Makindo Medical Notes.com

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

About

• A femoral Hernia is a weakness in the abdominal wall
• This allows abdominal contents to enter Herniated material may just be peritoneum and fat but can be small bowel.

Anatomy

Types

• Herniated material can be pushed back: reducible hernia
• Herniated material may not be able to be pushed back: non reducible
• Incarcerated: Bowel can become trapped and cause obstruction.
• Strangulated: Bowel can have its vascular supply compromised and be strangulated
• These are acute surgical emergencies

Risks

• Males > Females x 8, Increasing age
• Family history, Prostatectomy
• Low BMI, Connective tissue disorders

Indirect and Direct

• Indirect: exits via the external inguinal ring and is due to an inherited predisposition from birth. It may not become apparent until later in life. Women and children may develop this type of hernia but far commoner in men.
• Direct: Bulges through the posterior wall of the inguinal canal and tends to be seen in older patients. This type of hernia primarily occurs in men. Rare in women and children. More common with Obesity, Heavy lifting, Coughing, Straining with urination or defecation, COPD, Ascites, Peritoneal dialysis, Ventriculoperitoneal shunt

Clinical

• Swelling lies below inguinal ligament
• Emerges above and medial to the pubic tubercle
• It has a positive cough impulse
• The hernia can extend to the scrotum
• May cause pain and discomfort
• Tenderness may suggest possible strangulation
• Sudden increase in pain or discomfort should seek assessment

Investigations

• FBC, U&E, LFT, CRP, Group and save
• AXR and Erect CXR
• CT Abdomen
• USS/CT/MRI may be used to image the defect

Management

• Acute Presentation - ABC, IV fluids, Nil by Mouth, Analgesia, Fluid Resuscitation if pain or incarcerated/strangulated/obstructed needs urgent surgical review. May need IV antibiotics. The strangulated bowel can result in necrosis and gangrene.
• Delayed treatment may be fatal. Some may need laparotomy and resection of the large or small bowel. Others may require a period of conservative assessment if not obstructed.
• Most people with inguinal hernias will need surgery to repair the hernia
• Choice is between open and laparoscopic hernia surgery are available.
• Depends on factors such as the size of the hernia and age, health, and medical history.

Open hernia surgery

• Can be done under local anaesthesia.
• Surgeon makes a cut in your groin to view and repairs and reduces the hernia.
• Surgeons use stitches and a piece of mesh to close the abdominal wall.
• This strengthens the weak area where the hernia occurred.
• Sometimes stitches alone can close and strengthen the weak area

Laparoscopic hernia surgery

• Usually done under General anaesthesia
• Surgeon makes several small cuts in your lower abdomen and inserts special tools to view and repair the hernia.
• The surgeon uses a piece of mesh to close and strengthen the abdominal wall.
• Recovery time after laparoscopic surgery may be shorter than with open repair.

Potential Surgical Complications

• Risk of general anaesthesia. Common complications include nausea, vomiting, urinary retention, sore throat, and headache. More serious problems include MI, stroke, pneumonia, and blood clots in the legs.
• DVT/PE: Follow local policies. Getting out of bed after surgery and moving as soon as the doctor allows will help reduce the risk of complications such as pneumonia and blood clots.
• Hernia recurrence. A hernia can recur up to several years after repair. Recurrence is the most common complication of inguinal hernia repair, causing patients to undergo a second operation.
• Bleeding. May cause severe swelling and bluish discolouration of the skin around the incision. Surgery may be necessary to open the incision and stop the bleeding. Bleeding is unusual and occurs in less than 2% of patients.
• Wound infection: Risk is less than 2 per cent. May have a fever, discharge from the incision, and redness, swelling, or tenderness around the incision. Postoperative infection requires antibiotics and review.
• Painful scar. Sometimes people experience sharp, tingling pain in a specific area near the incision after it has healed. The pain usually resolves with time. LA may be injected to help.
• Injury to internal organs. Although extremely rare, injury to the intestine, bladder, kidneys, nerves and blood vessels leading to the legs, internal female organs, and vas deferens-the tube that carries sperm-can occur during hernia surgery and may lead to more operations.

References