Karen Brasel, MD, MPH Medical College of Wisconsin Inguinal hernia Karen Brasel, MD, MPH Medical College of Wisconsin

Mr. Roberts Your patient in the office is a 28 year-old male with a several day history of groin and testicular pain.

History What other points of the history do you want to know?

History, Mr. Roberts Characterization of symptoms Temporal sequence Consider the Following Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors: Pertinent PMH, ROS, MEDS. Relevant family hx. Associated signs and symptoms

History, Mr. Roberts Pertinent PMH: none ROS: no dysuria MEDS: Tylenol SH: married, single partner. Construction worker Relevant Family Hx. Noncontributory Characterization of Symptoms: R groin pain began at work after lifting 50 lb boxes. Abrupt onset, now constant. Alleviating / Exacerbating factors: Improved with lying down, worse with standing Associated signs/symptoms: Eating normally, no diarrhea or constipation

What is your Differential Diagnosis?

Differential Diagnosis Based on History and Presentation Inguinal hernia Testicular torsion Epididymitis Prostatitis Muscle strain

Physical Examination What would you look for?

Physical Examination, Mr. Roberts Vital Signs: T 98.6, pulse 82, BP 132/76, RR 16 Appearance: healthy, uncomfortable Chest: clear Rectal: normal tone, prostate nontender CV: RRR GU: testes descended, nontender, normal position. Epididymis and inguinal canal tender; bulge in R. inguinal canal Abd: soft, nontender, normoactive bowel sounds Remaining Examination findings non-contributory

Would you like to revise your Differential Diagnosis?

Revised Differential Inguinal hernia Epididymitis

Laboratory What would you obtain?

Labs ordered, Mr. Roberts CBC

Lab Results, Discussion In a young, otherwise healthy patient in whom the diagnosis can be made clinically, laboratory studies are unnecessary. An elevated white blood cell count might help you make the distinction between epididymitis, an infectious process, and an incarcerated inguinal hernia. However, it can be normal in epididymitis and might be elevated in an incarcerated hernia due to compromised or ischemic bowel within the hernia sac

Lab Results, Discussion “Routine” preoperative laboratory studies are costly, and false positives occur up to 10% of the time. Selective ordering should be the routine. History and physical are the best way to screen for coagulation abnormalities. Hematocrits should be obtained only for Patients who are at risk for abnormalities. Procedures with significant blood loss. Patients with considerable comorbidity.

Lab Results, Discussion Guidelines for obtaining routine chemistries BUN/Creatinine, potassium Renal disease Diabetics >60 years old CV disease Diuretics, digoxin corticosteroids Glucose- diabetics

What would you do now?

Interventions at this point? Re-examine the patient Obtain diagnostic studies Schedule patient for surgery

Studies What further studies would you want at this time?

Studies, Mr. Roberts An ultrasound can be helpful if the diagnosis of a hernia is truly in doubt. However, often a careful re-examination of the patient with specific attention paid to examining the epididymis separately from the inguinal canal will make an ultrasound unnecessary.

Revised Differential Diagnosis Inguinal hernia, incarcerated

What next?

What next? Immediate OR Attempt at reduction

What next? Reduction should be attempted in the patient with an incarcerated hernia. This allows an operation to be performed electively rather than emergently, and allows choice of anesthesia and operative approach. Reduction is best accomplished by elongating the neck of the hernia sac while applying pressure to reduce the hernia. The patient should be given adequate sedation and analgesia, and placed in Trendelenberg position.

Management Discussion of patient response to management recommendations: If reduction is unsuccessful, the patient should be prepared for urgent operation.

Management Although symptomatic hernias should all be repaired operatively, it is not clear that all small, asymptomatic hernias should be fixed. Age, comorbid conditions, patient activity and patient preference should be considered. Current trials are studying the natural history of these small hernias.

Management Hernias do not always present as a “groin bulge”, and not all patients will complain of groin pain. Consider the following: An 80-year old woman who resides at a nursing home has lost several pounds over the last 3 months. For the last 3 days she has not been able to eat anything, has been vomiting, and was found in bed this morning confused and quite ill. Her abdominal exam is fairly unremarkable without any previous scars.

Management This woman likely has an obturator or possibly a femoral hernia. Obesity can make examination of the groin difficult. Her management is much different than the previous case.

Management How might this change your management? Plain films of the abdomen should also be obtained, as the patient may have a bowel obstruction due to small bowel incarceration in the hernia. How might this change your management?

Discussion The majority of hernias should be repaired when discovered, as the mortality increases 9 to 10 fold with emergent compared to elective repair. Elective repair done with an open approach can be performed under local, spinal, or general anesthesia. It can also be done laparoscopically, which requires general anesthesia. In addition to the elective or urgent/emergent nature or the repair, anesthetic choice, patient preference, and primary or recurrent nature of the hernia factor into the decision regarding operative approach. A laparoscopic approach, or an open preperitoneal approach, is best for recurrent or bilateral hernias. For unilateral primary groin hernias, the approaches have similar recurrence rates, similar disability times, and similar costs.

Discussion Indirect hernia: contents protrude through the indirect inguinal ring through a patent processus vaginalis into the inguinal canal. In men, they follow the spermatic cord and may present as scrotal swelling, while in females they may present as labial swelling. Direct hernia: contents protrude through Hesselbach’s triangle medial to the inferior epigastric vessels. Femoral hernia: contents protrude through the femoral canal, bounded by the inguinal ligament superiorly, the femoral vein laterally, and the pyriformis and pubic ramus medially. Unlike inguinal hernias, these hernias protrude below, rather than above, the inguinal ligament.

Discussion Obturator hernia: Herniation through the obturator canal alongside the obturator vessels and nerves. This hernia occurs mostly in women, particularly elderly women with a history of recent weight loss. A mass may be palpable in the medial thigh, particularly with the hip flexed, externally rotated and abducted (Howship-Romberg sign). Sliding hernia: A hernia in which one wall of the hernia is made up of an intraabdominal organ, most commonly sigmoid colon, ascending colon, or bladder.

Laparoscopic Hernia Reduction

Laparoscopic Repair

QUESTIONS ??????

Summary Inguinal hernia is primarily a clinical diagnosis Ultrasound can be helpful in diagnosing testicular torsion; also if hernia diagnosis unclear Surgical repair, elective or emergent Various operative and anesthetic approaches Obturator and occasionally femoral hernias may present as nonspecific abdominal pain, nausea/vomiting

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