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Inguinal Hernia
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Normal Anatomy Inguinal canal is a 3d cylinder between the deep and superficial inguinal rings Superior Wall – fibres of internal oblique and transversus abdominis Posterior wall – conjoined tendon on internal oblique, transversus abdominis and fascia transversalis Anterior wall – aponeurosis of the external oblique Inferior wall – inguinal ligament, lacunar ligament and the ilio-pubic tract Inguinal Canal Spermatic cord – in men Ilioinguinal nerve Genito-femoral nerve
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Normal Anatomy Inguinal canal is a 3d cylinder between the deep and superficial inguinal rings Superior Wall – fibres of internal oblique and transversus abdominis Posterior wall – conjoined tendon on internal oblique, transversus abdominis and fascia transversalis Anterior wall – aponeurosis of the external oblique Inferior wall – inguinal ligament, lacunar ligament and the ilio-pubic tract Inguinal Canal Spermatic cord – in men Ilioinguinal nerve Genito-femoral nerve
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Pathology A bulge or protrusion of tissue (usually intestine) from the abdominal cavity Tissue may or may not be able to moved back Reducible Hernia hernia sac can be manipulated and tissue moved back in Incarcerated/Irreducible the content of the hernia sac cannot be returned to the abdominal cavity can lead to complications Strangulated The blood supply to the entrapped contents is compromised Medical emergency
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Mechanism of Injury Insidious Multifactorial More common in males
Pathological changes in the connective tissue of the abdominal wall Chronic coughing and manual labour jobs have NOT been shown to increase risk of intra-abdominal pressure
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Classification Direct Hernia Indirect Hernia
Portion of the intestine protrudes directly outward through a weak point in the abdominal wall Superior to the inguinal ligament Painless Reduces when lying supine Round swelling near pubis area of deep inguinal ring Indirect Hernia Portion of the intestine pushes downward through the deep inguinal ring into the inguinal canal Through the deep inguinal ring Can pass into the scrotum (men) or labia (women) Pain with straining May decrease when lying supine Swelling that increases with intraabdominal pressure
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Subjective Examination
Intermittent or persistent bulge in the groin May report groin pain- can be pain free Pain worse with Valsalva maneuvers Heavy or dragging sensation in the groin Scrotal pain in men Worse at the end of the day or after prolonged activity Activities that increase intra-abdominal pressure worsen symptoms (pain and/or bulging) Coughing Lifting Straining More noticeable following heavy meal or standing for long periods Bulge disappears in a supine position
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Objective Examination
Swelling in the groin at rest or coughing Bulging in femoral or inguinal areas in standing
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Special Testing Internal examination of inguinal ring
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Further Investigation
Rarely required Ultrasound MRI
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Management Surgery considered for symptomatic, large or recurrent hernias Small, minimally symptomatic hernias managed conservatively Physiotherapy post operatively for rehabilitation
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Conservative Advised to monitor for symptoms of incarceration or strangulation
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Plan B Hernia repair Open Laparoscopic
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References Broadhurst, J. F. and C. Wakefield (2015). "Adult groin hernias: acute and elective." Surgery (Oxford) 33(5): Fitzgibbons, R. J., Jr. and R. A. Forse (2015). "Clinical practice. Groin hernias in adults." N Engl J Med 372(8): Irwin, T. and A. McCoubrey (2012). "Adult groin hernias." Surgery - Oxford International Edition 30(6): LeBlanc, K. E., L. L. LeBlanc and K. A. LeBlanc (2013). "Inguinal hernias: diagnosis and management." Am Fam Physician 87(12):
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