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, usually in the inguinal canal.
• Contents may include peritoneum, fat, or small bowel, leading to possible complications.

Anatomy

Types of Inguinal Hernias

• Reducible: Contents can be pushed back into the abdomen.
• Non-reducible: Herniated material cannot be pushed back, increasing risk of complications.
• Incarcerated: Trapped bowel may lead to bowel obstruction.
• Strangulated: Blood supply to the bowel is compromised, leading to ischaemia. This is a surgical emergency.

Risk Factors

• Male gender: 8 times more likely than females.
• Increasing age, family history of hernias, previous prostate surgery.
• Low BMI, connective tissue disorders.

Indirect and Direct Inguinal Hernias

• Indirect: Passes through the external inguinal ring, typically due to a congenital weakness. Common in men but can also affect women and children.
• Direct: Protrudes through the posterior wall of the inguinal canal. Often seen in older men and linked to obesity, heavy lifting, chronic coughing, or straining.

Clinical Presentation

• Swelling appears below the inguinal ligament, above and medial to the pubic tubercle.
• Positive cough impulse; hernia may extend to the scrotum.
• Symptoms include pain and discomfort, with tenderness indicating possible strangulation.
• Sudden increase in pain warrants immediate medical 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 to evaluate the defect.

Management

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

Open Hernia Surgery

• Performed under local anaesthesia.
• Involves an incision in the groin to reduce the hernia, with stitches and mesh reinforcing the weak area.

Laparoscopic Hernia Surgery

• Usually performed under general anaesthesia.
• Uses small abdominal incisions, allowing the surgeon to repair the hernia with mesh placement. Shorter recovery time compared to open repair.

Potential Surgical Complications

• General Anaesthesia Risks: Nausea, vomiting, urinary retention, sore throat, and in rare cases, MI, stroke, pneumonia, and blood clots.
• DVT/PE: Early mobilization post-surgery reduces blood clot and pneumonia risks.
• Hernia Recurrence: May require additional surgery.
• Bleeding: Can cause swelling and discolouration; rare cases may need surgery for control.
• Wound Infection: Seen in less than 2% of cases, may need antibiotics if symptoms arise.
• Painful Scar: Some patients may experience pain near the incision, usually resolving over time or with local anaesthetic injections.
• Injury to Internal Organs: Rare, but accidental damage to organs (e.g., bladder, intestines) may require further intervention.

References

• Anatomy of Inguinal Hernias - Kenhub