Clinical presentation contributing factors obesity, chronic cough, pregnancy, constipation,straining on urination, asc...
Clinical presentation
- contributing factors
- obesity, chronic cough, pregnancy, constipation,straining on urination, ascites, activities which increase intra-abdominal pressure
- previous hernia repair
- groin mass of variable size
- develops insidiously in most cases
- occasionally precipitated by single forceful muscular event
- associated discomfort
- worse at end of day
- relieved at night when patient reclines and hernia reduces
- relieved with manual reduction
- +/- obstruction
- +/- local tenderness
- must examine patient in both supine and standing positions
- hernial sac and contents enlarge and transmit palpable impulse when patient coughs or strains
- may auscultate bowel sounds
- unable to “get above” groin mass with palpation
- mass does not transilluminate
- strangulation results in
- intense pain followed by tenderness
- intestinal obstruction
- gangrenous bowelsepsis
- a surgical emergency
- small, new hernias more likely to strangulate
- do not attempt to manually reduce hernia if sepsis present or contents of hernial sac thought to be gangrenous
Treatment
- surgical: goals are to prevent strangulation, eviscerations
and for cosmetics - indirect hernias - principle of repair is high ligation of sac and tightening of the internal ring
- direct hernias - principle of repair is to rebuild Hesselbach's triangle: need good fascia or a prosthesis
- femoral hernias - principle of repair is to remove sac of fat and close the femoral canal with sutures
Postoperative complications
- scrotal hematoma
- deep bleeding - may enter retroperitoneal space and not be initially apparent
- difficulty voiding
- painful scrotal swelling from compromised venous return of testes
- neuroma/neuritis
- stenosis/occlusion of femoral vein when treating femoral hernias causing acute leg swelling
Prognosis (inguinal hernia repair)
- indirect: < 1% risk of recurrence
- direct: 3-4% risk of recurrence
