cm above the midpoint of inguinal ligament. i.e b/w pubic tubercle and ASIS.

Mx

  • Indirect – Herniotomy and Mesh repair
  • Direct – (No herniotomy) Reduce the sac and tension free mesh repair

Para-Umbilical hernia

Whole Umbilicus will be distended in umbilical hernia.

In PUH part of umbilicus is depressed (like a smiley face)

Look for diverication of recti (above umbilicus)

Mx is herniotomy and mesh repair

Incisional Hernia

  1. Ask for recovery period after Sx (infection, sutures removed and wound kept open)
  2. Symptoms
  3. Complications

After surgery muscles get only 80% of their strength.

Broad neck, less chance of strangulation

Femoral hernia

Seen in elderly females

NAVY