Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Surgery PPT 4 Groin Hernia Lecture Notes
Groin Hernia- Clinical
features and Management
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
3. The differential diagnosis
4. What investigations would be most useful and why
5. What treatment options are appropriate
Case 1
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
that he felt a tearing sensation as it happened. He attends the
emergency department.
Case 2
`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
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
from years of smoking. Over the last 2 weeks he has not been able to
reduce the lump.
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
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
started to vomit.
What is a hernia?
Where do they occur?
What can they contain?
? Omentum and small bowel
? Meckel's diverticulum
? Appendix
Why are they important?
Case 1: I've developed a lump in my groin'
What is the likely differential diagnosis?
? Inguinal hernia
? Femoral hernia
? Enlarged inguinal lymph node
? Lipoma
? Less likely: groin abscess, epididymitis, undescended testis, saphena
varix, femoral artery aneurysm, psoas abscess, tumour
Case 1:`I've developed a lump in my groin'
What features of the given history support the diagnosis?
? Heavy exertion
? Tenderness
? acute onset hernia
? enlarged lymph node or psoas abscess (signs of systemic illness would also be
expected)
Case 1? `I've developed a lump in my groin'
What additional features in the history would you seek to support
your diagnosis?
? Past H/O hernia
? Family H/O hernias
? Past surgical history
? Has he been otherwise well?
Case 1 ? `I've developed a lump in my groin'
What clinical examination would you perform and why?
? Examine the groins and external genitalia.
? Cough impulse and reducibility
? Indirect
? Direct
? Distinguishing between the two types makes no difference to
treatment
Case 1 ? `I've developed a lump in my groin'
What investigations would be most useful and why?
? CBC
? Ultrasound
Case 1? `I've developed a lump in my groin'
What treatment options are appropriate?
? Surgical:
? The most common approach for repair is still an open operation
? laparoscopic repair for recurrent, bilateral and unilateral inguinal
? Permanent synthetic mesh is implanted
? Laparoscopic repair requires a general anaesthetic, while open repair
can be performed under local anaesthetic
? 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
anymore'
What is the likely differential diagnosis?
? Inguinal hernia
? Femoral hernia
? Enlarged lymph node (infection, metastatic tumour)
? Femoral artery aneurysm
? Saphena varix
Case 2 ? `I can't push my lump back in
anymore'
What features of the given history support the diagnosis?
? 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
anymore'
What additional features in the history wil support your
diagnosis?
? Ask about urinary symptoms ?BPH
? Increases the risk of post-operative acute urinary retention
Case 2 ? `I can't push my lump back in
anymore'
What clinical examination would you perform and why?
? 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
anymore'
What investigations would be most useful and why?
? Ultrasound may be useful to differentiate between clinically unclear
entities.
Case 2 ? `I can't push my lump back in
anymore'
What treatment options are appropriate?
? Surgical: early elective repair is indicated
Case 3 ? `My hernia is sore and I've started to
vomit'
What is the likely differential diagnosis?
? Inguinal hernia, with ischaemia and bowel obstruction
? Femoral hernia, with ischaemia and bowel obstruction
? Psoas abscess
? Infected lymph node
Case 3 ? `My hernia is sore and I've started to
vomit'
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
tight neck of the femoral canal
Case 3 ? `My hernia is sore and I've started to
vomit'
What additional features in the history would you seek to support
your diagnosis?
? Exclude infections that would drain to the inguinal lymph nodes
? Local inflammation could explain the erythema of the skin and
tenderness of the lump
? Systemic sepsis can secondarily cause paralytic ileus that would cause
vomiting
Case 3 ? `My hernia is sore and I've started to
vomit'
What clinical examination would you perform and why?
? 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
strangulation
Case 3 ? `My hernia is sore and I've started to
vomit'
What investigations would be most useful and why?
? A plain abdominal x-ray
? An ABG test may show a metabolic acidosis and raised lactate,
suggesting ischaemia
? Other investigations will be directed at readying the patient for
emergency surgery
Case 3 ? `My hernia is sore and I've started to
vomit'
What treatment options are appropriate?
? Medical:
? fluid resuscitation
? nasogastric tube reduces the risk of vomiting and aspiration
? Surgical:
? emergency surgery is needed
? lower midline laparotomy,
? any non-viable bowel will need to be resected
? repair of hernia
OSCE Counselling case 1 ? `Should I have my
hernia repaired?'
? Risks of treatment Vs Risk of not treating the hernia
? There is strong consensus that groin hernias should usually be
repaired
OSCE Counselling case 1.2 ? `Why did my
surgeon suggest I see a urologist first?'
? H&E
? PSA
? TRUS
? Prostate biopsy if necessary
? Cystoscopy to assess the bladder and prostatic urethra
? Medications may be all that are required to manage the symptoms
? TURP may be required
? This assessment and treatment is best performed prior to
uncomplicated elective hernia repair
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
vomiting, and was found in bed this morning confused and quite ill.
Her abdominal exam is fairly unremarkable without any previous scars.
? 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.
Management
? Plain films of the abdomen should also
be obtained, as the patient may have
a bowel obstruction due to small
bowel incarceration in the hernia.
? How might this change your
management?
Laparoscopic Hernia Reduction
Laparoscopic Repair
Conclusion
? 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.
? Ultrasound is sometimes required to diagnose atypical hernias (or hernias
in unusual sites), and to exclude conditions that may mimic hernia, such as
lymphadenopathy.
? Hernia repair may be open or laparoscopic. Each method has specific
advantages and risks, which should be discussed with the patient. Neither
has a fundamental advantage over the long term.
? Patients who present with bowel obstruction should be checked for hernia
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.
This post was last modified on 07 April 2022