Hernia history and examination

Good for clinical skills - content for history and examination for a patient with hernia

1. Hernia – Hx & Examn Dr Vandana Krishna

2. Hernia External hernia - Inguinal ( direct and indirect) - femoral hernia - Umbilical hernia - Incisional hernia Internal hernia - hiatus

3. H ernia Complicated – incarcerated, obstructed and strangulated Uncomplicated – can be reduced

4. DDx Lymph node Hydrocele Orchitis Saphenous varix Abscess Undescended testis Malignancy

5. Hx OPQRST on swelling W hen did you notice the swelling? Where exactly is the swelling? Is it uncomfortable? Any pain? Any particular position makes it worse/more prominent – eg . lying down or standing? Any association with heavy lifting or straining ( eg coughing, defecation) Are you able to reduce it (push it back)? How big is the swelling ? Does it affect your normal activity? Does it come and go or is always there? -

6. Hx cont … OPQRST on pain/discomfort if present O: comes up when lump appears or when lump has been there for long time and they are in standing or straining situation P: lump site and also lower abdomen on the side of the lump Q: pain is normally dull and is of dragging discomfort; if hernia complicated, can become intestinal colic (initial obstruction sign) if intestine is the hernial content. If omentum is the hernial content, obstruction signs will not be there. It can also become acute abdomen if complicated ( eg . perforation ) with development of fever R: lying down/reduction of lump; A: same as for lump formation S: depends – if uncomplicated they are able to bear the discomfort; if complicated can reach scale of 10 T: evaluate if the pain has become consistent ( persistent pain with abdominal tenderness suggests intestinal ischaemia eg strangulated hernia); is it worsening or not (suggests continuing incarceration and/or other complication)

7. ROS Purpose is to check for other differentials and to check for complications of hernia: Fever, weight changes, appetite Any boil or cut anywhere esp in the lower limbs Coughing Vomiting ( since when, colour (bilious denotes intestinal content), how much, 1 st time with this swelling); Bowel opening/flatus; PU Discharge (urethral/vaginal)

8. Hiatus hernia Hiatus hernia often presents heartburn, belching, waterbrash , difficulty swallowing, chest or abdominal pain, feeling especially full after meals, nausea , vomiting  or retching (dry heaves ); vomiting blood or passing black stools, which may indicate gastrointestinal bleeding .

9. Other H x PMHx - hernia hx - operations esp for incisional and epigastric hernias - DMT2, HTN, IHD (assessing risk for operation if needed) - hx of STI - chronic constipation - comorbidities like COAD and Asthma (chronic cough), BPH (forceful micturition)

10. Other hx cont.. FHx – for congenital hernias; comorb conditions; cancer SHx – smoking (weakens tissue/affects healing/risk of Ca ); occupation (to assess risk factor for hernia - hard labour , involves lot of standing, weight lifting) Allergies/Meds e.g if someone on warfarin – need to adjust prior to operation if needed

11. Examination Greet Introduce yourself Explain your plan Get the consent

12. ‘Options’ for hernia In a reducible hernia the contents can be returned to the abdominal cavity, spontaneously or by manipulation ; If they cannot, the hernia is irreducible (incarcerated) . If the blood supply to the contents of the hernia (bowel or omentum ) is restricted , the hernia is strangulated . It is tense and tender and has no cough impulse. If bowel is contained within the hernia, obstruction may occur. Strangulated and obstructed hernia are surgical emergencies and, untreated , either of them will lead to bowel infarction, perforation, peritonitis, sepsis and shock .

13. DDx Lymph node Hydrocele Orchitis Saphenous varix Abscess Undescended testis M alignancy

14. Aim Right or left Inguinal or femoral If inguinal, then direct or indirect If indirect, then complete or incomplete Complicated or uncomplicated Content – intestine vs omentum

15. Hernia examination Inspection Palpation Percussion Auscultation

16. GA/Vitals/HEENT Inspect the general appearance – distress? gait (antalgic )? Wants to remain still? Vitals HEENT – assess for dehydration (dry mouth/lips)

17. Position Standing – inspection and palpation Supine – palpation, percussion and auscultation Exposure : Ideally abdomen up to mid thigh Chaperone

18. Standing

19. Inspection Examine the groin with the patient standing upright Check for operation marks, Check for signs of inflammation Inspect the inguinal and femoral canals and the scrotum (in males) for any lumps or bulges . Ask the patient to cough; look for an impulse over the femoral and inguinal canals and scrotum. Identify the anatomical relationships between the bulge, the pubic tubercle and the inguinal ligament to distinguish a femoral from an inguinal hernia.

20. Surface marking Inguinal canal In the abdomen Approx 4 cm long in adults Deep (internal) inguinal ring – mid point of inguinal ligament (1.3cm above); lateral to epigastric artery (this relation to artery is important during surgery) Superficial (external) inguinal ring – above and medial to pubic tubercle (about 1 cm); medial to epigastric artery Just above and parallel to inguinal ligament Femoral Canal In the thigh (anterior , medial and proximal) 1.3cm long Inferior and lateral to the pubic tubercle Below the inguinal ligament Inguinal ligament – ASIS to pubic tubercle

21. Palpation Palpate the external inguinal ring and along the inguinal canal for possible muscle defects. Ask the patient to cough and feel for a cough impulse.

22. Supine

23. Inspection Check whether the hernia reduces spontaneously Check for signs for obstruction (in the abdomen) - obvious dilatation of the abdomen; peristaltic movements if any Check for signs of acute abdomen – patient is still, abdomen looks rigid

24. Palpation Palpate the swelling for any tenderness, warmth (tense, tender and signs of inflammation suggests strangulation) Assess consistency and size Assess for cough impulse (swelling enlarges with coughing) over the swelling – absent cough impulse can suggest obstruction or other DDx like hydrocele

25. Palpation cont … Attempt to reduce it gently (can ask the patient to do so) If it does reduces, press two fingers over the deep inguinal ring and ask the patient to cough while you maintain pressure over the deep inguinal ring If the hernia reappears, it is a direct hernia. If it can be prevented from reappearing, it is an indirect inguinal hernia. Examine the opposite side to exclude the possibility of asymptomatic hernias.

26. An indirect inguinal hernia bulges through the deep inguinal ring and follows the course of the inguinal canal. It may extend beyond the external ring and enter the scrotum. Indirect hernias comprise 85% of all hernias and are more common in younger men . Indirect inguinal hernias are palpable above and medial to the pubic tubercle. A direct inguinal hernia forms at a site of muscle weakness in the posterior wall of the inguinal canal and rarely extends into the scrotum. It is more common in older men and women Both the hernias are above the inguinal ligament

27. A femoral hernia projects through the femoral ring and into the femoral canal. Femoral hernias are palpable below the inguinal ligament and lateral to the pubic tubercle.

28. Palpation cont … Palpate the scrotum – feel for testis (hydrocele testes is not palpable; in orchitis , testis is very tender; in undescended testis there is no testes felt). Feel for the hernial content and try to follow it up to the inguinal canal (swelling extends above scrotum in a hernia; in hydrocele, can localise the swelling; omentum feels doughy) Palpate the superficial inguinal ring – try to put finger inside and check if you can feel the swelling ( invaginate the skin of the scrotum with little or index finger superomedial to pubic tubercle). If you do feel the swelling in the canal, you an ask the patient to cough and it will come and hit your finger tips (in indirect hernia) and side of finger (in direct hernia)

29. Palpation cont … Palpate the abdomen for Signs of generalised peritonitis or acute abdomen – guarding, rigidity, rebound (auscultate for bowel sounds during auscultation) Signs of obstruction – abdomen may look distended; firm and tender abdomen

30. Percussion Percuss the abdomen to check for rebound tenderness Tympanic (hyper resonant if intestine dilated due to obstruction)

31. Auscultate Over the swelling to hear for any bowel sounds (if h ernia contains bowels, can hear bowel sounds; in hydrocele no bowel sounds; if the bowel has become obstructed, after some time, there will be no bowel sounds either) Over the abdomen to hear for absent bowel sounds if any; initially during obstruction, bowel sounds are high pitched

32. Transillumination Present in a hydrocele

33. DRE Check for risk factors for hernia Sphincter tone Prostate enlargement Haemorrhoids Soft vs hard stool Check for DDx – tenderness, masses

34. Fluid in ascites Shifting dullness – 500mls Fluid thrill – 1.5L