Inguinal hernia Karen Brasel, MD, MPH Medical College of Wisconsin Mr. Roberts Your patient in the office is a 28 year-old male with a several day history of groin and testicular pain. History What other points of the history do you want to know? History, Mr. Roberts Consider the Following    Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors:    Pertinent PMH, ROS, MEDS. Relevant family hx. Associated signs and symptoms History, Mr. Roberts  Characterization of Symptoms: R groin pain began at work after lifting 50 lb boxes. Abrupt onset, now constant.  Alleviating / Exacerbating factors: Improved with lying down, worse with standing  Associated signs/symptoms: Eating normally, no diarrhea or constipation  Pertinent PMH: none  ROS: no dysuria  MEDS: Tylenol  SH: married, single partner. Construction worker  Relevant Family Hx. Noncontributory What is your Differential Diagnosis? Differential Diagnosis Based on History and Presentation      Inguinal hernia Testicular torsion Epididymitis Prostatitis Muscle strain Physical Examination What would you look for? Physical Examination, Mr. Roberts  Vital Signs: T 98.6, pulse 82, BP 132/76, RR 16  Appearance: healthy, uncomfortable Chest: clear CV: RRR Abd: soft, nontender, normoactive bowel sounds Rectal: normal tone, prostate nontender GU: testes descended, nontender, normal position. Epididymis and inguinal canal tender; bulge in R. inguinal canal Remaining Examination findings non-contributory Would you like to revise your Differential Diagnosis? Revised Differential  Inguinal hernia  Epididymitis Laboratory What would you obtain? Labs ordered, Mr. Roberts  CBC Lab Results, Discussion • In a young, otherwise healthy patient in whom the diagnosis can be made clinically, laboratory studies are unnecessary. • An elevated white blood cell count might help you make the distinction between epididymitis, an infectious process, and an incarcerated inguinal hernia. • However, it can be normal in epididymitis and might be elevated in an incarcerated hernia due to compromised or ischemic bowel within the hernia sac Lab Results, Discussion  “Routine” preoperative laboratory studies are costly, and false positives occur up to 10% of the time. Selective ordering should be the routine.  History and physical are the best way to screen for coagulation abnormalities.  Hematocrits should be obtained only for • Patients who are at risk for abnormalities. • Procedures with significant blood loss. • Patients with considerable comorbidity. Lab Results, Discussion  Guidelines for obtaining routine chemistries • BUN/Creatinine, potassium − Renal disease − Diabetics − >60 years old − CV disease − Diuretics, digoxin − corticosteroids • Glucose− >60 years old − diabetics − corticosteroids What would you do now? Interventions at this point?  Re-examine the patient  Obtain diagnostic studies  Schedule patient for surgery Studies What further studies would you want at this time? Studies, Mr. Roberts  An ultrasound can be helpful if the diagnosis of a hernia is truly in doubt. However, often a careful re-examination of the patient with specific attention paid to examining the epididymis separately from the inguinal canal will make an ultrasound unnecessary. Revised Differential Diagnosis  Inguinal hernia, incarcerated What next? What next? 1. Immediate OR 2. Attempt at reduction What next?  Reduction should be attempted in the patient with an incarcerated hernia. This allows an operation to be performed electively rather than emergently, and allows choice of anesthesia and operative approach.  Reduction is best accomplished by elongating the neck of the hernia sac while applying pressure to reduce the hernia. The patient should be given adequate sedation and analgesia, and placed in Trendelenberg position. Management Discussion of patient response to management recommendations: If reduction is unsuccessful, the patient should be prepared for urgent operation. Management  Although symptomatic hernias should all be repaired operatively, it is not clear that all small, asymptomatic hernias should be fixed.  Age, comorbid conditions, patient activity and patient preference should be considered.  Current trials are studying the natural history of these small hernias. Management   Hernias do not always present as a “groin bulge”, and not all patients will complain of groin pain. Consider the following: An 80-year old woman who resides at a nursing home has lost several pounds 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. Management  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? Discussion  The majority of hernias should be repaired when discovered, as the mortality increases 9 to 10 fold with emergent compared to elective repair. Elective repair done with an open approach can be performed under local, spinal, or general anesthesia. It can also be done laparoscopically, which requires general anesthesia.  In addition to the elective or urgent/emergent nature or the repair, anesthetic choice, patient preference, and primary or recurrent nature of the hernia factor into the decision regarding operative approach. A laparoscopic approach, or an open preperitoneal approach, is best for recurrent or bilateral hernias. For unilateral primary groin hernias, the approaches have similar recurrence rates, similar disability times, and similar costs. Discussion  Indirect hernia: contents protrude through the indirect inguinal ring through a patent processus vaginalis into the inguinal canal. In men, they follow the spermatic cord and may present as scrotal swelling, while in females they may present as labial swelling.  Direct hernia: contents protrude through Hesselbach’s triangle medial to the inferior epigastric vessels.  Femoral hernia: contents protrude through the femoral canal, bounded by the inguinal ligament superiorly, the femoral vein laterally, and the pyriformis and pubic ramus medially. Unlike inguinal hernias, these hernias protrude below, rather than above, the inguinal ligament. Discussion  Obturator hernia: Herniation through the obturator canal alongside the obturator vessels and nerves. This hernia occurs mostly in women, particularly elderly women with a history of recent weight loss. A mass may be palpable in the medial thigh, particularly with the hip flexed, externally rotated and abducted (Howship-Romberg sign).  Sliding hernia: A hernia in which one wall of the hernia is made up of an intraabdominal organ, most commonly sigmoid colon, ascending colon, or bladder. Laparoscopic Hernia Reduction Laparoscopic Repair QUESTIONS ?????? Summary  Inguinal hernia is primarily a clinical diagnosis  Ultrasound can be helpful in diagnosing testicular torsion; also if hernia diagnosis unclear  Surgical repair, elective or emergent  Various operative and anesthetic approaches  Obturator and occasionally femoral hernias may present as nonspecific abdominal pain, nausea/vomiting Acknowledgment The preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials we welcome your comments/ suggestions at: [email protected]