HERNIAS

 

Etiology:

  1. Direct inguinal = acquired (chronic cough, obesity), often bilateral, protrudes  into  Hasselbach's  triangle.
     
  2. Indirect inguinal = congenital, can present at any age, protrudes into inguinal ring and lateral to  Hasselbach's triangle.
     
  3. Femoral = affects women > male , inferior to inguinal ligament and palpable below groin.
     
  4. Spigelian = hernia through a weak spot between fascia of oblique muscle and rectus muscle. Easy to miss since is hard to palpate.
  5. Richter's = only one loop of  viscus is strangulated.
     
  6. Epigastric = protrusion through linea alba above the umbilicus. Symptom free.
     
  7. Incisional / Ventral = dehiscence of wnd from previous surgery.
     
  8. Umbilical = often presents in infancy and repairs spontaneously, yet may reappear 2ry to ­   intrabdominal pressure (pregnancy, ascites).

S & S:

  1. Generally all hernias present with  lumps in the above described areas, and they accentuate with  maneuvers such as sitting-up, coughing.  Pts c/o pressure, but GI symptoms such as indigestion, N/V/C/D are absent, unless complications are present.
     
  2. To distinguish between Indirect vs. Direct inguinal hernia index finger is placed in pt's scrotum till it reaches inguinal ring. Pt is instructed to cough or bear  down. In case of  Indirect hernia this may descend into scrotum and touch finger, while in case of  Direct hernia, this almost never descend and hernia bulges anteriorly  to groin. This description is purely  theoretical and is not definitive for diagnosis. A hernia that bulges anteriorly to groin also occurs with femoral hernia (see above)

Complications:  

  1. Irreducible/Incarcerated - hernia cannot be pushed back with proper maneuvers. It does not mean  that there is SBO or strangulation unless Vital Signs (VS) are abnormal and  there is elevation in  WBC. Abnormal VS also suggests that hernia was out for quite sometime and risk of strangulation and/or dead bowel is present. If spontaneously reduced and patient feels better, pt should be admitted for  observation
  2. Strangulated - compromised blood supply to incarcerated viscus. Skin overlying the hernia is  erythematous/pale, very tender. N/V/F, abdo pain and abnormal VS are present. This must  not be  reduced and if reduced (by pt or spontaneously), pt must be opened and dead bowel must be removed.
  3. Infected Mash - occurs after hernia repair and pt presents with N/V/F, abdo pain. Dx is made with CT. Elevation in WBC generally is present.
     
  4. SBO -  obstruction does not imply strangulation although this may occur concomitantly.

DX:

  1. When asymptomatic, lump and sense of pressure  in described location are the only complains. Bowel sounds are present and this distinguishes between hernia and other causes of mass.
     
  2. Differential  between  Direct and Indirect hernia are described above.
     
  3. For complications, one must review VS, order routine labs ( WBS in case of strangulation), do thorough physical exam. AXray  to r/o SBO and CT to r/o infected mash are done when indicated.

Treatment:

  1. Asymptomatic pt is referred to f/u with surgical clinic.
     
  2. In Irreducible hernia, only if symptoms occurred recently, reduction is attempted by placing pt in Trendelenburg, IV MSO4, ice pack to  hernia and gentle but constant pressure. Pt with reducible hernia can be then D/C with surgical f/u once hernia is reduced. Otherwise, if incarceration  occurred  several  hrs. ago, hernia should not be reduced and surgical consult for operation should be obtained.
     
  3. Strangulation and SBO are indications for surgery ASAP. No attempt to reduce strangulated  hernia  is made. Both in  SBO and  strangulation pt is given IVF, NGT and Broad spectrum antbx.

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