Hernia Examination
Always start with the patient STANDING
Inspect standing
- Exposure is very important – ensure you can see from umbilicus to knees at
least!
- Look in the groin for evidence of a swelling – if you cant see one, then ask the
patient which side they have noticed a lump
- Look for evidence of previous hernia surgery – oblique scar often well hidden
in pubic hair line
- Any other obvious skin changes, swellings, lumps that may be relevant
- Ask the patient to look over their shoulder and cough (so they don’t cough into
your face!)
- As they cough, look at the lump to see if there is a cough impulse
Palpate standing
- Palpate the swelling
- Can you get above it (suggesting originates in scrotum/spermatic cord e.g.
hydrocoele)
- Does it feel soft, fluctuant, Pulsatile etc.
- Ask the patient again to cough, palpating for a cough impulse
- Ensure that you feel the opposite side, as bilateral hernias are very common,
often one being much more prominent
Auscultate
- Take this opportunity to auscultate the lump, as if it is readily reducible, there
will be nothing to listen too when the patient lies down.
Lie the patient down
Inspection
- Again, inspect the groin to ensure there is nothing missed from standing
inspection.
- Offer to palpate the abdomen for any cause of raised intra-abdominal pressure
such as ascites or mass, which can predispose to herniation
Palpation
- Having identified a hernia, the next task is to assess if it is indirect or direct.
- Ask the patient if they can reduce the hernia, if it has not done so by being
supine – NEVER do this standing as it is painful.
- Palpate the groin to assess if the hernia has completely reduced
- Warn the patient that you will palpate some bony points
- Feel for the anterior superior iliac spine and the pubic tubercle (delineating the
inguinal ligament – as opposed to the ASIS to pubic symphysis, to identify the
mid-inguinal point, the landmark for the femoral artery)
- Palpate the midpoint of the inguinal ligament (the surface landmark for the
deep inguinal ring) and ask the patient to cough
- If the hernia is CONTROLLED by pressure over the deep inguinal ring, it
suggests that the hernia is indirect.
- In order to confirm that you were in fact controlling the hernia, ask the patient
to cough without pressure to ensure that the hernia now appears.
- Offer to examine the scrotum, where you should palpate the testis and
epididymis (my finals hernia case had epididymal cysts which were expected
to be found)
That completes the examination of the hernia, but offer to examine the abdomen for
masses etc.
People often find hernias difficult as there is not much opportunity to practice –
however, as finals loom ensure you seek out hernia lists in day surgery as these cases
often come up.
Some theory
Hernia = protrusion of viscus through the confines of the cavity within which the
viscus normally lies
There are many types of hernia – ensure you are aware of the following types
-
Inguinal – see below
-
Femoral
o 1/3 hernias in women – i.e. more common in women but inguinal still
commoner
o Rare in males
o Arise inferiorly and laterally to the pubic tubercle
o More rigid boundary - inguinal ligament, pectineal ligament, lacunar
ligament and femoral vein being the boundaries
o More likely to strangulate
o Can be ‘richter hernia’ where a knuckle of bowel wall is trapped rather
than the entire circumference
o Can present as obstruction with no localising signs
-
Sphigelian
-
Umbilical
-
Para-umbilical
- Epigastric
- Lumbar
- Obturator
- Hiatus
Inguinal hernias
These are the commonest type of hernia in both males and females.
Indirect – hernial sac passes through the deep inguinal ring, through the inguinal canal
and can pass into the scrotum. These tend to be found in younger men
Direct – hernial sac passes directly through the transversalis fascia and rarely pass
into the scrotum. These tend to be more prevalent in the older man. More precisely,
direct hernias pass through Hasselbachs triangle, delineated by the inferior epigastric
artery laterally, the rectus abdominus muscle medially and inguinal ligament
inferiorly.
In the exam, it would be prudent to comment that although your clinical findings
suggest that this is an indirect/direct hernia, this can only be confirmed at operation.
The precise definition of direct vs indirect is in relation to the inferior epigastric
vessels. Direct hernias arise medially to these vessels and indirect laterally.
It would be worth revising the anatomy of the inguinal canal and the contents of the
spermatic cord:
- 3 arteries – testicular artery, artery to vas, artery to cremaster
- 3 nerves – genital branch of genitofemoral, sympathetics and ilioinguinal (this
nerve actually travels WITH the spermatic cord rather than within
- 3 others – vas deferens, lymphatics, pampiniform venous plexus
- Some also include the 3 layers of fascia.
Common exam questions
1. What is the difference between indirect and direct? – see above
2. Discuss anatomy of inguinal canal
3. What investigation could be performed if unsure if hernia? – ultrasound is
often used if it is unclear if there is a hernia or not
4. What is the management?
- The answer should be repair of the hernia, as there is a risk of the hernia
becoming strangulated – unless there are contraindications to surgery –
however the repair can even be done under local anaesthesia
5. What are the operative options?
- There is the option of performing the repair open (Lichenstein procedure)
or using a pre-peritoneal laparoscopic approach which has the advantage in
bilateral hernias to do both with the same incision, and in redo operations.
The ‘pre-peritoneal’ means that the peritoneum is not breached.
Laparoscopic surgery is becoming more popular and is associated with
sooner return to work. Both types can be done as day surgery. The
principal of both types is the use of ‘tension free mesh repair’, whereby a
mesh is used to incite a fibrous reaction to create a strong barrier to
herniation that doesn’t rely upon the tension of sutures closing the defect
6. What is the differential diagnosis of a lump in the groin?
- Approach this systematically:
o Skin – sebaceous cyst
o Subcutaneous – lipoma, fibroma
o Arterial – femoral pseudo/aneurysm
o Venous – saphena varix
o Lymphatic – lymphadenopathy
o Psoas abscess
o Hernia – inguinal, femoral
o Ectopic testis
