Hernia Part 1

8/9/2019 Hernia Part 1

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Anatomy of the inguinal region


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Hasselbachs Triangle

Anatomical triangle used to define Inguinal Hernias

Boundaries of Hasselbach's Triangle Medial boundary: Rectus abdominis

Lateral boundary: Inferior epigastric vessels

Inferior boundary: Inguinal ligament

Interpretation Indirect Inguinal Hernia (out of Hasselbach's Triangle)

Enters Inguinal Canal lateral to inferior epigastrics

Exits Inguinal Canal inferior to inguinal ligament

Direct Inguinal Hernia (within Hasselbach's Triangle) Breaches posterior inguinal wall

Passes medial to inferior epigastric vessels


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Symptoms and signs of

inguinal herniaHistory

Age

-May appear at any age- peak time , first few months of life, late

teens , and between 40 and 60

occupation , heavy work puts greatstrain on the abdominal muscles


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Local symptoms

The most common symptoms are discomfort

and pain (dragging, aching pain, which

increase with the days )Severe pain and tenderness indicates

strangulation

In most cases patient presents havingnoticed a swelling in the groin or scrotum

without any pain


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other abdominal symptoms

- Bowel obstruction, with colicky pain felt inthe central abdomen instead of the groin

- Large hernia may interfere with bowel

habit

Ask about other diseases that may cause

increased intra abdominal pressure, such

as bronchitis with persistent cough


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definition of terms used in the

description of herniae Incarcerated, the contents are imprisoned

In the sac , but are alive and functioning

Obstructed, the intestinal lumen isobstructed but not the blood vessels

Strangulated, blood supply to the contentshas been cut off , and they are dead ordying


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examination

The main aim of examination is to determine the

site, size and constituents of the lump,

reducibility and expansile cough impulse .

position (position of the hernial sac & and the

point of reduction)

Colour & Temperature of the skin should benormal unless the hernia is strangulated it

becomes reddened and warm


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Tendernes

- Non-strangulated Hernia ..only discomfort- Strangulated hernia is very tender

- Irreducible non-strangulated hernia istender only with excessive pressure

Size

Surface, according to the contents

Composition, e.g.

- soft, resonant and fluctuant when there is gut

- dull, firm and non-fluctuant when itcontains omentum


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Cough impulse

Reducibility

State of local tissue, look for any scars

near the hernia

general examination

Look for the common causes of raised

intra-abdominal pressure, chronic

bronchitis with cough, chronic urineretention, asciets, intraabdominal mass


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Technique for the examination of

an inguinal hernia Ask the patient to stand up, to see the true

size of the hernia and to be able to confirm

the diagnosis

Look at the lump from in front, determine

the exact site and shape, whether is

extend to the scrotum or not, and inspect

the normal side


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Feel the front

- examine the scrotum and its contents

- try to feel the upper edge of the lump and see if

you can get above it

Feel from the side

stand at the side of the patient on the same sideas the hernia , place one hand on the patients

back to support him and your examining hand on

the lump with your fingers parallel to the inguinal

ligament.( position, temp., tenderness, shape, size,

composition, reducibility )


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Expansile cough impulse , expand and become moretense with coughing

Is the swelling reducible?

press firmly to reduce the tension of the lump, thencompres the lower part of the swelling, left it towards theexternal ring, oce it passes through that point , slide your

fingers upwards and lateraly towards the internal ring

( direct vs. indirect ) if the hernia remains controlled bypressure on the external ring

( direct vs. indirect ) direction of protrusion after reduction


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* if the hernia reduces at a point above and

medial to the pubic tubercle, its an inguinal

hernia.

if the point of reduction is below and lateral

to the pubic tubercle, its a femoral hernia


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Remove your hand and watch the herniareappear.

the direction of movement confirms thedifference between a direct & an indirecthernia

Percuss and ouscultate Feel the other side ( inguinal hernia are

commonly bilateral

Examine the abdomen searching for

causes of raised intra-abdominal pressure


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Umbilical hernia

a true umbilical hernia comes through the

umbilical scar and has the umbilical skin

tethered to it .

HistoryAge: even though the weakness is present at birth,

the hernia may not be noticed untill the umbilical

cord has separated and healed.

- Its not common in adults

Ethnicity (more common in afro-caribbean)

symptoms, rarely cause other symptoms


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Examination

- Shape and size ( usually hemispherical 0.5to 10 cm diameter )

- Explore the depth of the umbilicus with the

tip of the finger to find the defect

- Composition

- Usually reduce spontaneously when lying

down and becomes tense when the child

cries

- Cough impulse


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Para-umbilical hernia

Acquired hernia that appears through a defect thatis adjacent to the umbilical scar

history

Age, middle and old age and more common infemales

Symptoms, most common are discomfort andswelling

Strangulation whether it has been noticed by

the patient or not, it usually contains extraperitoneal fat or

omentum , so when strangulated , the bowel isnot obstructed


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Examination

Position beside the umbilicus

Pushes the umbilicus and gives a crescentshape

Surface and edge ( smooth and well

defined ) Composition (usually fat or omentum)

Cough impulse

Relations, the skin at the centre of theumbilicus is not attached to centre of thesac

Documents

Hernia Part 1