Groin Hernia- Clinical
features and Management
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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
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3. The differential diagnosis4. What investigations would be most useful and why
5. What treatment options are appropriate
Case 1
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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
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that he felt a tearing sensation as it happened. He attends theemergency department.
Case 2
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`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
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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
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from years of smoking. Over the last 2 weeks he has not been able toreduce the lump.
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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
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she ignored. Over the last 3 days it has become progressively morepainful, with redness of the overlying skin. She has not passed stools or
flatus during this time (which is unusual for her), and yesterday she
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started to vomit.
What is a hernia?
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Where do they occur?
What can they contain?
? Omentum and small bowel
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? Meckel's diverticulum? Appendix
Why are they important?
Case 1: I've developed a lump in my groin'
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What is the likely differential diagnosis?
? Inguinal hernia
? Femoral hernia
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? Enlarged inguinal lymph node? Lipoma
? Less likely: groin abscess, epididymitis, undescended testis, saphena
varix, femoral artery aneurysm, psoas abscess, tumour
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Case 1:`I've developed a lump in my groin'
What features of the given history support the diagnosis?
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? Heavy exertion? Tenderness
? acute onset hernia
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? enlarged lymph node or psoas abscess (signs of systemic illness would also beexpected)
Case 1? `I've developed a lump in my groin'
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What additional features in the history would you seek to supportyour diagnosis?
? Past H/O hernia
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? Family H/O hernias? Past surgical history
? Has he been otherwise well?
Case 1 ? `I've developed a lump in my groin'
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What clinical examination would you perform and why?
? Examine the groins and external genitalia.
? Cough impulse and reducibility
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? Indirect
? Direct
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? Distinguishing between the two types makes no difference totreatment
Case 1 ? `I've developed a lump in my groin'
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What investigations would be most useful and why?? CBC
? Ultrasound
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Case 1? `I've developed a lump in my groin'What treatment options are appropriate?
? Surgical:
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? The most common approach for repair is still an open operation
? laparoscopic repair for recurrent, bilateral and unilateral inguinal
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? Permanent synthetic mesh is implanted? Laparoscopic repair requires a general anaesthetic, while open repair
can be performed under local anaesthetic
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? For unilateral primary groin hernias, the approaches have similarrecurrence rates, similar disability times, and similar costs
Case 2 ? `I can't push my lump back in
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anymore'What is the likely differential diagnosis?
? Inguinal hernia
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? Femoral hernia? Enlarged lymph node (infection, metastatic tumour)
? Femoral artery aneurysm
? Saphena varix
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Case 2 ? `I can't push my lump back inanymore'
What features of the given history support the diagnosis?
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? 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
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anymore'
What additional features in the history wil support your
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diagnosis?? Ask about urinary symptoms ?BPH
? Increases the risk of post-operative acute urinary retention
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Case 2 ? `I can't push my lump back inanymore'
What clinical examination would you perform and why?
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? 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
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anymore'What investigations would be most useful and why?
? Ultrasound may be useful to differentiate between clinically unclear
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entities.
Case 2 ? `I can't push my lump back in
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anymore'What treatment options are appropriate?
? Surgical: early elective repair is indicated
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Case 3 ? `My hernia is sore and I've started tovomit'
What is the likely differential diagnosis?
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? Inguinal hernia, with ischaemia and bowel obstruction
? Femoral hernia, with ischaemia and bowel obstruction
? Psoas abscess
? Infected lymph node
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Case 3 ? `My hernia is sore and I've started to
vomit'
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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
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tight neck of the femoral canal
Case 3 ? `My hernia is sore and I've started to
vomit'
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What additional features in the history would you seek to support
your diagnosis?
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? Exclude infections that would drain to the inguinal lymph nodes? Local inflammation could explain the erythema of the skin and
tenderness of the lump
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? Systemic sepsis can secondarily cause paralytic ileus that would causevomiting
Case 3 ? `My hernia is sore and I've started to
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vomit'
What clinical examination would you perform and why?
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? 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
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strangulationCase 3 ? `My hernia is sore and I've started to
vomit'
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What investigations would be most useful and why?? A plain abdominal x-ray
? An ABG test may show a metabolic acidosis and raised lactate,
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suggesting ischaemia? Other investigations will be directed at readying the patient for
emergency surgery
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Case 3 ? `My hernia is sore and I've started to
vomit'
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What treatment options are appropriate?? Medical:
? fluid resuscitation
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? nasogastric tube reduces the risk of vomiting and aspiration
? Surgical:
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? emergency surgery is needed? lower midline laparotomy,
? any non-viable bowel will need to be resected
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? repair of hernia
OSCE Counselling case 1 ? `Should I have my
hernia repaired?'
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? Risks of treatment Vs Risk of not treating the hernia? There is strong consensus that groin hernias should usually be
repaired
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OSCE Counselling case 1.2 ? `Why did mysurgeon suggest I see a urologist first?'
? H&E
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? PSA? TRUS
? Prostate biopsy if necessary
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? Cystoscopy to assess the bladder and prostatic urethra
? Medications may be all that are required to manage the symptoms
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? TURP may be required? This assessment and treatment is best performed prior to
uncomplicated elective hernia repair
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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
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vomiting, and was found in bed this morning confused and quite ill.
Her abdominal exam is fairly unremarkable without any previous scars.
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? 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.
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Management? Plain films of the abdomen should also
be obtained, as the patient may have
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a bowel obstruction due to small
bowel incarceration in the hernia.
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? How might this change yourmanagement?
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Laparoscopic Hernia ReductionLaparoscopic Repair
Conclusion
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? Hernias should usual y be surgical y repaired when present, in order totreat symptoms of discomfort, and to reduce the risk of serious
complications.
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? Ultrasound is sometimes required to diagnose atypical hernias (or hernias
in unusual sites), and to exclude conditions that may mimic hernia, such as
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lymphadenopathy.? Hernia repair may be open or laparoscopic. Each method has specific
advantages and risks, which should be discussed with the patient. Neither
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has a fundamental advantage over the long term.
? Patients who present with bowel obstruction should be checked for hernia
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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.
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