Body Wall Hernias
These present as:
Soft lump on abdominal wall
May be reducible or irreducible
May protrude on coughing or bending over
Aching, pulling or dragging sensation
When examining these patients, it's important to assess these things:
Is it visible? - If not, ask to cough
Is it reducible? - If not, ask to cough
Can you get above it? - If yes, it’s a scrotal swelling instead of an inguinal swelling
Is it solid or cystic? - Will know by if it transilluminates
Complications:
Incarceration - hernia becomes irreducible as bowel is trapped in a herniated position
Obstruction - Hernia causes bowel obstruction, presenting with abdominal pain, vomiting, and absolute constipation
Strangulated - Bowel ischaemia, presenting with severe abdominal pain and tenderness (surgical emergency)
Differentials:
Femoral hernia
Cryptorchidism
Hydrocoele
Lymph node
Abscess
Indirect inguinal hernia: (80%)
These typically occur in younger patients, and is caused by a congenital patent processus vaginalis. It's differentiated from a direct inguinal hernia with an examination. Following its reduction, pressure over the deep ring prevents its reappearance on coughing. This type is at a much higher risk if stangulation.
Direct inguinal hernia: (20%)
These typically occur in older patients, and is caused by a weakness in the abdominal wall at Hesselbach’s Triangle. Risk factors for this includes heavy lifting, chronic cough in smokers, and constipation. Following its reduction, pressure over the deep ring doesn't prevent its reappearance on coughing.
N.B. The boundaries of Hesselbach’s Triangle are the rectus abdominis (medial), inferior epigastric vessels (superior/lateral), and inguinal ligament (inferior).
Management:
If large and symptomatic - surgical repair (typically open/laparoscopic mesh repair)
If small and/or asymptomatic - watchful waiting and advice on risk factor management
N.B. Mesh repairs carry a low rate of recurrence, but a higher risk of infection.