Inguinal hernias: Clinical sciences

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Introduction0:00–2:09

An inguinal hernia is a defect or weakness in the abdominal wall that allows the passage of abdominal contents through the lower abdominal wall into the inguinal region, or groin.
Some common risk factors for the development of an inguinal hernia include male sex, age younger than 5 years or older than 75 years, family history of inguinal hernia in first-degree relatives, impaired collagen metabolism, and previous history of benign prostatic hyperplasia or prostatectomy.Inguinal hernias can be classified by etiology, meaning they can be either congenital or acquired.
Congenital inguinal hernias occur when the processus vaginalis fails to close during gestation. On the other hand, acquired hernias can be due to patent processus vaginalis or a weakness in the abdominal wall, allowing intra-abdominal contents to protrude through the defect.
Common causes of tissue weakness include abdominal wall injury or connective tissue abnormalities. Inguinal hernias can also be classified anatomically as either direct or indirect.
A direct inguinal hernia protrudes medially to the inferior epigastric vessels within Hesselbach’s triangle, which is formed inferiorly by the inguinal ligament, laterally by the inferior epigastric vessels, and medially by the rectus abdominis muscle.
Direct hernias are usually a result of a weakened inguinal canal floor.On the other hand, indirect inguinal hernias occur in the internal inguinal ring, lateral to the inferior epigastric vessels.
In males, this is the site where the spermatic cord exits, while in females it’s the site where the round ligament exits the abdomen.
Indirect inguinal hernias are the most common type of hernia, and they occur more frequently on the right side. Both direct and indirect hernias can present as either asymptomatic, symptomatic, incarcerated, or strangulated.When you encounter a patient with signs and symptoms suggestive of an inguinal hernia, you should first perform an ABCDE assessment to determine whether the patient is stable or unstable.

Unstable patient2:09–2:39

If the patient is unstable, stabilize their airway, breathing, and circulation. This means that you may need to intubate the patient, obtain IV access, and administer fluids before continuing with your assessment.Alright, now that unstable patients are taken care of, let’s talk about stable patients.

Stable patient - Asymptomatic inguinal hernia2:39–3:46

If the patient is stable, your first step is to obtain a focused history and physical examination. There are a few findings you might see here.
First, you might identify a patient with an asymptomatic inguinal hernia. In this case, your patient does not currently have symptoms.
However, on physical examination, you’ll notice a small, easily reducible bulge in the groin area, superior to the inguinal ligament.
The bulge may also protrude when you ask your patient to perform a Valsalva maneuver. If you see this, you can diagnose an asymptomatic inguinal hernia.When it comes to treatment, asymptomatic inguinal hernias can often be managed with watchful waiting, and might not need surgical intervention.
However, you should advise your patient to seek medical attention if they have new-onset or worsening groin pain, or if they are suddenly unable to reduce the hernia.Okay, let’s go back to history and physical exam and talk about symptomatic hernias.

Symptomatic inguinal hernia3:46–4:43

A patient with a symptomatic inguinal hernia might have a history of pressure or sharp pain in the groin, as well as heaviness after activity or at the end of a day.
On physical exam, you might see a bulge in the groin area superior to the inguinal ligament, especially when the patient does a Valsalva maneuver.
Just like with asymptomatic patients, this bulge is easily reducible. In this case, you can diagnose the patient with a symptomatic inguinal hernia.Now, if your patient’s hernia is symptomatic, they should be scheduled for an elective surgical repair, so be sure to call the surgical team for a consultation.
In the meantime, you should counsel your patient to seek immediate medical attention if their pain worsens, or if they are suddenly unable to reduce their hernia contents.Alright, let’s move on to patients who present with signs and symptoms of an incarcerated inguinal hernia.

Incarcerated inguinal hernia4:43–6:16

In this case, history might reveal pressure and constant sharp pain in the groin area. The pain might radiate to the scrotum or inner thigh.
Your patient may also report changes in bowel and bladder habits, like constipation, or difficulty urinating. On their physical exam, you’ll typically see a bulge that is superior to the inguinal ligament.
Now, unlike asymptomatic or symptomatic inguinal hernias, it will not be easily reducible. This is an incarcerated inguinal hernia.Once you diagnose an incarcerated inguinal hernia, you should assess the onset of the patient’s signs and symptoms, because this will determine the management.
In the case of an acutely incarcerated inguinal hernia, the patient will usually require urgent surgical repair, so call the surgical team for a consultation.
On the flip side, if the hernia is chronically incarcerated, you might attempt to reduce the hernia first. Before you perform a manual reduction of an incarcerated inguinal hernia, you should administer pain medications and possible sedation prior to the procedure.
Have the patient lie down and place them in the Trendelenburg position. Apply gentle pressure to the hernia while manipulating the contents back into the abdominal cavity.
After attempting to reduce the hernia, you should call the surgical team for possible hernia repair.Now that the treatment for incarcerated inguinal hernia is complete, let’s talk about a serious condition called a strangulated inguinal hernia.

Strangulated inguinal hernia6:16–7:33

In this case, the blood supply to the herniated bowel becomes obstructed, leading to ischemia. Patients with strangulated inguinal hernias typically have a history of fever; severe, sharp pain in the groin; difficulty passing urine; and possible signs of bowel obstruction such as abdominal pain, nausea, vomiting, and absent bowel movements and flatus.
As always, the physical examination might show a bulge in the groin superior to the inguinal ligament. Additionally, the skin may be erythematous, warm, and very tender to palpation.
In this case, you are dealing with a strangulated inguinal hernia, and you should not attempt to reduce the contents back into the abdominal cavity, since the hernia sac may contain necrotic bowel.Once you have diagnosed a strangulated inguinal hernia, you should start the patient on IV fluids, as well as broad-spectrum IV antibiotics, and place a nasogastric tube if the patient is vomiting due to a bowel obstruction.
Once these measures are started, call the surgical team for an emergent repair of the strangulated inguinal hernia.Alright, as a quick recap… Patients with inguinal hernias can present as unstable or stable.

Review7:33–8:42

In unstable patients, stabilize the airway, breathing, and circulation before continuing with the workup. Patients who are stable can either have an asymptomatic, symptomatic, incarcerated or strangulated inguinal hernia.
Asymptomatic inguinal hernias usually only need watchful waiting. On the other hand, if the hernia is symptomatic, call the surgical team for an elective repair.
When it comes to incarcerated hernias, you should assess the onset of symptoms first. If the hernia is acute, call the surgical team for an urgent repair.
However, if it’s chronic you can attempt to reduce it first. Reducible incarcerated hernias require elective repair, while the ones that can't be reduced should be repaired urgently.
Finally, if the hernia is strangulated, do not attempt to reduce it! Start the patient on IV fluids and broad-spectrum antibiotics, and possibly place a nasogastric tube.
Once you’ve done this, call the surgical team for an
Inguinal hernias: Video, Causes, and Symptoms | Osmosis