Surgical Emergencies
Question 20 of 180
A 57 year old man presents to the Emergency Department with a 2 day history of pain and swelling in the left groin. On examination you note a reducible swelling and suspect an inguinal hernia. Which of the following is NOT a risk factor for inguinal hernias?
Answer:
Risk factors include:- Male sex.
- Connective tissues disorders (such as Marfan's syndrome, or Ehlers-Danlos syndrome).
- Family history.
- Older age — incidence increases with age.
- Smoking.
Inguinal Hernia
Surgical Emergencies
Last Updated: 8th September 2021
An inguinal hernia is a protrusion of the abdominal or pelvic contents through a dilated internal inguinal ring alongside the spermatic cord, but also extend down the inguinal canal into the scrotum. An inguinal hernia is bilateral in up to 20% of cases.
Pathophysiology
Inguinal hernias are categorised as either direct or indirect, based on the relationship of the hernia sac to the inferior epigastric artery.
- Indirect inguinal hernias usually occur because of a persistent processus vaginalis. The hernia sac comes through the deep inguinal ring, lateral to the inferior epigastric artery, passing through the inguinal canal and exiting via the superficial ring. If an inguinal hernia extends into the scrotum, it is almost always indirect.
- Direct hernias occur because of degeneration and fatty changes in the aponeurosis of the transversalis fascia that constitutes the inguinal floor or posterior wall in the Hesselbach triangle area. The hernia sac comes through the inguinal floor medial to the inferior epigastric artery and the deep inguinal ring.
Risk factors
Risk factors include:
- Male sex.
- Connective tissues disorders (such as Marfan's syndrome, or Ehlers-Danlos syndrome).
- Family history.
- Older age — incidence increases with age.
- Smoking.
Complications
Complications are rare, but include:
- Incarceration — the contents of a hernia are fixed in the sac and the hernia cannot be reduced. The risk of incarceration is estimated to be 0.3–3.0% per year for all inguinal hernias, but the risk is 10 times higher with indirect inguinal hernias than direct inguinal hernias. An incarcerated hernia can lead to a bowel obstruction or strangulation.
- Strangulation — the blood supply of the contents of the hernia is compromised, causing ischaemia.
- Intestinal obstruction — the abdominal wall defect acts as a tourniquet around the hernial contents, causing bowel obstruction.
Clinical features
- Onset may be acute or chronic.
- Often painless but pain may be present, particularly if the hernia is incarcerated or strangulated.
- Abdominal or groin discomfort with bulge.
- There may be a dull dragging discomfort in the scrotum.
- May enlarge with Valsalva-type manoeuvres, and disappear on lying down (if reducible).
- On examination, it is not possible to 'get above' the swelling, or palpate the spermatic cord or inguinal ring; and there is a positive cough impulse.
Differential diagnosis
- Undescended testis
- Femoral hernia
- Lymphadenopathy
- Femoral aneurysm
- Psoas abscess
- Hydrocele
- Spermatocele
- Saphena varix
Investigations
- Most inguinal hernias are diagnosed clinically by observation and palpation. Additional investigations are not usually required. Imaging may be useful when there is diagnostic uncertainty (e.g. in a very obese patient, or other complex cases).
- Ultrasound scan of groin may be useful when there is diagnostic uncertainty.
Management
- Exclude strangulation or obstruction, which are suggested by:
- An acutely painful, firm, tender, irreducible mass (strangulation).
- Vomiting, constipation, absence of flatus, and abdominal pain and distension (obstruction).
- If there are features of strangulation or obstruction, admit immediately. Urgent surgical repair is indicated for acute incarcerated hernia to prevent strangulation and necrosis of the affected intestine.
- If there are no features of strangulation or obstruction:
- For an infant or young boy, refer urgently to a paediatric surgeon (preferably to be seen within 2 weeks).
- For men or older boys:
- Refer urgently for surgical repair if the hernia is irreducible, or only partially reducible.
- Refer all others routinely for surgical repair, unless they have minimally symptomatic inguinal hernias and significant comorbidity, and do not want to have surgery.
Femoral hernia
- Femoral hernias account for only about 5% of abdominal hernias.
- They are more common in women than men, and with advancing age.
- Femoral hernias may not present any symptoms at all, especially if they are of a small or medium size.
- Larger hernias may become visible as a lump or bulge in the area of the upper thigh, lateral and inferior to the pubic tubercle.
- The risk of strangulation is much greater than that of an inguinal hernia, and thus all femoral hernias should be repaired as an elective procedure.
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
