Classification of inguinal hernia

 

Simplified classification by European Hernia Society : 

1. Primary or recurrent (P or R)
2. Lateral, medial or femoral (L, M or F).
3. Defect size in fingerbreadths assumed to be 1.5 cm.

A primary indirect, inguinal hernia wit 3 cm defect size will be PL

(A) According to relation with inguinal canal :

1. Direct inguinal hernia: When contents comes out through posterior wall of the inguinal canal.
2. Indirect inguinal hernia: When contents comes out through the deep inguinal ring.

(B) According to extent of content of hernia:

Complete inguinal hernia: When contents reach the lower part of the scrotum.

Incomplete inguinal hernia: When contents do not reach the lower part of the scrotum.

Steps of Examination of ingunio – scrotal swelling.

Important points you will notice during physical examination of lump in the groin:

>>>In standing position:

1) Inspection:

• Side where limp present: right or left.
• Size of the lump
• Shape Position and extent of lump
• Surface: smooth or irregular.
• Margin
• Expansile cough impulse
• Skin over the swelling any scar, engorged vein or pigmentation.
• Any visible peristalsis
• Position of penis: any deviation
• Testis

2) Palpation:

1. Temperature over the swelling
2. Tenderness over the swelling
3. Whether it is possible to get above the swelling or not. For an inguinoscrotal swelling it is not possible to get above swelling.
4. Palpable cough impulse.
5. Position and extent of the swelling.
6. Size, shape, margin, surface
7. Consistency.
8. Soft and elastic (when content is intestine).
9. Doughy (When content is omentum)
10. Tense and tenor (obstructed hernia).
11.  Relation of the swelling to pubic tubercle:

• The swelling is situated above and medial to pubic tubercle: Inguinal hernia.
• The swelling is situated below and lateral to the pubic tubercle: Femoral hernia).

✔ Relation of swelling to testis: Whether testis can be felt separately from the swelling or not.

✔ Palpation of testis, epididymis and spermatic cord.

3) Percussion:

✔ Resonant note over the swelling suggests enterocele.

✓ Dull note over the swelling suggests omentocele.

4) Auscultation: 

Bowel sound over the swelling suggests enterocoele.

>>> In lying position:

1) Reducibility:

• In enterocele, first part is difficult to reduce but last part reduces easily.
• In omentocele, first part reduces easily but last part is difficult to reduce.

2) Deep ring occlusion test: Test is positive when no impulse is seen on coughing after the deep ring is occluded by the thumb suggesting this to be an indirect inguinal hernia.

Management of inguinal hernia:

□ Clinical features:

Symptoms :

1. Sudden severe pain, at first situated over the hernia, is followed by generalized abdominal pain.
2. Abdominal pain, colicky in character and often located mainly at the umbilicus
3. Neusea & subsequently vomiting.
4. Patient may complain of an increase in hernia size.

Signs of inguinal hernia :

1) Hernia is tease and extremely tender

2) Hernia is irreducible.

3) There is no expensile cough impulse.

4) There may be signs of peritonitis

5) Features of septicaemia :

• uper Pulse rate
• down BP
• Shallow breathing
• low Urinary output

Treatment of inguinal hernia :

Immediate resuscitation followed by emergency operation.

Immediate resuscitation:

• Complete bed rest
• Nothing by mouth
• Nasogastric suction
• Intravenous fluid & electrolytes
• Parenteral antibiotics
• Catheterization, if necessary

Operative treatment:

✔ Relief of obstruction

✔ Testing the viability of the gut: Signs of viability are

• Presence of peristalsis
• Reddish in colour.
• Covering with warm mop improves circulation and dark color becomes lighter
• Administration of pure O2 (per rectally) for 3 minutes causes dark color to become lighter.

**If viable — Returning of the gut into abdomen

** If not viable — Resection and end to end anastomosis.

Then heriotomy or herniotomy with hermionhaphy is done.

The surgical options for inguinal hernia. 

Operations done for inguinal hernia;

1) Herniotomy

2) Open suture repair

• Bassini
• Shouldice
• Desanda

3) Open flat mesh repair: Lichtenstein

4) Open complex mesh repair:

• Plugs
• Hernia systems.

5) Open preperitoneal repair: Stoppa.

6) Laparoscopic repair:

• Totally extraperitoneal (TEP) approach.
• Transabdominal preperitoneal (TAPP) approach.

Treatment of indirect inguinal hernia:

Operation is the treatment of choice.

Inguinal herniotomy:

1. Dissecting out and opening of the hernial sac.
2. Reducing any contents.
3. Transfixing the neck of the sac.
4. Removing the remainder.

Herniotomy and repair (herniorrhaphy):

1. Excision of the hernial sac.
2. Repair of the stretched internal inguinal ring and the fascia transversalis.
3. Further reinforcement of the posterior wall of the inguinal canal.

management of direct inguinal hernia.

Clinical features & investigations: Please see from above discussion.

Treatment: Hemiotomy with hemiorrhaphy.

Differential diagnoses of inguinoscrotal swelling. 

D/D of indirect inguinal hernia (male):

1. Vaginal hydrocele.
2. Encysted hydrocele of the cord.
3. Spermatocele.
4. Lipoma of the cord.
5. Femoral hernia.
6. Incompletely descended testis in the inguinal canal.

DD of indirect inguinal hernia (female):

1) Hydrocele of the canal of Nuck

2) Femoral hernia

Complications of hernia:

1) Irreducible hemia.

2) Obstructed hernia.

3) Incarcerated hernia.

4) Strangulated hernia.

5) Inflamed hernia due to inflammation of the contents of hernia.

6) Hydrocele of the hernial sac.

The causes of recurrences of inguinal hernia :

Factors responsible for recurrent inguinal hernia:

Pre-operative;  

Faulty selection of patient.

1) Presence of predisposing factors:

• Smoking.
• Chronic cough.
• Constipation.
• Old age.
• Anaemia.

2) Increased intrabdominal pressure of any cause:

• BEP.
• Ca prostate.
• Stricture urethra.
• Ascites.

3) Factors impairing wound healing:

• Hypoproteinaemia.
• Malnutrition.

4) Size of the hernia: Larger the hernia, greater the chance of recurrence.

Operative:

Faulty technique of operation

1. Tension in the sutures.
2. Failure to identify & leaving behind a part of the sac.
3. Using absorbable suture in case of repair.
4. Inadequate haemostasis predisposing to wound haematoma & infection
5. Faulty repair of the posterior wall.
6. Weak abdominal wall.
7. Done by junior & inexperienced surgeon.

Post-operative:

1. Wound infection (50%).
2. Wound haematoma.
3. Retained sac in pantaloons hernia.
4. Straining.