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Inguinal Hernia (Examination (Inspection (Look for any masses in groins.…

- - - - Above (and medial): inguinal hernia
      - Below (and lateral): femoral hernia
    - - Inguinoscrotal hernia are more likely to be indirect
    - - Hernia may lack bowel sounds if it just contains fat.
  - - - Mid pt. of ing. lig. or 1.5cm above femoral pulse
      - Hernia controlled = indirect
      - Not controlled = direct
- - - - Manage RFs: e.g. constipation, cough
        Weight loss
        Elasticated corset or truss
    - - Open: Lichtenstein Tension Free Mesh
      - Lap: TEP or TAPP mesh
  - - - Direct: 20%
        
        Commoner in elderly
        Acquired: weak posterior wall of canal
        Emerge through Hesselbach’s triangle
        Can acquire internal and external spermatic fascia
        Rarely descend into scrotum
        Rarely strangulate
      - Clinical Distinction
        
        Cameron, BJS 1994
        56% of direct hernias were wrongly classified as indirect on
        examination by consultant surgeons.
      - Indirect: 80%
        
        Commoner in young
        Congenital patent processus vaginalis
        Emerge through deep ring
        Same 3 coverings as cord and descend into the scrotum
        Can strangulate
    - - Femoral Hernia
        
        Commoner in females (wider femoral canal)
        Middle aged and elderly
        Neck is inferior and lateral to pubic tubercle
        High risk of obstruction and strangulation
        
        Mx
        50% risk of strangulation w/i 1mo
        Urgent surgery
        
        Elective: Lockwood Low Approach
        
        Low incision over hernia w/ herniotomy and
        herniorrhaphy (suture ing. ligt. to pectineal ligt.)
        
        Emergency: McEvedy High Approach
        
        High approach in inguinal region to allow inspection
        and resection of non-viable bowel.
        Then herniotomy and herniorrhaphy
    - - Inguinal Canal
        
        Ant: ext. oblique + int. oblique for lateral 3rd
        
        Post: transversalis fascia + conjoint tendon for medial 3rd
        
        Floor: inguinal ligament
        
        Roof: arching fibres of transversus and int. oblique
      - Femoral Canal
        
        Lat: femoral vein
        
        Ant: inguinal ligament
        
        Post: pectineal ligament (of Cooper)
        
        Med: lacunar ligament
        
        Contents: fat and Cloquet’s Node
      - Contents of Inguinal Canal
        M: spermatic cord + ilioinguinal N.
        F: round lig., ilioinguinal N., gen branch of genfem N.
      - Operative Distinction
        
        Indirect: arise lateral to inf. epigastric vessels
        
        Direct: arise medial to inguinal ligament, through
        Hesselbach’s Triangle
        
        Med: rectus abdominis muscle
        
        Lat: inf. epigastric artery
        
        Inf: inguinal ligament
    - - 3 layers of fascia
      - 3 arteries + 3 veins
      - 2 nerves
      - 3 other things
    - - Post-Op Recovery
        
        Pee before leaving
        
        Early mobilisation is important
        
        Can be painful: given good analgesia
        
        Avoid constipation: lactulose
        
        Keep the area clean and dry: wash carefully
        
        Can bathe immediately
        
        Work in 1-2wks (6wks if heavy lifting)
    - - Lap
        
        2 main techniques
        
        Totally ExtraPeritoneal (TEP)
        
        Trans-Abdominal Pre-Peritoneal (TAPP)
        
        Better for bilateral hernia
      - Open
        Lichtenstein Tension Free Mesh Repair
        
        LA or GA: day case
        Less recurrence cf. older Shouldice Repair
        NB. In children, simple ligation and division of the patent
        processus suffices: no mesh needed.
    - - Early
        
        Urinary retention
        
        Haematoma / seroma formation: 10%
        
        Infection: 1%
        
        Intra-abdominal injury (lap)
      - Late
        
        Recurrence: <2%
        
        Ischaemic orchitis: 0.5%
        
        2O thrombosis of pampiniform plexus
        
        Chronic groin pain / paraesthesia: 5%