History

Fact Explanation
Lump in the groin [2] [8] [10] They most commonly present with a lump in the groin area due to bulging of the abdominal contents. The lump increases in size with standing up, heavy work, coughing, straining or any other instances in which intra abdominal pressure rises. It usually disappears when lying down. [2] [8] [10]
Vague pain in the groin area [2] [8] [10] Sometimes patients present with a vague pain in the groin which again increases with heavy weight lifting, coughing, straining. [2] [8] [10]
Acute intermittent abdominal pain [4] [6] [7] [9] A hernia can get obstructed and the patient can present with intestinal obstruction. Abdominal pain can be located according to the part of the intestine that gets obstructed and is classically intermittent. [4] [6] [7] [9]
Nausea, Vomiting [4] [6] [7] [9] This is a feature of acute intestinal obstruction and usually when the part of the intestine which is obstructed is proximal. [4] [6] [7] [9]
Constipation [4] [6] [7] [9] This is a feature of acute intestinal obstruction and mainly if large bowel gets obstructed. It can be absolute in which the passage of flatus doesn't occur as well. [4] [6] [7] [9]
Abdominal distension [4] [6] [7] [9] More distal the bowel obstruction is greater the distension. [4] [6] [7] [9]
Increased thirst, Reduced level of consciousness [4] [6] [7] [9] These are features of dehydration due to intestinal obstruction. With obstruction of the bowel oedema of the bowel wall occurs and fluid gets sequestered in the bowel lumen. It also causes defective absorption of fluid via the bowel wall. Additionally more fluid is lost due to vomiting. [4] [6] [7] [9]
References
  1. ABRAMSON JH, GOFIN J, HOPP C, MAKLER A, EPSTEIN LM. The epidemiology of inguinal hernia. A survey in western Jerusalem. J Epidemiol Community Health [online] 1978 Mar, 32(1):59-67 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1087312
  2. RUHL C. E., EVERHART J. E.. Risk Factors for Inguinal Hernia among Adults in the US Population. American Journal of Epidemiology [online] 2007 March, 165(10):1154-1161 [viewed 04 September 2014] Available from: doi:10.1093/aje/kwm011
  3. JANSEN PETRA, KLINGE UWE, JANSEN MARC, JUNGE KARSTEN. Risk factors for early recurrence after inguinal hernia repair. Array [online] 2009 December [viewed 04 September 2014] Available from: doi:10.1186/1471-2482-9-18
  4. DESARDA MOHAN P. . BMC Surg [online] 2003 December [viewed 04 September 2014] Available from: doi:10.1186/1471-2482-3-2
  5. JAMADAR DAVID A., JACOBSON JON A., MORAG YOAV, GIRISH GANDIKOTA, EBRAHIM FARHAD, GEST THOMAS, FRANZ MICHAEL. Sonography of Inguinal Region Hernias. American Journal of Roentgenology [online] 2006 July, 187(1):185-190 [viewed 04 September 2014] Available from: doi:10.2214/AJR.05.1813
  6. NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 04 September 2014] Available from: doi:10.1186/1757-1626-2-21
  7. SARTELLI MASSIMO, et al. WSES guidelines for emergency repair of complicated abdominal wall hernias. Array [online] 2013 December [viewed 04 September 2014] Available from: doi:10.1186/1749-7922-8-50
  8. GWANMESIA I I. Unexplained groin pain: safety and reliability of herniography for the diagnosis of occult hernias. [online] 2001 April, 77(906):250-251 [viewed 04 September 2014] Available from: doi:10.1136/pmj.77.906.250
  9. VALLICELLI CARLO, COCCOLINI FEDERICO, CATENA FAUSTO, ANSALONI LUCA, MONTORI GIULIA, DI SAVERIO SALOMONE, PINNA ANTONIO D. Small bowel emergency surgery: literature's review. Array [online] 2011 December [viewed 04 September 2014] Available from: doi:10.1186/1749-7922-6-1
  10. RICHARDSON WS, JONES DG, WINTERS JC, MCQUEEN MA. The Treatment of Inguinal Pain Ochsner J [online] 2009, 9(1):11-13 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096235

Examination

Fact Explanation
Lump in the groin [1] [4] The size of the hernia can increase with lifting of heavy weight, coughing, straining when the intra-abdominal pressure rises. When the patient is examined in the standing position, it appears and maybe apparent with coughing. Manual reduction maybe possible initially but when the hernia increases in size, it can get irreducible due to formation of fibrous adhesions. Direct and indirect hernias can be differentiated clinically only when the hernia is reducible. When the hernia is reduced, the finger is held over the internal ring and the patient is asked to cough. If the lump appears the hernia is direct and if not it's an indirect hernia as indirect hernias enter the inguinal canal through the internal ring. [1] [4]
Expansile cough impulse [1] [4] Finger is held over the lump and patient is asked to cough which produces an expansile cough impulse. Sliding hernias are probable with large scrotal hernias [1] [4]
Redness over the lump [5] [6] There can be redness over the lump. This usually indicates strangulation of the hernia with resultant bowel ischemia. [5] [6]
Tenderness over the lump [5] [6] There can be tenderness over the lump. Severe tenderness usually indicates strangulation of the hernia with resultant bowel ischemia. [5] [6]
Scar at the groin [1] [2] [3] [4] Inguinal hernias are known to recur. Therefore a previous hernia repair scar maybe present. [1] [2] [3] [4]
Exaggerated bowel sounds [5] [6] This is a feature of intestinal obstruction and due to increased peristalsis. [5] [6]
References
  1. RUHL C. E., EVERHART J. E.. Risk Factors for Inguinal Hernia among Adults in the US Population. American Journal of Epidemiology [online] 2007 March, 165(10):1154-1161 [viewed 26 August 2014] Available from: doi:10.1093/aje/kwm011
  2. BURCHARTH JAKOB, PEDERSEN MICHAEL, BISGAARD THUE, PEDERSEN CARSTEN, ROSENBERG JACOB, BURNEY RICHARD E.. Nationwide Prevalence of Groin Hernia Repair. PLoS ONE [online] 2013 January [viewed 26 August 2014] Available from: doi:10.1371/journal.pone.0054367
  3. DABBAS N., ADAMS K., PEARSON K., ROYLE G.. Frequency of abdominal wall hernias: is classical teaching out of date?. JRSM Short Reports [online] December, 2(1):5-5 [viewed 26 August 2014] Available from: doi:10.1258/shorts.2010.010071
  4. DESARDA MOHAN P. . BMC Surg [online] 2003 December [viewed 26 August 2014] Available from: doi:10.1186/1471-2482-3-2
  5. NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 26 August 2014] Available from: doi:10.1186/1757-1626-2-21
  6. RAVIKUMAR H, BABU S, GOVINDRAJAN MJ, KALYANPUR A. Reduction en-masse of inguinal hernia with strangulated obstruction. Biomed. Imaging Interv. J. [online] 2009 October [viewed 26 August 2014] Available from: doi:10.2349/biij.5.4.e14

Differential Diagnoses

Fact Explanation
Femoral hernia [1] [2] [3] This appears in the thigh below and lateral to the pubic tubercle whereas inguinal hernias appear above and medial. Even though inguinal hernias are more common in males, femoral hernias are common in females. [1] [2] [3]
Hydrocele [4] A hydrocele is a collection of fluid within the tunica vaginalis of the scrotum. It is possible to get above a hydrocele and the testis is bot separately palpable in a hydrocele. Additional clinical findings such as transillumination can also be observed. [4]
Spermatic cord hydrocele [7] fluid collection along the spermatic cord is called a spermatic cord hydrocele. This is a developmental abnormality. [7]
Lymph node enlagement [8] Enlarged lymph nodes in the groin due to an infective cause or a malignancy can mimic inguinal hernia. [8]
Groin abscess [9] Abscess in the groin area also appear as a lump but will be tender and overlying skin may be reddened. Additionally patient may be febrile. [9]
Saphena varix [10] This is a dilation of the saphenous vein at its junction with the femoral vein in the groin. [10]
Varicocele [11] Dilatation and tortuosity of veins of the pampiniform plexus result in varicoceles. Patients present with scrotal pain and swelling, or as a cause of male infertility. [11]
Undescended testis [12] There's failure of the testis to descend from its intra-abdominal location into the scrotum and can lie anywhere in it's usual pathway from abdomen to the scrotum. [12]
Lipoma of the cord [5] [6] This is commonly seen in males and benign [5] [6]
References
  1. SUZUKI SHIGERU, FURUI SHIGERU, OKINAGA KOTA, SAKAMOTO TSUTOMU, MURATA JUN, FURUKAWA AKIRA, OHNAKA YASUO. Differentiation of Femoral Versus Inguinal Hernia: CT Findings. American Journal of Roentgenology [online] 2007 August, 189(2):W78-W83 [viewed 26 August 2014] Available from: doi:10.2214/AJR.07.2085
  2. ATMATZIDIS STEFANOS, CHATZIMAVROUDIS GRIGORIOS, DRAGOUMIS DIMITRIOS, ATMATZIDIS KONSTANTINOS. Incarcerated Femoral Hernia Containing Ipsilateral Fallopian Tube. Case Reports in Medicine [online] 2010 December, 2010:1-3 [viewed 26 August 2014] Available from: doi:10.1155/2010/741915
  3. NIKOLOPOULOS IOANNIS, ODERUTH ESHAN, NTAKOMYTI ELENI, KALD BENGT. Intestinal Obstruction due to Bilateral Strangulated Femoral Hernias. Case Reports in Surgery [online] 2014 December, 2014:1-3 [viewed 26 August 2014] Available from: doi:10.1155/2014/195736
  4. KAPLAN G. W.. Scrotal Swelling in Children. Pediatrics in Review [online] 2000 September, 21(9):311-314 [viewed 26 August 2014] Available from: doi:10.1542/pir.21-9-311
  5. LONDEREE WILLIAM, KERNS TAMIE. Liposarcoma of the Spermatic Cord Masquerading as an Inguinal Hernia. Case Reports in Medicine [online] 2014 December, 2014:1-4 [viewed 26 August 2014] Available from: doi:10.1155/2014/735380
  6. VASHU RAVINDRAN, SUBRAMANIAM MANISEKAR. Large lipoma of the spermatic cord presenting as post-operative recurrent hernia in a middle aged gentleman: a case report. Array [online] 2009 December [viewed 26 August 2014] Available from: doi:10.4076/1757-1626-2-8500
  7. D MANIMARAN. Encysted Spermatic Cord Hydrocele in a 60-year-old, Mimicking Incarcerated Inguinal Hernia: A Case Report. JCDR [online] 2014 December [viewed 26 August 2014] Available from: doi:10.7860/JCDR/2014/6998.4039
  8. HUSSEINZADEH H., COTTA C. V., GORDON S., LICHTIN A.. A young woman with enlarged lymph nodes. Cleveland Clinic Journal of Medicine [online] December, 80(5):276-280 [viewed 26 August 2014] Available from: doi:10.3949/ccjm.80a.12086
  9. MALLICK I H. Iliopsoas abscesses. Postgraduate Medical Journal [online] 2004 August, 80(946):459-462 [viewed 26 August 2014] Available from: doi:10.1136/pgmj.2003.017665
  10. JAMADAR DAVID A., JACOBSON JON A., MORAG YOAV, GIRISH GANDIKOTA, DONG QIAN, AL-HAWARY MAHMOUD, FRANZ MICHAEL G.. Characteristic Locations of Inguinal Region and Anterior Abdominal Wall Hernias: Sonographic Appearances and Identification of Clinical Pitfalls. American Journal of Roentgenology [online] 2007 May, 188(5):1356-1364 [viewed 26 August 2014] Available from: doi:10.2214/AJR.06.0638
  11. MIYAOKA RICARDO, ESTEVES SANDRO C.. A Critical Appraisal on the Role of Varicocele in Male Infertility. Advances in Urology [online] 2012 December, 2012:1-9 [viewed 26 August 2014] Available from: doi:10.1155/2012/597495
  12. STANG A.. Undescended testis and the risk of testicular cancer: importance of source and classification of exposure information. [online] 2001 October, 30(5):1050-1056 [viewed 26 August 2014] Available from: doi:10.1093/ije/30.5.1050

Investigations - for Diagnosis

Fact Explanation
Ultrasound scan of the groin [1] [2] [3] [4] This has nearly 100% specificity and can detect herniae [1] [2] [3] [4]
CT scan of the groin [1] [2] [3] [4] If the ultrasound scan is negative and clinical suspicion is high further evaluation by CT of the groin may be done. But a negative CT scan will not exclude the possibility of a hernia and valsalva manoeuvre performed at time of the scan can increase the rate of detection. [1] [2] [3] [4]
Herniography [1] [2] [3] [4] This is an invasive investigation therefore not commonly done. [1] [2] [3] [4]
MRI scan of the groin [1] [2] [3] [4] Even though it's very sensitive and specific not commonly performed because this is an expensive investigation. [1] [2] [3] [4]
Urine full report [9] This may be done to rule out a urinary tract infection as a urinary tract infection may cause pain in the groin that can be mistaken for hernia pain [9]
Full blood count [5] [6] [7] [8] If strangulation is suspected, a full blood count may show high white cell count and high hematocrit due to dehydration. [5] [6] [7] [8]
X-ray abdomen [5] [6] [7] [8] If bowel obstruction is suspected, x-ray abdomen is done which shows multiple air fluid levels and dilated bowel loops. [5] [6] [7] [8]
Chest x-ray [10] If there's any predisposing chronic cough or any features of chronic obstructive pulmonary disease, which causes hernia, this need to investigated prior to management of hernia [10]
Flexible sigmoidoscopy [10] If there's chronic constipation, this needs to be investigated using a flexible sigmoidoscopy to assess the colon [10]
Ultrasound kidney, ureters and bladder [10] Straining at micturition can cause hernia as well. Therefore to detect any prostatic enlargement, or any obstruction this is done. [10]
References
  1. ABRAMSON J H, GOFIN J, HOPP C, MAKLER A, EPSTEIN L M. The epidemiology of inguinal hernia. A survey in western Jerusalem.. Journal of Epidemiology & Community Health [online] 1978 March, 32(1):59-67 [viewed 26 August 2014] Available from: doi:10.1136/jech.32.1.59
  2. BURCHARTH JAKOB, PEDERSEN MICHAEL, BISGAARD THUE, PEDERSEN CARSTEN, ROSENBERG JACOB, BURNEY RICHARD E.. Nationwide Prevalence of Groin Hernia Repair. PLoS ONE [online] 2013 January [viewed 26 August 2014] Available from: doi:10.1371/journal.pone.0054367
  3. DABBAS N., ADAMS K., PEARSON K., ROYLE G.. Frequency of abdominal wall hernias: is classical teaching out of date?. JRSM Short Reports [online] December, 2(1):5-5 [viewed 26 August 2014] Available from: doi:10.1258/shorts.2010.010071
  4. DESARDA MOHAN P. . BMC Surg [online] 2003 December [viewed 26 August 2014] Available from: doi:10.1186/1471-2482-3-2
  5. NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 26 August 2014] Available from: doi:10.1186/1757-1626-2-21
  6. RAVIKUMAR H, BABU S, GOVINDRAJAN MJ, KALYANPUR A. Reduction en-masse of inguinal hernia with strangulated obstruction. Biomed. Imaging Interv. J. [online] 2009 October [viewed 26 August 2014] Available from: doi:10.2349/biij.5.4.e14
  7. ANDRESEN K., BURCHARTH J., ROSENBERG J.. The Initial Experience of Introducing the Onstep Technique for Inguinal Hernia Repair in a General Surgical Department. Scandinavian Journal of Surgery [online] 2014 April [viewed 26 August 2014] Available from: doi:10.1177/1457496914529930
  8. SARTELLI MASSIMO, et al. WSES guidelines for emergency repair of complicated abdominal wall hernias. Array [online] 2013 December [viewed 26 August 2014] Available from: doi:10.1186/1749-7922-8-50
  9. WILSON MICHAEL L., GAIDO LORETTA. Laboratory Diagnosis of Urinary Tract Infections in Adult Patients. CLIN INFECT DIS [online] 2004 April, 38(8):1150-1158 [viewed 26 August 2014] Available from: doi:10.1086/383029
  10. RUHL C. E., EVERHART J. E.. Risk Factors for Inguinal Hernia among Adults in the US Population. American Journal of Epidemiology [online] 2007 March, 165(10):1154-1161 [viewed 26 August 2014] Available from: doi:10.1093/aje/kwm011

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] [2] To exclude anemia prior to surgery [1] [2]
Coagulation studies [1] [2] To exclude any coagulopathy prior to surgery [1] [2]
Serum creatinine, Blood urea nitrogen [1] [2] To exclude any renal dysfunction prior to anesthesia [1] [2]
References
  1. KUMAR A, SRIVASTAVA U. Role of routine laboratory investigations in preoperative evaluation J Anaesthesiol Clin Pharmacol [online] 2011, 27(2):174-179 [viewed 26 August 2014] Available from: doi:10.4103/0970-9185.81824
  2. SHULMAN M. A., THOMPSON B. R.. I. Not fit for a haircut ... how should we assess fitness and stratify risk for surgery?. British Journal of Anaesthesia [online] December, 112(6):955-957 [viewed 26 August 2014] Available from: doi:10.1093/bja/aeu003

Management - General Measures

Fact Explanation
Patient education [1] [2] If the hernia is small, the patient may only need reassurance and education regarding the etiology, nature and available treatment options. He should be educated on warning signs of intestinal obstruction and when to seek treatment. Patient should also be advised to avoid smoking. [1] [2]
Treatment of predisposing factors [1] [2] If there's underlying chronic cough, constipation, straining on micturition, these problems need to be properly addressed and should be treated prior to surgical management. As well as patient should be educated to avoid heavy weight lifting as this may aggravate hernia [1] [2]
Acute management of intestinal obstruction [3] [4] [5] Patient is dehydrated, therefore normal saline intravenously given. Potassium can also be given. Nasogastric tube is placed to decompress the stomach. The patient should be monitored with regard to heart rate, respiratory rate, blood pressure, urine output, temperature and clinical status. Administration of analgesia is important as patient is in pain and antiemetics are given as there's severe vomiting. Administration of antibiotics are to cover against gram-negative and anaerobic organisms [3] [4] [5]
References
  1. RUHL C. E., EVERHART J. E.. Risk Factors for Inguinal Hernia among Adults in the US Population. American Journal of Epidemiology [online] 2007 March, 165(10):1154-1161 [viewed 26 August 2014] Available from: doi:10.1093/aje/kwm011
  2. PARSONS G.. Patient education after inguinal hernia surgery did not differ from routine information for pain at rest at 7 days. Evidence-Based Nursing [online] 2008 January, 11(1):26-26 [viewed 26 August 2014] Available from: doi:10.1136/ebn.11.1.26
  3. SARTELLI MASSIMO, et al. WSES guidelines for emergency repair of complicated abdominal wall hernias. Array [online] 2013 December [viewed 26 August 2014] Available from: doi:10.1186/1749-7922-8-50
  4. RAVIKUMAR H, BABU S, GOVINDRAJAN MJ, KALYANPUR A. Reduction en-masse of inguinal hernia with strangulated obstruction. Biomed. Imaging Interv. J. [online] 2009 October [viewed 26 August 2014] Available from: doi:10.2349/biij.5.4.e14
  5. NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 26 August 2014] Available from: doi:10.1186/1757-1626-2-21

Management - Specific Treatments

Fact Explanation
Emergency management of a strangulated hernia [1] [2] [4] This becomes a surgical emergency through obstruction and incarceration and then emergency surgery is indicated for possible strangulation where the hernial sac is operated.[1] [2] [4]
Open repair of hernia [3] [7] [8] [9] Bassini's operation invloves apposition of the transversus abdominis and transversalis fascia and the lateral rectus sheath to the inguinal ligament. The Shouldice technique is another surgical technique. But now Lichtenstein tension free hernial repair technique is widely used and a polypropylene mesh is used to reinforce the abdominal wall. Possible complications are Recurrence (rate is very low), ischemic orchitis, wound infection, bladder injury, intestinal injury, pain, hematoma formation. [3] [7] [8] [9]
Laparoscopic repair of hernia [5] [6] Similar to any laparoscopic surgery, this has less postoperative pain and return to work is faster than in an open surgery. But it is expensive and not widely available. There are two approaches which are the transabdominal preperitoneal (TAPP) or the preperitoneal appraoch (TEP) procedure. In TEP peritoneal cavity is not entered into whereas TAPP needs entry into the peritoneal cavity. [5] [6]
Conservative management [7] If the patient refuses surgery, a truss may be used. [7]
Management of a congenital inguinal hernia [10] [11] The operation is undertaken as soon as possible either as open or laparoscopically. [10] [11]
References
  1. NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 26 August 2014] Available from: doi:10.1186/1757-1626-2-21
  2. RAVIKUMAR H, BABU S, GOVINDRAJAN MJ, KALYANPUR A. Reduction en-masse of inguinal hernia with strangulated obstruction. Biomed. Imaging Interv. J. [online] 2009 October [viewed 26 August 2014] Available from: doi:10.2349/biij.5.4.e14
  3. ANDRESEN K., BURCHARTH J., ROSENBERG J.. The Initial Experience of Introducing the Onstep Technique for Inguinal Hernia Repair in a General Surgical Department. Scandinavian Journal of Surgery [online] 2014 April [viewed 26 August 2014] Available from: doi:10.1177/1457496914529930
  4. SARTELLI MASSIMO, et al. WSES guidelines for emergency repair of complicated abdominal wall hernias. Array [online] 2013 December [viewed 26 August 2014] Available from: doi:10.1186/1749-7922-8-50
  5. O'DWYER P. J.. Current status of the debate on laparoscopic hernia repair. British Medical Bulletin [online] 2004 August, 70(1):105-118 [viewed 26 August 2014] Available from: doi:10.1093/bmb/ldh027
  6. MOORE JOHN B, HASENBOEHLER ERIK A. Orchiectomy as a result of ischemic orchitis after laparoscopic inguinal hernia repair: case report of a rare complication. Array [online] 2007 December [viewed 26 August 2014] Available from: doi:10.1186/1754-9493-1-3
  7. MOKETE M. Evolution of an inguinal hernia surgery practice. [online] 2001 March, 77(905):188-190 [viewed 26 August 2014] Available from: doi:10.1136/pmj.77.905.188
  8. BURCHARTH JAKOB, PEDERSEN MICHAEL, BISGAARD THUE, PEDERSEN CARSTEN, ROSENBERG JACOB, BURNEY RICHARD E.. Nationwide Prevalence of Groin Hernia Repair. PLoS ONE [online] 2013 January [viewed 26 August 2014] Available from: doi:10.1371/journal.pone.0054367
  9. DESARDA MOHAN P. . BMC Surg [online] 2003 December [viewed 26 August 2014] Available from: doi:10.1186/1471-2482-3-2
  10. WANG K. S.. Assessment and Management of Inguinal Hernia in Infants. PEDIATRICS [online] December, 130(4):768-773 [viewed 26 August 2014] Available from: doi:10.1542/peds.2012-2008
  11. LAKSHMANAN P. M., REDDY A. K., NUTAKKI A.. A surprising content of congenital hernia: complete splenogonadal fusion band. Case Reports [online] December, 2014(mar26 1):bcr2014203640-bcr2014203640 [viewed 26 August 2014] Available from: doi:10.1136/bcr-2014-203640