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Surg Oral Exam: 11. Hernia

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Differential diagnosis for 62 year old man with bulge and pain in groin?
o Groin:
- Hernia (reducible, incarcerated, strangulated): Inguinal (direct, indirect), Femoral;
- other scrotal mass: Hydrocele, Varicocele, Hematoma, Lymphadenopathy, Abscess, Musculoskeletal groin pain
o Abdomen: Hernia (reducible, incarcerated, strangulated): Umbilical, Incisional; other: Abscess, Abdominal wall tumor (lipoma, hemangioma, fibroma, metastasis), Rectus diastasis
62 year old man with bulge and pain in groin. initial steps?
"I would first assess the patient's general appearance and vital signs. I would then determine if there is any need for immediate resuscitation."
Relevant HPI for 62 year old man with bulge and pain in groin?
OLD CART
- Reducible?
- Pain?
- discoloration?
- BMs?
Associated symptoms: weight loss, fever, n/v/nc
Relevant PMH and PSH for 62 year old man with bulge and pain in groin?
-PMH: Prior hernia, Obesity, COPD, Cirrhosis w/ascites, Constipation, Peritoneal dialysis, BPH, Pregnancy (female), Pelvic tumor
- PSH: Abdominal surgery, Inguinal surgery, Prior hernia repair (with or without mesh?)
Relevant meds, allergies, SH, FH, ROS for 62 year old man with bulge and pain in groin?
- Any meds or allergies
- SH: Job or hobby involving heavy lifting. History of alcohol, smoking, drug use.
- FH: relevant family history
- ROS: constitutional, GI, GU systems
Relevant physical exam for 62 year old man with bulge and pain in groin?
• General: Toxic,
• Abdomen: Inspect (scars, bulge - stand/supine/valsalva), Auscultate: for bowel sounds in mass, Palpate (standing/supine), Reducible; Percuss (peritonitis)
• Genitourinary: Inguinal ring exam (cough)
How would an indirect hernia present on physical exam?
Inguinal ring exam - finger into scrotum to external inguinal ring and cough.
More often descends into scrotum and is elliptical, felt at tip of finger.
How would an direct hernia present on physical exam?
Inguinal ring exam - finger into scrotum to external inguinal ring and cough. More often circular swelling at external ring, posterior wall relaxed or absent on palpation, feel on side of finger.
How would an femoral hernia present on physical exam?
Palpate the inguinal folds for bulge in medial thigh inferior to inguinal ligament (may indicate presence of femoral hernia).
Relevant labs for bulging inguinal mass?
• CBC (May see elevated WBC with strangulated bowel)
• Electrolytes, BUN/Cr (if surgery necessary)
• Type and screen, coags (if surgery necessary)
Imaging for bulging inguinal mass?
• Often a clinical diagnosis, studies not always necessary.
• Consider ultrasound for questionable swelling or obscure pain.
• Consider acute abdominal series for signs of obstruction (air-fluid levels) or perforation (free intraperitoneal air).
• Consider CT if body habitus prevents good physical exam.
Bulge that returns into abdomen spontaneously or with manual pressure. May cause pain. Dx and Tx?
Reducible Hernia
• Dx: Impulse in the mass with coughing. Bulge can be reduced.
• Non-operative management: Asymptomatic or mildly symptomatic hernias may be observed in the elderly or those at risk for high operative morbidity.
• Operative management: Hernias should be repaired electively when the patient can tolerate surgery to prevent future incarceration and strangulation.
Sudden development of painful, tender bulge that cannot be reduced. Dx and Tx?
Incarcerated Hernia
• Non-operative management: Give analgesics and sedation to promote muscle relaxation and attempt manual reduction. If it reduces, operative management may be delayed if there is no concern for strangulated bowel.
• Operative management: If non-operative reduction fails, operative repair should be attempted urgently and bowel should be inspected due to concern for strangulation (ischemia). The abdominal wall should be repaired in a tension-free manner.
Painful, tender bulge that cannot be reduced. May have signs of intestinal obstruction (nausea, vomiting). Appears toxic. Dx and Tx?
Strangulated Hernia
• Dx: Non-reducible, tender bulge on physical exam, leukocytosis, peritoneal signs if perforated. Order acute abdominal series (dilated bowel, air-fluid levels -> obstruction, free intraperitoneal air-> perforation).
• Non-operative management: Start broad spectrum antibiotics. Place NGT if concern for obstruction.
• Operative management: This is a surgical emergency and operative repair should proceed emergently. All necrotic bowel should be resected.
Scrotal swelling in men and labial swelling in women. When examining through scrotum the examiner feels hernia at tip of finger when patient coughs. Dx and Tx?
Indirect Inguinal Hernia
o Operative Management: Goals are to reduce hernia sac, tighten the internal ring, and repair abdominal wall defect (patent processus vaginalis).
- Lichtenstein (most common): Suture mesh over the inguinal floor defect to the transversalis fascia and conjoint tendon above and the shelving edge of the inguinal ligament below.
- Laparoscopic repair: For recurrent or bilateral hernias
- Bassini: Transversalis fascia and conjoint tendon are sutured to the shelving edge of the inguinal ligament.
- McVay: Transversalis fascia and conjoint tendon are sutured to Cooper's ligament (periosteum of the pubic ramus). Must also do a "relaxing incision."
Patent processus vaginalis allows abdominal contents to protrude through the internal inguinal ring into the inguinal canal. Defect is lateral to the inferior epigastric vessels
Indirect Inguinal hernia
Scrotal swelling in men and labial swelling in women. Circular swelling at external ring. When examining through scrotum examiner feels bulge on side of finger when patient coughs, posterior wall relaxed or absent on palpation.
o Operative Management: Goals are to reduce hernia sac, tighten the internal ring, and repair abdominal wall defect (patent processus vaginalis).
- Lichtenstein (most common): Suture mesh over the inguinal floor defect to the transversalis fascia and conjoint tendon above and the shelving edge of the inguinal ligament below.
- Laparoscopic repair: For recurrent or bilateral hernias
- Bassini: Transversalis fascia and conjoint tendon are sutured to the shelving edge of the inguinal ligament.
- McVay: Transversalis fascia and conjoint tendon are sutured to Cooper's ligament (periosteum of the pubic ramus). Must also do a "relaxing incision."
Weakness in the transversalis fascia which forms the floor of Hesselbach's triangle (inguinal ligament, inferior epigastric vessels, lateral border of rectus muscle). Defect is medial to the inferior epigastric vessels. It does not pass into the scrotum.
Direct Inguinal Hernia
Bulge in medial thigh below inguinal ligament. More common in females. Palpable bulge below inguinal ligament. Dx and Tx?
Operative Management: Reduce the hernia and complete a Cooper's ligament repair (McVay procedure, see above) or use prosthetic mesh to repair defect in transversalis fascia.
Bulge protruding from umbilicus. Dx and Tx?
Umbilical Hernia
Operative Management: Fascial defect can be closed primarily or with mesh if defect is too large.
Defect in abdominal wall. Often exacerbated by ascites or pregnancy.
Umbilical hernia
Bulge at site of previous incision. Dx and Tx?
Incisional Hernia
• Management: Repaired after recover from previous operation. Fascial defect can be closed primarily or with mesh if defect is too large.
Poor wound healing from previous incision results in fascial defect through which abdominal contents can herniate.
Incisional Hernia
Hernia through the linea alba above the umbilicus.
Epigastric hernia
Hernia lateral to the rectus sheath at the semilunar line.
Spigelian hernia
Hernia through obturator canal.
Obturator hernia
Hernia through posterior abdominal wall somewhere in the lumbar region.
Lumbar hernia
Hernia through the muscles and fascia of the perineal floor.
Perineal hernia
Hernia around a stoma.
Parastomal hernia
Large medial hernia, usually at site of previous midline abdominal incision.
Ventral hernia
Hernia picture
Hernia in children?
Almost always indirect in children due to a patent processus vaginalis. Inguinal hernia in childhood should be repaired since they do not resolve spontaneously. The operation involves high ligation of the hernia sac with obliteration of the internal ring. Always directly visualize the opposite internal ring at the time of surgery to ensure that there is no hernia on the contralateral side.
Umbilical hernia need to be treated?
Common in children but usually closes spontaneously by age 2 years. Operative management is only indicated if the intestine becomes incarcerated, the defect is greater than 1.5 cm, or the child is > 4 years old.
When should you not use prosthetic mesh to repair a hernia defect?
When there is infection or gangrenous bowel.
Which nerves do you need to be mindful of when doing an inguinal hernia repair?
Genitofemoral and ilioinguinal
What is a Richter hernia?
Only part of the circumference of bowel is incarcerated or strangulated in the fascial defect.
What is a sliding hernia?
Hernia with a wall made up of an intra-abdominal organ such as the cecum, ascending colon, sigmoid colon, or bladder
Which groin hernia has the highest risk of incarceration and strangulation?
Femoral hernia due to the narrow neck.
What is a pantaloon hernia?
A hernia in which the peritoneum protrudes on both sides of the inferior epigastric vessels giving a combined indirect and direct hernia.
Are large or small hernias more likely to become incarcerated/strangulated?
Small
What is a component separation repair?
Operative technique used to close large ventral hernias resulting from previous midline abdominal incision. The external oblique and rectus anterior muscles are mobilized and moved medially in order to provide full, tension-free coverage of the ventral hernia.
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