Hernias Nick Harvey

Hernias What is a hernia? Protrusion of a viscus or part of a viscus through a defect in the wall that retains it. Basic Physical Signs of a Hernia Occur at a natural weak point Cough impulse Reducible

What is a hernia?

Protrusion of a viscus or part of a viscus through a defect in the wall that retains it.

Basic Physical Signs of a Hernia

Occur at a natural weak point

Cough impulse

Reducible

Hernias: Surgical Anatomy Sac neck, body, fundus Contents Bowel Omentum

Sac

neck, body, fundus

Contents

Bowel

Omentum

Hernias: Surgical Anatomy Common sites Inguinal (direct/indirect) Femoral Umbilical Paraumbilical Incisional Epigastric Rare sites Spigelian Lumbar Obturator Gluteal

Common sites

Inguinal (direct/indirect)

Femoral

Umbilical

Paraumbilical

Incisional

Epigastric

Rare sites

Spigelian

Lumbar

Obturator

Gluteal

Hernias: Pathological Type Reducible Irreducible ‘Incarcerated’ Obstructed Strangulated Inflamed

Reducible

Irreducible ‘Incarcerated’

Obstructed

Strangulated

Inflamed

Hernias: Special Types Sliding or Rolling Richter’s Maydl’s

Sliding or Rolling

Richter’s

Maydl’s

Hernias: Inguinal Anatomy Anterior Superior Iliac Spine (ASIS) Pubic Tubercle (PT) Pubic Symphysis (PS) Inguinal Ligament Vessels (NAVY)

Anterior Superior Iliac Spine (ASIS)

Pubic Tubercle (PT)

Pubic Symphysis (PS)

Inguinal Ligament

Vessels (NAVY)

Hernias: Inguinal Anatomy

Hernias: Inguinal Anatomy

Hernias: Indirect Inguinal Hernia

Hernias: Direct Inguinal Hernia

Hernias: Femoral Hernia

Hernias: History Onset, Course, Duration Painful or Painless? Other Lumps Present or past? Same type? Effect on General Condition Symptoms and signs of bowel obstruction Cause? Chronic cough, chronic constipation, symptoms of urinary obstruction Does the lump disappear?

Onset, Course, Duration

Painful or Painless?

Other Lumps

Present or past?

Same type?

Effect on General Condition

Symptoms and signs of bowel obstruction

Cause?

Chronic cough, chronic constipation, symptoms of urinary obstruction

Does the lump disappear?

Hernias: Examination Patient standing Stand on the same side as the hernia Ask the patient to cough Examine as in any other swelling Try to reduce the henia Comment in direction/contents Try to find the cause Examine abdomen, chest, DRE

Patient standing

Stand on the same side as the hernia

Ask the patient to cough

Examine as in any other swelling

Try to reduce the henia

Comment in direction/contents

Try to find the cause

Examine abdomen, chest, DRE

Hernias: Inspection Site Size Shape Symmetry Surface Skin overlying Scars Special signs Cough impulse

Site

Size

Shape

Symmetry

Surface

Skin overlying

Scars

Special signs

Cough impulse

Hernias: Palpation Tenderness Temperature Can you get above the swelling? Surface Edge Consistency Doughy or gurgly? Relation to Surrounding Structures Pubic Tubercle, Vessels Draining Lymph Nodes Special signs Cough impulse Reducibility

Tenderness

Temperature

Can you get above the swelling?

Surface

Edge

Consistency

Doughy or gurgly?

Relation to Surrounding Structures

Pubic Tubercle, Vessels

Draining Lymph Nodes

Special signs

Cough impulse

Reducibility

Hernias: Relationship with pubic tubercle

Hernias: Special Signs Cough impulse Reducibility? Comment on direction/contents Internal ring test

Cough impulse

Reducibility?

Comment on direction/contents

Internal ring test

Differential Diagnosis of a Groin Lump Surgical sieve! Inguinal hernia Femoral hernia Enlarged lymph nodes Ectopic testis Femoral aneurysm Sapheno-varix

Surgical sieve!

Inguinal hernia

Femoral hernia

Enlarged lymph nodes

Ectopic testis

Femoral aneurysm

Sapheno-varix

Hernias: Diagnosis Anatomical Side, inguinal, femoral umbilical… Pathological Reducible, irreducible, obstructed, strangulated, inflamed. Recurrent or not?

Anatomical

Side, inguinal, femoral umbilical…

Pathological

Reducible, irreducible, obstructed, strangulated, inflamed.

Recurrent or not?