Quick Overview
Hernias represent protrusions of viscera through fascial defects and are among the most common surgical conditions. Inguinal hernias (indirect/direct) account for 75% of abdominal wall hernias, followed by femoral (3%), umbilical (10%), and incisional (10%). Recognition of strangulation (irreducible with vascular compromise) is critical-it constitutes a surgical emergency requiring intervention within 6 hours to prevent bowel necrosis.
Core Facts & Concepts
Anatomical Classification & Landmarks
| Hernia Type | Anatomical Route | Key Landmark | M:F Ratio |
|---|---|---|---|
| Indirect inguinal | Through deep ring, lateral to inferior epigastric vessels | Internal ring | 7:1 |
| Direct inguinal | Through Hesselbach's triangle, medial to inferior epigastric vessels | Hesselbach's triangle | 3:1 |
| Femoral | Through femoral canal, below inguinal ligament | Femoral ring (medial to femoral vein) | 1:4 |
| Umbilical | Through umbilical ring | Umbilicus | 1:3 |
| Incisional | Through previous surgical incision | Prior laparotomy site | 1:1 |
📌 Remember: NAVEL - Nerve, Artery, Vein, Empty space (femoral canal), Lymphatics (lateral to medial in femoral triangle)
Emergency Presentations
- Incarceration: Irreducible hernia without vascular compromise (contents trapped but viable)
- Strangulation: Vascular compromise → ischaemia within 6 hours
- 🚩 Red flags: Severe pain, fever, tachycardia, tender/erythematous overlying skin, absent bowel sounds
- Mortality: 5-8% if bowel resection required
NICE NG104 Repair Indications
- Mesh repair: Standard for inguinal hernias (recurrence 2-4% vs 10-15% non-mesh)
- Non-mesh (tissue) repair: Contaminated fields, patient preference after counselling
- Watchful waiting: Asymptomatic/minimally symptomatic inguinal hernias acceptable if patient informed of risks
- Not suitable for femoral hernias (high strangulation risk: 40% within 2 years)
Problem-Solving Approach
Clinical Assessment Pathway
- Position patient: Examine standing and supine; ask patient to cough
- Palpate deep ring: Reduce hernia, occlude deep ring (mid-inguinal point), ask to cough
- Controlled = indirect; not controlled = direct
- Assess reducibility: Gentle taxis with patient supine, hips flexed
- Evaluate for strangulation: Check skin changes, tenderness, systemic signs
Emergency Management
- Strangulated hernia: NBM, IV access, analgesia, emergency surgery within 6 hours
- Incarcerated but not strangulated: Trial of reduction (analgesia + Trendelenburg position)
- If unsuccessful after 30 minutes → urgent surgery (within 24 hours)
⚠️ Warning: Never attempt prolonged forceful reduction-risk of reducing necrotic bowel into abdomen ("reduction en masse")
Analysis Framework
Differential Diagnosis: Groin Lump
| Feature | Inguinal Hernia | Femoral Hernia | Lymph Node | Saphena Varix |
|---|---|---|---|---|
| Position relative to pubic tubercle | Above and medial | Below and lateral | Variable | Below |
| Cough impulse | Present | May be present | Absent | Present |
| Reducibility | Usually yes | Often no | No | Yes (with leg elevation) |
| Fluid thrill | No | No | No | Yes |
Decision Rule: Surgical Urgency
- Immediate (<6h): Strangulation signs present
- Urgent (<24h): Irreducible without strangulation signs
- Elective: Symptomatic reducible hernias
- Watchful waiting: Asymptomatic inguinal only (NOT femoral)
Visual Aid
Risk Factors for Incisional Hernias
- Surgical: Midline incisions (10-15%), wound infection, emergency surgery
- Patient: Obesity (BMI >30), smoking, diabetes, chronic cough, ascites
- 📊 Incidence: 10-15% at 2 years post-laparotomy
Key Points Summary
✓ Anatomical distinction: Indirect (lateral to inferior epigastric vessels), direct (medial), femoral (below inguinal ligament, high strangulation risk 40%)
✓ Strangulation = emergency: Requires surgery within 6 hours; red flags include pain, fever, skin changes, irreducibility
✓ NICE NG104: Mesh repair standard (recurrence 2-4%); watchful waiting acceptable for asymptomatic inguinal hernias only-never for femoral
✓ Femoral hernias: Always require repair due to 40% strangulation risk within 2 years; commonest in elderly women
✓ Examination technique: Assess standing and supine with cough impulse; occlude deep ring to differentiate direct vs indirect
✓ Incisional hernia prevention: Optimize BMI, smoking cessation, glycaemic control pre-operatively
✓ Never force reduction: Risk of reducing necrotic bowel ("reduction en masse")-if unsuccessful after 30 minutes with analgesia, proceed to surgery
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