Hernia

Hernia

Protrusion of tissue through the fascial, muscle layer, or other barrier design to contain them

Inguinal

A hernia the originates above the inguinal ligament (96% of groin hernias)

Femoral

A hernia the originates below the inguinal ligament (4% of groin surgery) and develops in the empty space at the medial aspect of the femoral canal, inferior to the inguinal ligament, medial to the femoral vein - more common in women

Incarcerated

Hernia contents are NOT reducible - presents with cramping pain, abdominal pain, and distention

Strangulated

Contents of the hernia are incarcerated and ischemic

Indirect inguinal hernia

Develops at the internal inguinal ring and are lateral to the inferior epigastric artery caused by a patent processus vaginalis (intestinal contents travel down the spermatic cord through the deep and superficial inguinal ring) - most common hernia in both sexes

Direct inguinal hernia

Occurs through Hesselbach’s triangle, which is formed by the inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the rectus muscle medially

bulge in groin, acute/chronic, maybe abdominal distention, N/V

Presentation of indirect inguinal hernia

Acquired 2/2 weakened floor of the inguinal canal - enlarges with time, doesn’t pass through the DEEP ring

Pathophys for Direct inguinal hernia

Obesity, pregnancy, heavy lifting, chronic cough, straining to void (BPH, prostate cancer), constipation, cirrhosis with ascites

Risk factors for direct inguinal hernia

Bulging in groin, acute/chronic, maybe abdominal distention, N/V, normally doesn’t extend to the scrotum, if incarcerated/strangulated then its a surgical emergency

Presentation of direct inguinal hernia

Identify the external ring (invaginate the scrotum and palpate while coughing - good enough 🥇), testicular eval, determine if strangulated/incarcerated, Groin U/S (Do this 1st), CT 🏆

How do you diagnose inguinal hernias

Control comorbidities (BPH), BMI under 30-35 (fix the underlying before repair),

Pre-op measures for Inguinal Hernia - all bets are off if strangulated/incarcerated

Chronic cough, prostatism, constipation, poor tissue quality, poor operative technique

What may contribute to the recurrence of the inguinal hernia - fix these before surgery

Laparoscopic (bilateral repairs, need for earlier return, recurrent, failed open unilateral repair), Open repair (initial unilateral repair)

How do you treat an inguinal hernia if symptomatic

bleeding/hematoma, injury to other structures (spermatic cord, ilioinguinal nerve), recurrence (infection)

Complications of inguinal hernia repairs (more with recurrent/large)

laparoscopic = 15 days, open = 34 days

Recovery time for inguinal hernia repair

groin bulge, groin pain, constipation, N/V, ileus

Presentation of femoral hernia

Bulge exacerbated by valsalva/cough, nontender (usually)

Physical Exam findings for femoral hernia

Surgical management - urgent if strangulated/non-reducible, if stable then elective

Treatment for femoral hernia

Leukocytosis, fever, bowel ischemia (necrosis → perforation)

Signs of strangulated hernia - must be resected

Epigastric hernia

A protrusion of peritoneal fat (usually) through the linea alba above the umbolicus

nontender mass, normally easily reducible, no ileus or obstruction

Presentation of epigastric hernia - get a U/S or CT

Referral for routine surgery, abdominal corset

Treatment for epigastric hernia

Most spontaneously close prior to school age, repair at age 2 if they persist

Treatment plan for umbilical hernia in Newborns/Children - incarceration is rare

multiparity, obesity, ascites, intra-abdominal tumors

Risk factors for an umbilical hernia in an adult

elective surgery repair (emergency repair is often necessary)

Treatment plan for an umbilical hernia in an adult

open procedure (can be lap or robotic), infra-umbilical incision following the contour of the umbilicus, lyse adhesions and reduce the omentum out o the umbilicus, place mesh over the defect and close the defect

Operative repair for umbilical hernia

Incisional hernia

A herniation through a previous operative site - dehiscence through the facial closure with intact skin

infection, cough, obesity, immunocompromised, comorbidities, local discomfort with bulging

Risk factors for incisional hernia

Surgical repair, abdominal binder

Treatment for incisional hernia

Wound dehiscence

A surgical complication when the sutures pop open, if the fascia pops out its a hernia (emergent surgical eval)

Diastasis recti

A widening of the linea alba due to pregnancy, obesity, increase intra-abdominal pressure - not a hernia, produces a midline bulge when the patient raises their hear

Sports hernia

A series of micro-tears of the adductor, rectus, femoris, psoas, hip flexor, oblique that can be a manifestation of osteitis pubis - not a true hernia

lifestyle limiting pain, failure of conservative treatment , exclusion of other diagnosis

Indications for surgical stabilization of osteitis pubis

Hydrocele

A complications of a patent processus vaginalis that results with a fluid filled sac next to testis that can be congenital, infection, trauma, or tumor - nontender, transilluminates

Epididymitis

Testicular pain that has an acute onset and is associated with prostatitis or vasectomy - may have WBCs in the urine

STI panel, NSAID, Scrotal support, Abx for STIs

Work up for a young man if its giving epididymitis

STI panel, scrotal support, NSAIDs, Abx for gram neg rods

Work up for an older man if its giving epididymitis

Spermatocele

A fluid filled mass attached to the epididymis that is normally nontender and a benign finding - confirm with U/S and treat surgically

Varicocele

Dilated veins on the scrotum that is normally on the left side - may be related to infertility (surgery is reserved for infertility of spermatic vein occlusion)

CANCER (urgent referral for U/S and surgery)

Solid mass on the testicular is what until proven otherwise

Urgent U/S with doppler and surgical evaluation → if viable re-profuse and tack it down (orchiopexy), if not viable (orchiectomy)

Workup for testicular torsion