Good for clinical skills - content for history and examination for a patient with hernia

1. HERNIA – HX & EXAMN
Dr Vandana Krishna

2. Hernia
• External hernia
- Inguinal (direct and indirect)
- femoral hernia
- Umbilical hernia
- Incisional hernia
• Internal hernia
- hiatus

3. Hernia
• Complicated – incarcerated, obstructed and strangulated
• Uncomplicated – can be reduced

4. DDx
• Lymph node
• Hydrocele
• Orchitis
• Saphenous varix
• Abscess
• Undescended testis
• Malignancy

5. Hx
OPQRST on swelling
• When did you notice the swelling?
• Where exactly is the swelling?
• Is it uncomfortable? Any pain?
• Any particular position makes it worse/more prominent – eg.
lying down or standing?
• Any association with heavy lifting or straining (eg coughing,
defecation)
• Are you able to reduce it (push it back)?
• How big is the swelling? Does it affect your normal activity?
• Does it come and go or is always there?
-

6. Hx cont…
OPQRST on pain/discomfort if present
O: comes up when lump appears or when lump has been there for long time and
they are in standing or straining situation
P: lump site and also lower abdomen on the side of the lump
Q: pain is normally dull and is of dragging discomfort; if hernia complicated, can
become intestinal colic (initial obstruction sign) if intestine is the hernial content. If
omentum is the hernial content, obstruction signs will not be there. It can also
become acute abdomen if complicated (eg. perforation) with development of fever
R: lying down/reduction of lump; A: same as for lump formation
S: depends – if uncomplicated they are able to bear the discomfort; if complicated
can reach scale of 10
T: evaluate if the pain has become consistent (persistent pain with abdominal
tenderness suggests intestinal ischaemia eg strangulated hernia); is it worsening or
not (suggests continuing incarceration and/or other complication)

7. ROS
Purpose is to check for other differentials and to check for
complications of hernia:
• Fever, weight changes, appetite
• Any boil or cut anywhere esp in the lower limbs
• Coughing
• Vomiting (since when, colour (bilious denotes intestinal
content), how much, 1st time with this swelling); Bowel
opening/flatus; PU
• Discharge (urethral/vaginal)

8. Hiatus hernia
Hiatus hernia often presents heartburn, belching,
waterbrash, difficulty swallowing, chest or abdominal pain,
feeling especially full after meals, nausea, vomiting or
retching (dry heaves); vomiting blood or passing black
stools, which may indicate gastrointestinal bleeding.

9. Other Hx
• PMHx
- hernia hx
- operations esp for incisional and epigastric
hernias
- DMT2, HTN, IHD (assessing risk for operation if
needed)
- hx of STI
- chronic constipation
- comorbidities like COAD and Asthma (chronic
cough), BPH (forceful micturition)

10. Other hx cont..
• FHx – for congenital hernias; comorb conditions; cancer
• SHx – smoking (weakens tissue/affects healing/risk of
Ca); occupation (to assess risk factor for hernia - hard
labour, involves lot of standing, weight lifting)
• Allergies/Meds e.g if someone on warfarin – need to
adjust prior to operation if needed

11. Examination
• Greet
• Introduce yourself
• Explain your plan
• Get the consent

12. ‘Options’ for hernia
• In a reducible hernia the contents can be returned to
the abdominal cavity, spontaneously or by manipulation;
• If they cannot, the hernia is irreducible (incarcerated).
• If the blood supply to the contents of the hernia (bowel or
omentum) is restricted, the hernia is strangulated. It is
tense and tender and has no cough impulse.
• If bowel is contained within the hernia, obstruction may occur.
• Strangulated and obstructed hernia are surgical emergencies
and, untreated, either of them will lead to bowel infarction,
perforation, peritonitis, sepsis and shock.

13. DDx
• Lymph node
• Hydrocele
• Orchitis
• Saphenous varix
• Abscess
• Undescended testis
• Malignancy

14. Aim
1) Right or left
2) Inguinal or femoral
3) If inguinal, then direct or indirect
4) If indirect, then complete or incomplete
5) Complicated or uncomplicated
6) Content – intestine vs omentum

15. Hernia examination
• Inspection
• Palpation
• Percussion
• Auscultation

16. GA/Vitals/HEENT
• Inspect the general appearance – distress? gait
(antalgic)? Wants to remain still?
• Vitals
• HEENT – assess for dehydration (dry mouth/lips)

17. Position
1) Standing – inspection and palpation
2) Supine – palpation, percussion and auscultation
Exposure:
Ideally abdomen up to mid thigh
Chaperone

18. Standing

19. Inspection
Examine the groin with the patient standing upright
• Check for operation marks,
• Check for signs of inflammation
• Inspect the inguinal and femoral canals and the scrotum
(in males) for any lumps or bulges.
• Ask the patient to cough; look for an impulse over the
femoral and inguinal canals and scrotum.
• Identify the anatomical relationships between the bulge,
the pubic tubercle and the inguinal ligament to distinguish
a femoral from an inguinal hernia.

20. Surface marking
• Inguinal canal
• In the abdomen
• Approx 4 cm long in adults
• Deep (internal) inguinal ring – mid point of inguinal ligament (1.3cm
above); lateral to epigastric artery (this relation to artery is important
during surgery)
• Superficial (external) inguinal ring – above and medial to pubic
tubercle (about 1 cm); medial to epigastric artery
• Just above and parallel to inguinal ligament
• Femoral Canal
• In the thigh (anterior, medial and proximal) 1.3cm long
• Inferior and lateral to the pubic tubercle
• Below the inguinal ligament
• Inguinal ligament – ASIS to pubic tubercle

21. Palpation
• Palpate the external inguinal ring and along the inguinal
canal for possible muscle defects. Ask the patient to
cough and feel for a cough impulse.

22. Supine

23. Inspection
• Check whether the hernia reduces spontaneously
• Check for signs for obstruction (in the abdomen) - obvious
dilatation of the abdomen; peristaltic movements if any
• Check for signs of acute abdomen – patient is still,
abdomen looks rigid

24. Palpation
• Palpate the swelling for any tenderness, warmth (tense,
tender and signs of inflammation suggests strangulation)
• Assess consistency and size
• Assess for cough impulse (swelling enlarges with
coughing) over the swelling – absent cough impulse can
suggest obstruction or other DDx like hydrocele

25. Palpation cont…
• Attempt to reduce it gently (can ask the patient to do so)
• If it does reduces, press two fingers over the deep
inguinal ring and ask the patient to cough while you
maintain pressure over the deep inguinal ring
• If the hernia reappears, it is a direct hernia. If it can be
prevented from reappearing, it is an indirect inguinal
hernia.
• Examine the opposite side to exclude the possibility of
asymptomatic hernias.

26. • An indirect inguinal hernia bulges through the deep inguinal
ring and follows the course of the inguinal canal. It may
extend beyond the external ring and enter the scrotum.
Indirect hernias comprise 85% of all hernias and are
more common in younger men. Indirect inguinal hernias are
palpable above and medial to the pubic tubercle.
• A direct inguinal hernia forms at a site of muscle
weakness in the posterior wall of the inguinal canal and
rarely extends into the scrotum. It is more common in
older men and women
Both the hernias are above the inguinal ligament

27. • A femoral hernia projects through the femoral ring and
into the femoral canal. Femoral hernias are palpable
below the inguinal ligament and lateral to the pubic
tubercle.

28. Palpation cont…
• Palpate the scrotum –
• feel for testis (hydrocele testes is not palpable; in orchitis, testis is
very tender; in undescended testis there is no testes felt).
• Feel for the hernial content and try to follow it up to the inguinal
canal (swelling extends above scrotum in a hernia; in hydrocele,
can localise the swelling; omentum feels doughy)
• Palpate the superficial inguinal ring –
• try to put finger inside and check if you can feel the swelling
(invaginate the skin of the scrotum with little or index finger
superomedial to pubic tubercle).
• If you do feel the swelling in the canal, you an ask the patient to
cough and it will come and hit your finger tips (in indirect hernia)
and side of finger (in direct hernia)

29. Palpation cont…
• Palpate the abdomen for
• Signs of generalised peritonitis or acute abdomen – guarding,
rigidity, rebound (auscultate for bowel sounds during auscultation)
• Signs of obstruction – abdomen may look distended; firm and
tender abdomen

30. Percussion
• Percuss the abdomen to check for
• rebound tenderness
• Tympanic (hyper resonant if intestine dilated due to obstruction)

31. Auscultate
• Over the swelling to hear for any bowel sounds (if hernia
contains bowels, can hear bowel sounds; in hydrocele no
bowel sounds; if the bowel has become obstructed, after
some time, there will be no bowel sounds either)
• Over the abdomen to hear for absent bowel sounds if any;
initially during obstruction, bowel sounds are high pitched

32. Transillumination
• Present in a hydrocele

33. DRE
• Check for risk factors for hernia
• Sphincter tone
• Prostate enlargement
• Haemorrhoids
• Soft vs hard stool
• Check for DDx – tenderness, masses

37. Fluid in ascites
• Shifting dullness – 500mls
• Fluid thrill – 1.5L