Hernia exam

• Exam can be done with the patient lay on the bed at a 45 degrees angle

  Can also be done with the patient stood up - will make any potential hernias more obvious
• General inspection clinical signs:

  • Pain
  • Obvious scars - incisional hernia
  • Abdominal distension - underlying bowel obstruction secondary to incarcerated hernia
  • Pallor - underlying anaemia
  • Cachexia - underlying malignancy
  • Hernias that may be visible from the end of the bed - can ask them to cough
• General inspection objects and equipment:

  • Stoma bag(s): note the location of the stoma bag(s) as this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, whereas ileostomies are usually located in the right iliac fossa). Parastomal hernias are a common complication of stoma formation.
  • Surgical drains: note the location of the drain and the type/volume of the contents within the drain (e.g. blood, chyle, pus).
  • Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
• Differentiating hernia from other types of lumps:

  • Number of lumps - single lump in inguinal region
  • Cough impulse - positive unless incarcerated
  • Consistency - soft
  • Ability to get above lump - unable to get above
  • Tenderness - painless unless incarcerated
  • Bowel sounds - bowel sounds present unless incarcerated
  • Bruit - no bruit
  • Transillumination - negative
  • Reducible - reducible unless incarcerated
• If any of the following clinical features are present, you should consider an alternative diagnosis:

  • Multiple lumps (e.g. lymphadenopathy)
  • Hard or nodular consistency (e.g. malignancy)
  • Able to get above the lump during palpation (e.g. scrotal mass)
  • Transillumination (hydrocoele)
  • Bruit on auscultation (e.g. arteriovenous malformation)
• Differentiating hernia subtypes - position of the hernia

  Assess the anatomical relationship of the hernia in relation to the pubic tubercle:

  • Inguinal hernias are typically located above and medial to the pubic tubercle.
  • Femoral hernias are typically located below and lateral to the pubic tubercle.
• Differentiating hernia - reducibility

  A reducible hernia is one which can be flattened out with changes in position (e.g. lying supine) or the application of pressure.

  To assess the reducibility of a hernia:

  1. Ask the patient to lay supine and observe for evidence of spontaneous reduction.

  2. If the hernia is still present, try to manually reduce it using your fingers.

  The hernia may re-appear if the patient stands up, coughs or the application of pressure is removed.

  A hernia which is tender and irreducible may be strangulated and requires urgent surgical review.
• If you suspect a hernia is inguinal in origin (i.e. it is located above and medial to the pubic tubercle) you should then try to determine if it is direct or indirect.

  1. Locate the deep inguinal ring (midway between the anterior superior iliac spine and pubic tubercle).

  2. Manually reduce the patient’s hernia by compressing it towards the deep inguinal ring starting at the inferior aspect of the hernia.

  3. apply pressure over the deep inguinal ring and ask the patient to cough.

  If hernia does not reappear it is more likely to be an indirect inguinal hernia
• Scrotal exam:

  • Inguinal hernias can extend into the scrotum. If a testicular swelling is noted or there is suspicion of an inguinal hernia, palpation of the scrotum should be performed with the patient’s consent.
  • When palpating an inguinal hernia in the scrotum you will not be able to get above the mass.