Guess not!? Question 1What problems might have clinical findings similar to these?
The finding of a mass that is reducible is rather straightforward. However, if the mass is irreducible, there are other considerations. A mass may be the result of an incarcerated hernia, lymphadenopathy (from infection, lymphoma, leukemia, etc), metastases to a local lymph node from a cancer, a primary cancer, an ectopic testis, hematoma, femoral artery aneurysm, a sebaceous cyst, and benign tumors.
If the diagnosis is unclear, further testing may be necessary, but some findings are suggestive. For example, pulsation suggests an aneurysm, whereas marked tenderness suggests an infected sebaceous cyst, an incarcerated hernia, or lymphadenopahy from infection. A small, non-tender, mobile soft mass in the skin structures suggests a lipoma. Question 2What are common history and examination findings in patients with an inguinal hernia?
A hernia is an abnormal protrusion of tissue through a defect in an anatomic wall, either through an internal structure (eg, the diaphragm) or an external wall (eg, the abdominal wall). Hernias most commonly develop in the abdominal wall, often in the inguinal area, though many other types of hernias exist. The more common sites are the inguinal, umbilical, and femoral areas as well as the fascia between the muscles of the abdominal wall. This protrusion or even the defect in the abdominal wall may be palpable, though a hernia that only protrudes periodically and then reduces may not be readily evident on examination.
A hernia is termed reducible if the protruding tissue can pass back through the defect into its normal position. If the tissue cannot pass back through the defect, it is referred to as incarcerated (irreducible).
A direct inguinal hernia is a protrusion medial to the internal inguinal ring and the inferior epigastric vein and artery. This results in an anterior protrusion through the inguinal region, as this patient had. An indirect inguinal hernia tracks down from the internal inguinal ring toward the external inguinal ring and then into the scrotum or labia majora, and it may have a presentation that is indistinguishable from that of the direct hernia. A femoral hernia protrudes below the inguinal ligament. Groin hernias are far more common in men, though an indirect inguinal hernia is the most common form of hernia in both men and women.
The patient may complain of pain, but severe pain suggests strangulation of the hernia, with a compromise of the vascular supply of the trapped tissue. If strangulation of bowel occurs, the patient may also present with signs and symptoms of bowel obstruction: vomiting, distended abdomen, and tenderness. If necrosis of any intra-abdominal tissues develops, the patient will have signs and symptoms of an acute abdomen.
Although inguinal hernia repair is the most common surgical procedure done on children, the presentation may be less than straightforward. Older children may notice a mass on themselves, but the history is often difficult to obtain in very young children, though parents may have discovered a mass. If incarceration or strangulation of the hernia has occurred, signs and symptoms of severe abdominal pain may be the only information available clinically. Full evaluation is important, particularly in very young infants, as 70% of incarcerated hernias develop in children under the age of 1 year. Question 3What studies would be useful in confirming the diagnosis?
Ultrasonography is a very sensitive and specific way to identify an inguinal hernia. The test is sensitive enough to allow the examiner to distinguish between a direct, an indirect, and a femoral hernia. If the lesion is more likely to be another type of mass lesion, computed tomography may be a more appropriate first test. Computed tomography is also more useful in the evaluation of hernias other than the inguinal type and in the case of an unusual presentation or apparent complication. Question 4What are the treatment options for this patient?
Hernias tend to worsen over time. As the size of the hernia enlarges from a small opening to a larger one, the chance for incarceration (and hence, strangulation) increases.
Surgery is the treatment of choice for most patients. The patient described here has an active job that requires a lot of lifting and climbing, so he should undergo surgical repair as soon as he is able to arrange sick leave from work. In the meantime, he should not participate in job duties that require any strenuous lifting or climbing or similar activities.
Both indirect and direct inguinal hernias are repaired with the same methods; this usually involves an anterior approach. Endoscopic repair is an option that offers quicker recovery times, but it is criticized by some as being expensive and technically more difficult than a direct operative approach. Complications with endoscopic repair are reported at a frequency less than 10%, and the reported recurrence rates range from 0% to 3%. A direct surgical approach has a somewhat higher complication rate because of a 1% to 2% rate of wound infection. Recurrence rates with the direct surgical approach range from 1% to 15%, with lower rates for procedures that are tension-free (mesh repairs). The VA Cooperative Study reported reported much higher rates of complications (39% vs 33%) and recurrence (10% vs 4.9%) with laparoscopic repair versus open repair, respectively, but the study has been criticized because the techniques used for repairs were not standardized (Grunwaldt et al) and because the primary surgeons were residents in training (Voeller).
If a patient has a very short life expectancy or is a poor candidate for surgery, expectant management is appropriate. In this case, a truss or other support measure will provide relief of the symptoms. These supports should be appropriately fitted, or they will not be as effective. Question 5What are potential complications of inguinal hernia?
As stated before, an untreated hernia tends to worsen over time. Although persistent or increasing pain is a complication, the most serious complication is ischemia in an incarcerated hernia (strangulation). This can lead to sepsis, bowel perforation, and even death.
Complications of surgery include persistent pain, wound infection, hematoma, ischemic orchitis, testicular atrophy, development of seroma, injury to the vas deferens or other local neurovascular structures, and general surgical complications such as hemorrhage and pulmonary embolism.