Let’s begin our discussion of inguinal and femoral hernias. This is the classic Hesselbach triangle.
You’ll notice there are two triangles formed divided by the epigastric vessels. To the left of the
screen is the medial side of the abdomen. Medial to the epigastrics are known as direct hernias.
Lateral to the epigastric vessels are indirect hernias. There are some different types of hernias
in the groin. We’ve talked about the indirect through the indirect ring, a direct hernia
which is medial to the epigastric vesels, and the femoral hernia which is below the inguinal ligament.
What are some of the findings or historical or physical findings associated with inguinal hernias?
Let’s discuss some of the high-frequency findings. First, a bulge. This is the initial picture you were seeing.
This patient has a large inguinal bulge. This patient also likely has been chronically incarcerated
as a large defect like this did not happen overnight. Additionally, there are variable presentations
of nausea and vomiting. The nausea and vomiting occurs either because of the discomfort
due to the intestinal contents going into the scrotal sac or through the inguinal canal
or it could actually represent a small bowel obstruction. The bowel obstruction, point of transition,
actually in the inguinal canal. Lastly, obstipation; obstipation means the inability to pass flatus
or have bowel movements, again a potentially late sign of a bowel obstruction. What are some
risk factors for hernias? Commonly, heavy lifting. Whether it’s part of exercise regimen
or part of daily work, people who have repetitive heavy lifting are at high risk. Chronic cough patients;
what are some possible diagnoses for patients with chronic cough? Smokers, COPDers and patients
with asthma; constipation, particularly chronic in nature; and obesity. The question is what do these
things have in common that risks the patient of having an inguinal hernia? Well, it’s basically
anything that increases Valsalva maneuvers and intraabdominal pressure puts the patient at
increased risk of developing hernias. Let’s go over the decisions you’re making for the diagnosis
of inguinal hernias. The vast majority of the time, I can diagnose anyone with hernia based on
physical examination alone. These physical exam maneuvers include invagination of the inguinal canal.
How is that performed? Warn the patient. Insert one finger through the scrotum and into the inguinal canal.
That’s why it’s called an invagination. Warn the patient that it can cause some discomfort.
Have the patient perform a Valsalva maneuver. You all remember. You see it on TV.
Turn your head and cough. They don’t have to cough. They just have to bear down
and produce a Valsalva maneuver to see whether or not we can elicit the hernia in the office.
If the physical examination is not so clear, sometimes you may need cross-sectional imaging
like a CT scan of the abdomen and pelvis. This is particularly true when it’s an equivocal exam
where there are limitations to your examination, whether the patient can't tolerate it or they're too
morbidly obese that your exam can’t be trustworthy. Here’s a management schema of inguinal
and femoral hernias. As a surgeon, I consider hernias both inguinal and femoral
as either reducible or not. The reducible hernias, you can buy a little bit of extra time.
The patients who are not reducible may need surgery more urgently. Let’s look at a patient
who has a reducible hernia. Those patients, I can offer an elective repair. I counsel the patient.
If the bulge comes out and you can’t push it back in, you develop signs of a bowel obstruction
such as nausea, vomiting, or lack of bowel movements or flatus. Those are signs to instruct your patient
to return to the emergency department. If the patient is not reducible, that’s a different story.
Those patients are then thought of as either strangulated or incarcerated. Recall earlier
in this lecture, strangulated patients means that the blood supply to content of the hernia are
compromised. Those patients need urgent repair or emergent repair rather.
If the patient is simply incarcerated and it’s an acute incarceration, I would recommend an urgent repair.
In select patients particularly high-risk patients, chronically incarcerated patients, the decision
to proceed with surgery is one that you have with the patient. Let’s discuss a little bit about
how to do an open inguinal hernia repair. In the subsequent slides, you’ll see the exposure after
incising the external oblique aponeurosis. Once you open up the external oblique aponeurosis,
underlying it is the spermatic cord. The cord contains important spermatic cord vessels, vas deferens,
and of course, your hernia sac. Once the hernia sac is reduced, it’s standard to place piece of mesh.
Mesh is usually medical grade plastic that patches your repair. As the tissues have already demonstrated,
they have some inherent weaknesses of their own. Question for you. Do all inguinal hernias
need to be repaired? I’ll let you think about this.