3. What is a hernia?
• “A hernia is an abnormal protrusion of a
structure, organ or part of an organ, through a
tear, hole or defect in the wall of a body cavity
from which it belongs.”
• External or Internal?
Oxford Handbook of Clinical Examination and Practical Skills
4. Types of hernias
Direct Inguinal Indirect Inguinal Bilateral femoral
Strangulated
femoral
Umbilical
Spigelian
Para-umbilical
Epigastric
Incisional
6. Inguinal Hernia Essentials (for OSCE)
• Direct V Indirect = inf. Epigastric art. /
Hesselbach’s triangle
• Patent process vaginalis
• Partial V Complete indirect
• Cover internal ring and cough
• Management is the same
7. What will impress a General Surgeon?
Regional anatomical structures
• Abdo wall – TA,IO (conjoint tendon) ,EO
(aponeurosis + crus) + ASIS + PT + Mid inguinal point,
Inguinal lig, = boundaries of canal
• Nerves – ilioinguinal, iliohypogastric, genitofemoral,
SNS, PNS,
• Vessels – Inf. Epigastric, superficial Epigastric,
femoral, ext. pudendal, Testicular, pampiniform
plexus, lymphatics,
• Spermatic cord (ductus deferens, int + ext spermatic
fascia, cremasteric muscle) / Round lig.
• Patent process vaginalis / tunica vaginalis
8.
9.
10.
11. Aetiology + Epidemiology
• Indirect inguinal = congenital weakness = Patent process
vaginalis
– young men (85% of all hernias – MacLeod’s Clin. Exam 12th)
• Direct inguinal = wear and tear
– old men > old women
• Femoral = wear and tear
– old women
• Umbilical = poorly developed musculature/ obesity / ascites
– Neonates (often close spontaneously)
• Incisional = iatrogenic weakness / obesity / ascites
12. Hernia Symptoms
• Painful/ tender / non-tender palpable lump
• Lump is often more obvious when standing
• Cough impulse
• Reducible or irreducible
• “A dragging sensation”
• Painful and swollen scrotum (men)
13. Red Flags
• Suddenly very painful
• Tender to the touch
• Bulge appears red, purple or dark
• Change in bowel habits – constipation/ diarrhoea
• Nausea
• Vomiting
• Fever
http://openi.nlm.nih.gov/detailedresult.php?img=3141709_1752-1947-5-258-
1&query=the&fields=all&favor=none&it=none&sub=none&sp=none&req=4&simCollection=2951179_JOE100120f01&npos=97&prt=3
Inflamed appendix protruding
into the femoral canal
= de Garengeot's hernia
14. Hernia Complications
Reducible or irreducible?
IncarcerationObstruction
StrangulationPerforation +/- Death
Oxford Handbook of Clinical Medicine
Time!
size
17. Management of Hernias
• ?Strangulated = emergency op.
• Watch and wait – elective repair
• Advise weight loss
• Avoid heavy lifting
• Surgery = Open (Lichtenstein repair) or
laparoscopic
23. Chronic pain
• Ilioinguinal nerve =
– Innervates upper and medial parts of the thigh, the
anterior scrotum, and the base of the penis.
• Iliohypogastric nerve =
– Innervates the skin above the pubis.
• Genital branch of the genitofemoral nerve =
– Innervates the cremaster muscle and provides sensory
innervation to the scrotum.
• Can be damaged during surgery
• Can be irritated post-op by mesh or sutures
• Common side effect of hernia repair – should
inform patient
25. References
• Cahill, D. R. 1997. Lachman’s Case Studies in Anatomy, 4th Ed.
Oxford University Press, New York.
• Moore, K. L., A. F. Dalley, and A M. R. Agur. 2010. Clinically
Oriented Anatomy, 6th Ed. Lippincott, Williams & Wilkins,
Baltimore.
• Moore, K. L. and T. V. N. Persaud. 2003. The Developing
Human. Clinically Oriented Embryology, 7th Ed. Lippincott,
Williams & Wilkins, Baltimore.
• http://emedicine.medscape.com/article/1534281-overview
• http://www.oucom.ohiou.edu/dbms-
witmer/Downloads/2011-04-26_Witmer_hernia.pdf
• Oxford handbook of clinical medicine
• MacLeod’s clinical examination 12th Ed.
• Emergency Abdominal surgery 3rd Ed.
