Hernia Examination

Introduction

Facts you should know:

- Mid inguinal point = ASIS to pubis symphysis (femoral artery)
- Midpoint of inguinal ligament = ASIS to pubic tubercle (deep inguinal ring: 1 to 2cm above femoral pulse)
- Superior inguinal ring = above & medial to pubic tubercle
- Inguinal hernia = above and medial to pubic tubercle
- Femoral hernia = below and lateral to pubic tubercle
- Indirect can extend into scrotum

- Divarication of the recti = This is not strictly a type of hernia. This occurs when the two rectus abdominus muscles (either side of the midline) deviate from one another. More pronounced superiorly, and is due to the either intrinsic laxity of the linea alba, or weakening secondary to repeated surgery or chronic abdominal distension/raised intra-abdominal pressure. To demonstrate a divarication, ask the patient to lift their head off the pillow whilst lying down - the divarication will become pronounced. It will then almost completely disappear when the patient lies flat again. It is not painful and does not require surgery.

- Remember to look for hernias at end of GI examination.

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Inguinal Hernias

General features:

- More common in men than women
- Congenital: secondary to patent processus vaginalis
- Acquired: weakness of wall

Indirect:

- often found in younger patients
- arise lateral to inferior epigastric artery - always acquired

Direct:

- often older patients (weaker abdominal walls)
- arise medial to inferior epigastric artery

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Examination

Key points:

1. Wash your hands, introduce yourself, and ask permission (consent) to examine. Always check if patient is in any pain. Adequately expose the area.

2. Ask patient to stand: see reducible hernias & see hernias on other side, as well as scars. Can examine lying down if the hernia is still obvious lying down. Otherwise examine patient whilst standing.

3. Kneel to side of patient (not directly in front, or will look slightly dodgy). Get patient to cough and feel for a cough impulse (suggestive of herniae).

4. Ask patient if they can reduce the lump or 'make it go away' themselves. This can be a useful way of demonstrating reduction without hurting the patient.

5. If not painful and a reduction is possible, put your fingers over the superficial ring and repeat cough test. If the hernia does not reappear then it is indirect.

6. Check the contralateral side.

7. Say to the examiner that you would also like to examine the abdomen.

8. Cover patient up/allow to redress

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Complications

Operative complications:

- vascular damage
- nerve damage (ilio-inguinal)
- spermatic cord damage
- bowel damage
- bruising
- recurrence

Complications of hernias:

- incarceration (become non-reducable)
- strangulation (become ischaemic, as vascular supply gets cut off)
- Richters hernia = strangulated but not obstructed (lumen partially obstructed)
- bowel obstruction

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Other Types Of Hernias

Umbilical:

- These are common, and are often congenital.
- Small ones usually spontaneously close by 2yrs. Larger ones/non-closing ones are usually operated on when the child is around 3-4yrs old.
- Can occur later in life (umbilicus is a 'weak spot') - often appear later in the elderly and women who have given birth.

Incisional:

- These are also very common post-operatively.
- A number of factors can predispose to an increased risk of incisional hernia. Learn these factors for good 'wound healing'. They are divided into pre-operative (nutritional status, age, obesity, etc.), operative (good surgical suture technique, good haemostasis, etc.) and post-operative (infections, controlling cough, etc.).
- These often frequently recur with repair.

Spigelian:

- Found along edge of rectus abdominus.

Obturator:

- Rare. Relatively more common in women.
- Hernia sac protrudes through obturator foramen. More likely to be symptomatic rather than cause a visible mass.

Epigastric:

- Occurs between the umbilicus and the xiphisternum (in the midline).
- Often composed of fat/omentum - rarely contain bowel. Can often be painless and easily reduced.

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