Clinical Examination of the Hernia

 

Inguinal hernia

Ask the patient to stand up (or can done in supine position first)

Always examine both inguinal regions

Look

at the lump from in front

Is this swelling a hernia?
  • Anatomical site of a hernia (groin)
  • Expansile impulse on cough (except if strangulated) (كح)
  • Reducible (except if irreducible, obstructed or strangulated) (تقدر ترجعها؟)
  • Opaque by transillumination (except in infants)
Which type (femoral or inguinal)?
  • Exact site (palpate ASIS and pubic tubercle ‘inguinal ligament’)   above or below?
Is it recurrent? (Scars)
Scrotum and penis
Feel Feel from in front (same items as inspection +)

Examine the scrotum

If you can “get above it

Feel from the side Stand at the side of the patient on the same side as the hernia. Place one hand in the small of the patient’s back to support him And your examining hand on the lump with your fingers and arm roughly parallel to the inguinal ligament

Examine for (Position – Temperature – Tenderness – Shape – Size – Tension)

Expansile cough impulse (كح)
Is the swelling reducible? Direction of reduction (تقدر ترجعها؟)
Internal ring test (direct or indirect?)
Percuss and auscultate

the lump

Gut in the sac may be resonant and there may be audible bowel sounds
What is the content?
Intestine (enterocele) vs. Omentum (omentocele)

Consistency: Soft  vs. Doughy

Gurgling: Occurs during reduction vs.  None

Ease of reduction: First part is more difficult to reduce than the last vs.  Last part is more difficult to reduce

Percussion: May be resonant vs.  Dull

Complete by

Ventral hernias

Ask the patient to stand up (or usually done in supine position first)
Look Is this swelling a hernia?
  • Anatomical site of a hernia
  • Expansile impulse on cough (except if strangulated (هم براسك او كح)
  • Reducible (except if irreducible, obstructed or strangulated) (تقدر ترجعها؟)
Which type ? Umbilical, paraumbilical or epigastric.
Is it recurrent? (Scars)
Feel Examine for (Position – Temperature – Tenderness – Shape – Size – Tension)
Expansile cough impulse (هم براسك او كح)
Is the swelling reducible? Direction of reduction (تقدر ترجعها؟)
Percuss and auscultate the lump Gut in the sac may be resonant and there may be audible bowel sounds
What is the content?
Intestine (enterocele) Omentum (omentocele)

Consistency: Soft vs.  Doughy

Gurgling: Occurs during reduction  vs. None

Ease of reduction: First part is more difficult to reduce than the last vs.  Last part is more difficult to reduce

Percussion: May be resonant vs.  Dull

Complete by

TAKING HISTORY FROM A PATIENT WITH A Hernia

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Lump
    • Anatomical site of hernia
    • Expansile impulse on cough (except if strangulated)
    • Reducible (except if irreducible, obstructed or strangulated)
  • Symptoms suggesting complication
    • Symptoms of intestinal obstruction (Pain – Vomiting – Distension – Absolute constipation)
    • Symptoms suggesting sliding hernia
      • Urinary symptoms (urinary bladder in inguinal hernia)
      • Dyspepsia (stomach in epigastric hernia)
  • History of suggesting cause
    • Congenital (sense birth)
    • Acquired
      • Raised intra-abdominal pressure (Chronic cough – Straining at micturation or stools – Heavy work – Obesity – Huge abdominal swelling)
      • Weak abdominal wall (Obesity – Senility – Debility – Pregnancy – Weak scar – Damage nerve supply of the muscles)

Differential diagnosis of hernias

Abdominal herniae
  • Common
    • Inguinal
    • Umbilical
    • Incisional
    • Femoral
    • Epigastric
  • Rare
    • Spigelian
    • Obturator
    • Lumbar
    • Gluteal
The differential diagnosis of a lump in the groin
  • Inguinal hernia
  • Femoral hernia
  • Enlarged lymph glands
  • Sapheno-varix
  • Ectopic testis
  • Femoral aneurysm
  • Hydrocele of the cord or hydrocele of the canal of Nuck
  • Lipoma of the cord
  • Psoas bursa
  • Psoas abscess
The differential diagnosis of inguinal hernia
  • Femoral hernia
  • Vaginal hydrocele
  • Hydrocele of the cord or the canal of Nuck
  • Undescended testis
  • Lipoma of the cord
Differences between indirect (oblique) inguinal hernia and direct inguinal hernia

Indirect inguinal hernia

Direct inguinal hernia

Age Any age Elderly
Side Uni or bilateral Commonly bilateral
Shape Oblong hemispherical
descent into the scrotum Can (and often does) Does not (hardly ever)
Direction of reduction upwards, then laterally and backwards upwards, then straight backwards
Internal ring test Controlled, after reduction ,by pressure over internal inguinal ring Not Controlled, after reduction ,by pressure over internal inguinal ring
The defect not palpable, as it is behind the fibres of the external oblique muscle may be felt in the abdominal wall above the pubic tubercle
Direction of descent After reduction, the bulge reappears in the middle of inguinal region and then flows medially before turning down to the neck of the scrotum After reduction, the bulge reappears exactly where it was before
at operation Neck of the sac is Lateral to the inferior epigastric artery Neck of the sac is Medial to the inferior epigastric artery
Anatomical types of oblique inguinal hernia
  • Congenital type
    • Reaches down to the bottom of the scrotum
    • Testis lies among the content of the sac
  • Infantile type
    • Operative finding
  • Adult type
    • Bubonocele
      • Limited to inguinal canal
    • Funicular hernia
      • Reaches down to the neck of the scrotum
    • Complete (scrotal) hernia
      • Descends to the bottom of the scrotum
      • Testis is behind the hernia and difficult to locate
The differential diagnosis of femoral hernia
  • Inguinal hernia
  • Enlarged lymph gland
  • Sapheno-varix
  • Ectopic testis
  • Psoas abscess
  • Lipoma
Complication of hernia
  • Irreducibility
  • Obstruction
    • Manifestations of intestinal obstruction
    • Locally hernia becomes (Distended – Irreducible – Soft)
  • Strangulation
    • Acute pain
    • Sudden enlargement of the hernia
    • Manifestations of intestinal obstruction
    • Locally hernia becomes (Tense – Tender – Irreducible – No impulse on cough)
  • Inflammation
    • Locally hernia becomes (Tender – Not tense – Overlying skin is red and oedematous)
  • Hydrocele of a hernia sac
  • Torsion of omentum
Causes for raised intra-abdominal pressure or weak abdominal wall?
  • Occupation
  • Multiplicity of hernias
  • Divercation of recti
  • Bulge of lower abdomen on straining
Operative differences between viable and non viable intestine

Viable

Non viable

Luster Normal luster Lusterless
Color Pink Grey or black
Mesenteric arteries pulsation Pulsating Not pulsating
Bleeding Bleeds if injured Does not bleed
Consistency Firm Flabby and thin
Effect of pinching Contract if pinched No response
Contents of spermatic cord

3 arteries

  1. Testicular artery (abdominal aorta)
  2. Artery of vas (inferior vesical)
  3. Cremasteric (inferior epigastric)

3 nerves

  1. Ilioinguinal
  2. Cremasteric
  3. Sympathetic

3 tubes

  1. Vas deferens
  2. Pampiniform plexus of veins
  3. Lymphatic vessels