FirstRanker Logo

FirstRanker.com - FirstRanker's Choice is a hub of Question Papers & Study Materials for B-Tech, B.E, M-Tech, MCA, M.Sc, MBBS, BDS, MBA, B.Sc, Degree, B.Sc Nursing, B-Pharmacy, D-Pharmacy, MD, Medical, Dental, Engineering students. All services of FirstRanker.com are FREE

📱

Get the MBBS Question Bank Android App

Access previous years' papers, solved question papers, notes, and more on the go!

Install From Play Store

Download MBBS General Surgery PPT 4 Groin Hernia Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Surgery PPT 4 Groin Hernia Lecture Notes

This post was last modified on 07 April 2022


Groin Hernia- Clinical

features and Management

--- Content provided by FirstRanker.com ---

Learning Objectives

? At the end of the discussion a student should be able to understand:
1. The features of the given history which support the diagnosis
2. The clinical examination

--- Content provided by FirstRanker.com ---

3. The differential diagnosis
4. What investigations would be most useful and why
5. What treatment options are appropriate
Case 1

--- Content provided by FirstRanker.com ---

I've developed a lump in my groin'
A 25-year-old builder suddenly develops a golf-ball-sized, slightly

tender lump in his right groin after lifting a 20-kg bag of sand. He states

--- Content provided by FirstRanker.com ---

that he felt a tearing sensation as it happened. He attends the

emergency department.

Case 2

--- Content provided by FirstRanker.com ---


`I can't push my lump back in anymore'
A 70-year-old retired man presents to surgical outpatient clinic with a

slightly tender lump in his left groin. He has had the lump for many

--- Content provided by FirstRanker.com ---


months, but previously it would disappear overnight, or if necessary he

could gently push it back inside. His health is fine, other than a cough

--- Content provided by FirstRanker.com ---

from years of smoking. Over the last 2 weeks he has not been able to

reduce the lump.


--- Content provided by FirstRanker.com ---

Case 3

`My hernia is sore and I've started to vomit'
A slim 73-year-old woman has had a groin lump for some time which

--- Content provided by FirstRanker.com ---

she ignored. Over the last 3 days it has become progressively more

painful, with redness of the overlying skin. She has not passed stools or

flatus during this time (which is unusual for her), and yesterday she

--- Content provided by FirstRanker.com ---


started to vomit.


What is a hernia?

--- Content provided by FirstRanker.com ---


Where do they occur?
What can they contain?

? Omentum and small bowel

--- Content provided by FirstRanker.com ---

? Meckel's diverticulum
? Appendix

Why are they important?
Case 1: I've developed a lump in my groin'

--- Content provided by FirstRanker.com ---


What is the likely differential diagnosis?

? Inguinal hernia
? Femoral hernia

--- Content provided by FirstRanker.com ---

? Enlarged inguinal lymph node
? Lipoma
? Less likely: groin abscess, epididymitis, undescended testis, saphena

varix, femoral artery aneurysm, psoas abscess, tumour

--- Content provided by FirstRanker.com ---


Case 1:`I've developed a lump in my groin'

What features of the given history support the diagnosis?

--- Content provided by FirstRanker.com ---

? Heavy exertion
? Tenderness

? acute onset hernia

--- Content provided by FirstRanker.com ---

? enlarged lymph node or psoas abscess (signs of systemic illness would also be

expected)
Case 1? `I've developed a lump in my groin'

--- Content provided by FirstRanker.com ---

What additional features in the history would you seek to support

your diagnosis?

? Past H/O hernia

--- Content provided by FirstRanker.com ---

? Family H/O hernias
? Past surgical history
? Has he been otherwise well?

Case 1 ? `I've developed a lump in my groin'

--- Content provided by FirstRanker.com ---


What clinical examination would you perform and why?

? Examine the groins and external genitalia.
? Cough impulse and reducibility

--- Content provided by FirstRanker.com ---


? Indirect

? Direct

--- Content provided by FirstRanker.com ---

? Distinguishing between the two types makes no difference to

treatment
Case 1 ? `I've developed a lump in my groin'

--- Content provided by FirstRanker.com ---

What investigations would be most useful and why?

? CBC
? Ultrasound

--- Content provided by FirstRanker.com ---

Case 1? `I've developed a lump in my groin'

What treatment options are appropriate?

? Surgical:

--- Content provided by FirstRanker.com ---


? The most common approach for repair is still an open operation

? laparoscopic repair for recurrent, bilateral and unilateral inguinal

--- Content provided by FirstRanker.com ---

? Permanent synthetic mesh is implanted
? Laparoscopic repair requires a general anaesthetic, while open repair

can be performed under local anaesthetic

--- Content provided by FirstRanker.com ---

? For unilateral primary groin hernias, the approaches have similar

recurrence rates, similar disability times, and similar costs
Case 2 ? `I can't push my lump back in

--- Content provided by FirstRanker.com ---

anymore'

What is the likely differential diagnosis?

? Inguinal hernia

--- Content provided by FirstRanker.com ---

? Femoral hernia
? Enlarged lymph node (infection, metastatic tumour)
? Femoral artery aneurysm
? Saphena varix

--- Content provided by FirstRanker.com ---

Case 2 ? `I can't push my lump back in

anymore'

What features of the given history support the diagnosis?

--- Content provided by FirstRanker.com ---


? A previously reducible groin mass which is no longer so is a very clear

history of a groin hernia
Case 2 ? `I can't push my lump back in

--- Content provided by FirstRanker.com ---


anymore'

What additional features in the history wil support your

--- Content provided by FirstRanker.com ---

diagnosis?

? Ask about urinary symptoms ?BPH
? Increases the risk of post-operative acute urinary retention

--- Content provided by FirstRanker.com ---

Case 2 ? `I can't push my lump back in

anymore'

What clinical examination would you perform and why?

--- Content provided by FirstRanker.com ---


? Examine both groins and external genitalia
? Perform a digital rectal examination (DRE) to exclude BPH
Case 2 ? `I can't push my lump back in

--- Content provided by FirstRanker.com ---

anymore'

What investigations would be most useful and why?

? Ultrasound may be useful to differentiate between clinically unclear

--- Content provided by FirstRanker.com ---


entities.

Case 2 ? `I can't push my lump back in

--- Content provided by FirstRanker.com ---

anymore'

What treatment options are appropriate?

? Surgical: early elective repair is indicated

--- Content provided by FirstRanker.com ---

Case 3 ? `My hernia is sore and I've started to

vomit'

What is the likely differential diagnosis?

--- Content provided by FirstRanker.com ---


? Inguinal hernia, with ischaemia and bowel obstruction
? Femoral hernia, with ischaemia and bowel obstruction
? Psoas abscess
? Infected lymph node

--- Content provided by FirstRanker.com ---


Case 3 ? `My hernia is sore and I've started to

vomit'

--- Content provided by FirstRanker.com ---

What features of the given history support the diagnosis?

? Recent change in the groin lump
? Vomiting and constipation
? A femoral hernia is more likely to cause ischaemia as a result of the

--- Content provided by FirstRanker.com ---


tight neck of the femoral canal
Case 3 ? `My hernia is sore and I've started to

vomit'

--- Content provided by FirstRanker.com ---


What additional features in the history would you seek to support

your diagnosis?

--- Content provided by FirstRanker.com ---

? Exclude infections that would drain to the inguinal lymph nodes
? Local inflammation could explain the erythema of the skin and

tenderness of the lump

--- Content provided by FirstRanker.com ---

? Systemic sepsis can secondarily cause paralytic ileus that would cause

vomiting

Case 3 ? `My hernia is sore and I've started to

--- Content provided by FirstRanker.com ---


vomit'

What clinical examination would you perform and why?

--- Content provided by FirstRanker.com ---

? Examine the groin carefully
? Femoral hernias are seen more commonly in women than men
? Femoral hernias are felt below and lateral to the pubic tubercle
? Approximately 40 per cent of femoral hernias present with

--- Content provided by FirstRanker.com ---

strangulation
Case 3 ? `My hernia is sore and I've started to

vomit'

--- Content provided by FirstRanker.com ---

What investigations would be most useful and why?

? A plain abdominal x-ray
? An ABG test may show a metabolic acidosis and raised lactate,

--- Content provided by FirstRanker.com ---

suggesting ischaemia

? Other investigations will be directed at readying the patient for

emergency surgery

--- Content provided by FirstRanker.com ---


Case 3 ? `My hernia is sore and I've started to

vomit'

--- Content provided by FirstRanker.com ---

What treatment options are appropriate?

? Medical:

? fluid resuscitation

--- Content provided by FirstRanker.com ---


? nasogastric tube reduces the risk of vomiting and aspiration

? Surgical:

--- Content provided by FirstRanker.com ---

? emergency surgery is needed

? lower midline laparotomy,

? any non-viable bowel will need to be resected

--- Content provided by FirstRanker.com ---


? repair of hernia
OSCE Counselling case 1 ? `Should I have my

hernia repaired?'

--- Content provided by FirstRanker.com ---

? Risks of treatment Vs Risk of not treating the hernia
? There is strong consensus that groin hernias should usually be

repaired

--- Content provided by FirstRanker.com ---

OSCE Counselling case 1.2 ? `Why did my

surgeon suggest I see a urologist first?'
? H&E

--- Content provided by FirstRanker.com ---

? PSA

? TRUS

? Prostate biopsy if necessary

--- Content provided by FirstRanker.com ---


? Cystoscopy to assess the bladder and prostatic urethra

? Medications may be all that are required to manage the symptoms

--- Content provided by FirstRanker.com ---

? TURP may be required

? This assessment and treatment is best performed prior to

uncomplicated elective hernia repair

--- Content provided by FirstRanker.com ---



An 80-year old woman has lost several kgs over the last 3 months. For

the last 3 days she has not been able to eat anything, has been

--- Content provided by FirstRanker.com ---


vomiting, and was found in bed this morning confused and quite ill.

Her abdominal exam is fairly unremarkable without any previous scars.

--- Content provided by FirstRanker.com ---

? This woman likely has an obturator or possibly a femoral hernia.
? Obesity can make examination of the groin difficult.
? Her management is much different than the previous case.


--- Content provided by FirstRanker.com ---

Management

? Plain films of the abdomen should also

be obtained, as the patient may have

--- Content provided by FirstRanker.com ---


a bowel obstruction due to small

bowel incarceration in the hernia.

--- Content provided by FirstRanker.com ---

? How might this change your

management?


--- Content provided by FirstRanker.com ---

Laparoscopic Hernia Reduction

Laparoscopic Repair
Conclusion

--- Content provided by FirstRanker.com ---

? Hernias should usual y be surgical y repaired when present, in order to

treat symptoms of discomfort, and to reduce the risk of serious

complications.

--- Content provided by FirstRanker.com ---


? Ultrasound is sometimes required to diagnose atypical hernias (or hernias

in unusual sites), and to exclude conditions that may mimic hernia, such as

--- Content provided by FirstRanker.com ---

lymphadenopathy.

? Hernia repair may be open or laparoscopic. Each method has specific

advantages and risks, which should be discussed with the patient. Neither

--- Content provided by FirstRanker.com ---


has a fundamental advantage over the long term.

? Patients who present with bowel obstruction should be checked for hernia

--- Content provided by FirstRanker.com ---

as a possible cause.

? Chronic pain is an under-recognized complication of hernia repair, and

may occur in up to 10 per cent of patients.

--- Content provided by FirstRanker.com ---