“So, You’ve Got A Lump?”: A guide to inguinal hernias

with Hannah Brown

Disclaimer…I have checked all my information thoroughly, but if you think there is anything inaccurate, please say!I am also a student, not an expert, please bear this in mind!We are all learning, anything you would like to add please say/ help people in the chat if you feel inclined!Feel free to throw out any questions, no such thing as a stupid one!If I can I will answer questions as I go, if not I will get to it in a break/at the end.

Enjoy!!

Contents

What is a hernia?

Whos at Risk?

Direct Vs Indirect Inguinal Canal Anatomy

Hesselbachs Triangle

Patient Presentation Red Flags!!! Ix & Mx

Session ObjectivesüBe able to explain what an inguinal hernia is including the anatomyüTo recognise a hernia presentation and identify risk factorsüTo know red flag symptoms of an inguinal hernia

What is a hernia?“Protrusion of part of/whole organ/tissue through the wall of the cavity that normally contains it”

• Not all hernias are a lump!

Inguinal Canal

Anatomy

Inguinal Canal Anatomy

Ø Can be hard to visualiseØ Important to understand for

inguinal hernias

My beautiful drawings…

My beautiful drawings…

My beautiful drawings…

My beautiful drawings…

Knowing it now…but remembering it tomorrow…

M = muscles ROOFA = aponeurosis ANTERIOR WALLL = ligament FLOORT = Transversalis fascia POSTERIOR WALL

An important distinction…ØMid-inguinal point = Halfway between the Pubic

symphysis and Anterior superior iliac spine. Femoral pulse palpated here.

ØMidpoint of the inguinal ligament = Halfway between the pubic tubercle and Anterior superior iliac spine. Deep inguinal ring palpated here.

https://teachmeanatomy.info/abdomen/areas/inguinal-triangle/

Hesselbachs TriangleØAn area of abdominal wall typically

weak where a hernia can occur

ØDistinguishes between a direct and indirect inguinal hernia

Direct Vs IndirectUsing that anatomy…

Direct IndirectThrough Hesselbach triangle Through deep inguinal ring, canal and superficial

ringMedial to inferior epigastric vessels Lateral to inferior epigastric vessels

Will still protrude on compression of deep ring Will not protrude on compression of deep ring

Due to muscle weakening/increased intra-abdominal pressure

Congenital in origin

! Won’t know for sure until identifying which side of the inferior epigastric vessels the hernia is

Break time!Let's take a 2-3 minute break to recharge...

Any questions? Drop them in the Q&A!

The Patient

Who is at risk?ØInguinal hernias make up 75% of all abdominal herniasØOf those, 80% indirect 20% direct

Ø MaleØ Increasing age Ø Raised Intra-abdominal pressure Ø Obesity

Patient PresentationØSwelling/lump in groinØPainlessØGets bigger when coughing Ø“goes in” on laying downØAching in groinØDevelop over time/suddenlyØAsymptomatic - ?incidental finding

ØWhat else may you want to ask the patient?

Patient Presentation cont.Ø Where will a patient with a hernia present?General practiceA&EClinicLook out on inpatient wards!

Ø Differentials?LymphadenopathyLymphomaSaphina varixHydrocoele Abscess

Most Important

Point!!

Red Flags!!!!!!

ØReducible = Able to return the hernia to the usual anatomical site through the defect

ØIncarcerated = Fixed hernia that is compressed by the defect and cant be reducedØObstructed = Incarcerated and bowel is compressed Bowel obstructionØStrangulated = Compromised blood supply, incarceration causing ischaemia

Bit of Terminology…

Red Flags!!!!!!

ØPain – worse on coughing/bending, may be out of proportionØChange in bowel habitØSkin changes – erythemaØTender on palpationØTense

ØAs a junior, Identify – Emergency/Not?

Signs & Symptoms…

Investigations & Management Ø Clinical examination (another Webinar??)Ø USS if uncertaintyØ If features of obstruction or strangulation, CT scan

Ø Obstruction/Strangulation = Urgent surgical explorationØ Asymptomatic = conservative managementØ Open mesh repair = primary inguinal herniaØ Laparoscopic approach = Pts deemed high risk or history of recurrence

SurgeryConsiderations for open vs laproscopic

Ø Pts suitability for general anesthesiaØ Nature of the presenting herniaØ Suitability of the hernia for each optionØ Experience of the surgeon in each

technique

Ø British hernia society advises open for primary single-sided hernia

Summary1 2

AnatomyLearn in context. How will this help me with a

patient?

Direct vs IndirectDirect = through

Hesselbach triangle

Indirect = Through the canal

Red FlagsPain out of proportion

Skin changesTender

Change in bowel habit

1 2 3

Additional Resources

TeachMeAnatomy Series

Local guidelines NICE in UK

Guidelines “Conditions and diseases”

PassMedicine

Armando HasudunganYouTube videos

References1. https://www.drrpadmakumar.com/blog/hiatal-hernia/

2. https://teachmeanatomy.info/abdomen/areas/inguinal-canal/

3. https://teachmeanatomy.info/abdomen/areas/inguinal-triangle/

4. https://teachmesurgery.com/general/small-bowel/inguinal-hernia/

5. https://www.medicalisland.net/health-guide/natural-treatment-for-hiatal-hernia

6. https://www.dailymail.co.uk/health/article-4639024/NHS-hernia-mesh-repairs-leave-thousands-agony.html

7. https://www.nice.org.uk/guidance/ta83/chapter/4-Evidence-and-interpretation

8. https://pubmed.ncbi.nlm.nih.gov/22729252/

9. https://www.nhs.uk/conditions/inguinal-hernia-repair/

Thank you!Please Leave Feedback