00:01
Let's begin our discussion of
inguinal and femoral hernias.
00:06
This is the classic
Hasselbeck triangle.
00:09
You'll notice,
there are two triangles formed
divided by the epigastric vessels.
00:15
To the left of the screen is
the medial side of the abdomen.
00:19
Medial to the epigastric
are known as direct hernias.
00:23
Lateral to the epigastric vessels
are indirect hernias.
00:28
There are some different
types of hernias in the groin.
00:31
We've talked about the indirect
through the indirect ring.
00:35
A direct hernia, which is medial
to the epigastric vessels,
and the femoral hernia, which
is below the inguinal ligament.
00:45
What are some of the findings
or historic or physical findings
associated with inguinal hernias?
Let's discuss some of the
high frequency findings.
00:55
First, a bulge.
00:57
This is the initial picture
you are seeing.
00:59
This patient has a
large inguinal bulge.
01:02
This patient also likely
has been chronically incarcerated
as a large defect like this
did not happen overnight.
01:11
Additionally,
there's variable presentations
of nausea and vomiting.
01:16
The nausea vomiting occurs
either because of the discomfort
due to the intestinal contents
going into the scrotal sac
or through the inguinal canal.
01:25
Or it could actually represent
a small bowel obstruction.
01:29
The bowel obstruction
point of transition
actually in the inguinal canal.
01:34
And lastly, obstipation.
01:36
Obstipation means
the inability to pass flatus
or have bowel movements.
01:42
Again, a potentially late sign
of a bowel obstruction.
01:46
What are some
risk factors for hernias?
Commonly heavy lifting.
01:51
Whether it's part of an exercise
regimen or part of daily work,
people who have
repetitive, heavy lifting,
are a high risk.
01:59
Chronic cough patients.
02:00
What are some possible diagnoses
for patients for chronic cough?
Smokers, COPDiers,
and patients with asthma.
02:09
Constipation,
particularly in chronic in nature,
and obesity.
02:15
The question is,
what do these things have in common
that risks the patient of
having an inguinal hernia?
Well, it's basically anything
that increases Valsalva maneuvers,
and intra abdominal pressure
puts the patient at increased risk
of developing hernias.
02:33
Let's go over the
decision tree making
for the diagnosis
of inguinal hernias.
02:37
The vast majority of the time,
I can diagnose an inguinal hernia
based on
physical examination alone.
02:44
These physical exam maneuvers
include invagination
of the inguinal canal.
02:49
How is that performed?
Warn the patient.
02:52
Insert if one finger through the
scrotum and into the inguinal canal.
02:57
That's why it's called
an invagination.
02:59
Warn the patient that it
can cause some discomfort.
03:01
Have the patient perform
a Valsalva maneuver.
03:04
You all remember, you see it on TV.
03:06
Turn your head and cough.
03:08
They don't have to cough.
They just have to bear down
and produce a valsalva maneuver
to see whether or not
we can elicit the hernia
in the office.
03:17
If the physical examination
is not so clear,
sometimes you may need
cross sectional imaging
like a CT scan
of the abdomen and pelvis.
03:24
This is particularly true
when it's an equivocal exam
where there are limitations
to your examination.
03:29
Whether the patient
can't tolerate it,
or they're too morbidly obese that
your exam can't be trustworthy.
03:34
This is also the case in females
since physical examination
is limited.
03:40
Here's a management schema
of inguinal and femoral hernias.
03:45
As a surgeon, I consider hernias
both inguinal and femoral
as either reducible or not.
03:52
And the reducible hernias, you can
buy a little bit of extra time.
03:55
The patients who are not reducible
may need surgery more urgently.
03:59
Let's look at a patient
who has reducible hernia.
04:03
Those patients,
I can offer an elective repair,
and I counsel the patient.
04:08
If the bulge comes out
and you can't push it back in,
you develop
signs of obstruction such as
nausea, vomiting, or lack of
bowel movements, or flatus.
04:17
Those are signs to
instruct your patient
to return to the
emergency department.
04:23
If the patient is not reducible,
that's a different story.
04:26
Those patients
are then thought of
as either strangulated
or incarcerated.
04:31
Recall earlier in this lecture.
04:34
Strangulated patients
means that the blood supply
to content of the hernia
are compromised.
04:40
Those patients need urgent repair
or emergent repair rather.
04:45
If the patient's
simply incarcerated,
and it's an acute incarceration
I would recommend an urgent repair.
04:52
And select patients
particularly high risk patients,
chronically incarcerated patients,
the decision
to proceed with surgery
is one that you have
with the patient.
05:03
Let's discuss a little bit about
how to do an
open inguinal hernia repair?
In the subsequent slides,
you'll see the
exposure after incising
external oblique aponeurosis.
05:15
Once you open up the
external oblique aponeurosis
underlying
it is the spermatic cord.
05:19
The cord contains important
spermatic cord vessels,
vas deferens, and of course,
your hernia sac.
05:30
Once the hernia sac is reduced,
we, it's standard to place
a piece of mesh.
05:36
Mesh is usually
medical grade plastic
that buttress is your repair
as the tissues have
already demonstrated,
they have some inherent
weaknesses of their own.
05:48
Question for you.
05:49
Do all inguinal hernias
need to be repaired?
I'll let you think about this.