Makindo Medical Notes

"Incarcerated" and "Strangulated" Inguinal Hernias are surgical emergencies.

About

• An inguinal hernia occurs when abdominal contents push through a weakness in the abdominal wall, typically in the inguinal canal.
• Herniated material can include peritoneum, fat, and sometimes small bowel, increasing the risk of complications.

Anatomy

Types of Inguinal Hernias

• Reducible: Herniated material can be pushed back into the abdominal cavity.
• Non-reducible: Herniated material cannot be pushed back.
• Incarcerated: Trapped bowel can lead to bowel obstruction.
• Strangulated: Compromised blood supply to the bowel, leading to ischemia. This is a surgical emergency.

Risk Factors

• Gender: Males are at an 8x greater risk than females.
• Increasing age
• Family history of hernias
• History of prostatectomy
• Low BMI and connective tissue disorders

Indirect and Direct Inguinal Hernias

• Indirect: Exits via the external inguinal ring, often due to a congenital weakness. Seen more in men but can affect women and children.
• Direct: Bulges through the posterior wall of the inguinal canal, more common in older men. Often linked to obesity, heavy lifting, and conditions causing chronic coughing or straining.

Clinical Presentation

• Swelling lies below the inguinal ligament, emerging above and medial to the pubic tubercle.
• Positive cough impulse; the hernia can extend to the scrotum.
• Symptoms include pain and discomfort, with tenderness suggesting potential strangulation.
• A sudden increase in pain requires urgent assessment.

Investigations

• Blood tests: FBC, U&E, LFT, CRP, Group, and Save.
• Imaging:
  • Abdominal X-ray (AXR) and Erect Chest X-ray (CXR).
  • CT Abdomen for detailed visualization.
  • Ultrasound (USS), CT, or MRI for imaging the defect.

Management

• Acute Presentation: ABCs, IV fluids, Nil by Mouth, analgesia, and fluid resuscitation. If incarcerated or strangulated, needs urgent surgical review and possibly IV antibiotics to prevent necrosis and gangrene.
• Delayed Treatment: May be fatal in severe cases. Surgical options include laparotomy with resection if bowel is affected or conservative management if not obstructed.
• Most inguinal hernias require surgical repair, with options for open or laparoscopic surgery depending on patient factors (e.g., hernia size, age, and overall health).

Open Hernia Surgery

• Performed under local anaesthesia.
• The surgeon makes an incision in the groin to reduce the hernia, using stitches and mesh to close and reinforce the weak area.

Laparoscopic Hernia Surgery

• Usually performed under general anaesthesia.
• Involves small incisions in the lower abdomen, allowing the surgeon to use tools to repair the hernia with mesh placement.
• Often has a shorter recovery time than open repair.

Potential Surgical Complications

• General Anaesthesia Risks: Includes nausea, vomiting, urinary retention, sore throat, and in rare cases, MI, stroke, pneumonia, and blood clots.
• DVT/PE: Encouraged mobilization post-surgery to reduce the risk of blood clots and pneumonia.
• Hernia Recurrence: Common complication that may require a second operation.
• Bleeding: Can lead to swelling and discolouration; rare, but surgery may be needed to control bleeding.
• Wound Infection: Seen in less than 2% of patients, may need antibiotics and further review if symptoms arise.
• Painful Scar: Some patients may experience pain near the incision, which usually resolves over time or may require local anaesthetic injections.
• Injury to Internal Organs: Although rare, accidental damage to internal organs (e.g., bladder, intestines) can occur and may require further intervention.

References

• Anatomy of Inguinal Hernias - Kenhub

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