Hernias

• Differentials of groin lump:

  • Hernia - inguinal and femoral
  • Enlarged lymph nodes
  • Vascular abnormalities - femoral artery aneurysm, saphena varix (dilation of great saphenous vein)
  • Psoas abscess
• Groin hernias - inguinal, femoral and obturator

  Abdominal wall or ventral hernias - umbilical, epigastric and incisional
• Hernia = the protrusion of a viscus into an abnormal space
• Reducible = contents of the hernia can be manipulated back into their original position. Either left alone or repaired electively.
• Incarcerated or irreducible = the contents of the hernia are stuck and cannot be pushed back into their original position

  • This can be due to sudden constriction of the hernia at the level of the fascial defect resulting in painful swelling of the tissues
  • Require urgent referral due to risk of strangulation
• Groin hernia referral in men:

  • Reducible and asymptomatic inguinal - watch and wait
  • Reducible and symptomatic inguinal - routine referral
  • Femoral - urgent referral
  • Strangulated - emergency
• Groin lump referral in women:

  • Harder to distinguish between inguinal and femoral hernia in women so all hernias should be referred urgently
  • Strangulated - emergency
• Obstructed = the contents of a hernia containing bowel are compressed

  • Colicky abdominal pain
  • Distension
  • Vomiting
  • Absolute constipation
  • Emergency surgery unless they can be reduced very quickly
• Strangulated = compression of the contents of the hernia by the fascial defect prevents blood flow into the tissues, causing ischaemia which may lead to infarction and necrosis

  • Disproportionately severe constant pain
  • Systemic illness and sepsis
  • Emergency surgery
• hernias are caused by increased intra-abdominal pressure, weak or damaged tissues, or a combination of both.
• Causes of increased intra-abdominal pressure:

  • Chronic cough
  • Abdominal distension: pregnancy, peritoneal dialysis and obesity (ventral hernias)
  • Straining
  • Kyphoscoliosis
• Causes of weakened tissues:

  • Congenital defects: patent processus vaginalis, patent umbilical ring
  • Collagen disorders: EDS, vitamin C deficiency
  • Trauma including surgery
  • Ageing
  • Chronic malnutrition
  • Long term steroid use
• Inguinal vs femoral hernia:

  • Inguinal hernias are situated above and medial to the pubic tubercle
  • Femoral hernias are located below and lateral to the pubic tubercle (and medial to the femoral pulse)
  • Difficult to distinguish in women
• Symptoms:

  • Small hernias usually asymptomatic
  • Larger - uncomfortable, dragging sensation, sensation of bulge or mass
  • On exam - palpable bulge/mass, reducible or irreducible, cough impulse
  • Can become obstructed - vomiting, pain, distension, absolute constipation
  • Strangulation - redness (blood trapped), painful, associated signs of obstruction and can become gangrenous
• Contents of hernia confined within hernial sac - pouch of peritoneum that covers herniated organ
• Diagnosis is usually based on physical exam finding but sometimes imaging can help if you are unable to distinguish the type of hernia e.g. ultrasound, CT/MRI