Hernias

G'day and welcome to the Aussie MedEd, the Australian Medical Education broadcast, where we get to interview specialists in a variety of medical asking their opinion on their certain conditions, obtaining their insight into how they diagnose and treat that condition. In these COVID times it's a way of replacing a relaxed discussion around the hospital by allowing the listener to put forward questions to be answered. I hope you enjoyed the whole programme. Welcome once again to Aussie Medair.

In this edition we get interviewed. Yeah, just use the idea of what needs to be known. for medical students and the important aspects of herniaus. Not only would this information be useful for the general practitioner seeing a patient on a regular basis, but also for the medical student revising for their exams or preparing for their oscillation. I'm Gavin Norman, a North Peak excursion based in Adelaide in South Australia, and I'm the host of this podcast.

I'd like to begin this podcast by acknowledging the traditional custodians of the land for which this podcast has been produced, paying my respects to the elders both past and present. Gives me great pleasure to introduce Martin Bruny onto our show. He's a fellow of both the College of Surgeons of Edinburgh and in Australia. He also has a Masters in Surgery. He's a senior consultant at the Quintusburg Hospital and a visiting surgeon to Port Augusta, Sejun, and Roxby Down.

He holds the position of Senior Lecturer at the University of Adelaide, and he's going to talk to us about the tips and tricks of hernia for the medical student. Welcome Martin Bernie.

uh predominance. So seventy five percent of all abdominal hernias are inguinal hernias. And as men, uh, we are ten times more likely to get an inguinal hernia than women, uh, but women uh are more likely to get a femoral hernia. Um so I guess in order, inguinal hernia is probably the uh is the most common. Uh femoral hernia is perhaps less common, but certainly uh perhaps more of an emergency that you need to know what to do uh

four. Incisional hernias are common even in this day of increasing laparoscopic approaches to operations. And then uh umbilical hernia, we can't forget our old friend the umbilical hernia because um, you know, there's quite a few percentage of uh people that are born with an umbilical hernia. Uh and fortunately that closes uh uh usually self-resolves by the age of about, you know, two to three. So uh but of course as we all get older and get that uh middle aged spread.

Uh unlike our washboard stomachs of course, Gav. Um uh the little belly button can pop out and uh become a problem later in life. So look, ineral and femoral hernia's probably caused the most consternation. And then it's incisional and then umbrilycal I guess in that order. And there are some more weird and wonderful hernias like the lumbar hernia of Petite, the Spigillian hernia, which is in the linear c semilunaris

in the abdominal wall and, you know, other things like hiatus hernia. So I guess the first thing is a hernia is a protrusion of an organ from uh within the cavity within which it is contained. So it's usually a defect or a breach of some sort. Now uh for inguinal hernias of course we all have natural defects there with the deep inguinal ring and the superficial Um but of course they can stretch with with time or there can be congenital reasons for the hernia. So

I guess on that background, uh it's fair to say that the Inginal Hernia is uh very common. It's probably the most or at least the second most common general surgical procedure that gets performed and it's always gets a Guernseyan exam, so that's where

to the inferior epigastric vessels. Now, a lot of people have difficulty with inguinal anatomy and I I I've got no doubt that uh people spend hours and hours looking at inguinal anatomy in the books and s and really there's no substitute for when you're a medical student actually going into theatre asking to scrub in and actually having a look because uh the anatomy books are pretty good these days.

computer programs and all that sort of thing. But until you actually uh get your hands in there, it really is a difficult concept. So Um, if we start at the beginning, and what I tell my medical students is there's really only two things you need to know in terms of anatomy. You need to know where your anterior superior iliac spine is so everybody can feel that uh on their iliac crest up the top.

and your pubic tubercle. So everybody can feel that as well if they go to the pubic synthesis and go laterally one way or the other, that knobbly little bit at the at the lateral edge of the pubic the pubic tubercle. Now if you've got those two anatomical landmarks, you've you've got the whole concept of inguinal hernias uh and ligaments and canals and everything, you've got to start. So The the structure that runs from the anterior superior spine to the pubic tubercle is the inguinal ligament.

And that's once again it's one of the few things you need to know. So that's one of that's an important landmark, obviously, and it represents the folded uh lower border of the external oblique axe. So about halfway along that line or halfway along the mid-inguinal point, there's your deep inguinal ring, and then just at the level of the pubic tubercle or just medial to it, you've got your superficial.

So the space in between the deep ring and the superficial ring is the inguinal canal. And it's only a canal when you actually open it up. So it doesn't sort of exist like a nice neat little channel tunnel or anything. It's just a space uh through uh the muscles and and of course through that uh the spermatic cord and its contents run.

So the deep brain is bounded by on the medial aspect by the inferior epigastric vessel. So getting back to our anatomical definitions of a indirect versus a direct turnium, Technically speaking, an indirect hernia emanates lateral to the epigastric vessel. A direct inguinal hernia and a So it comes out, sort of punches out of the posterior inguinal canal wall, and the indirect hernia are the ones that sort of slide down with the spermatic cord and can end up being uh inguinoscrous.

And with the um there are there are two spikes where inguinal henias occur. So one spike is from the zero to five year range. Another spike is in the plus sixty-five year range. So uh in the younger age group, it's always due to a patent processes value. So that's the structure uh which sort of uh guides uh and has the coverings for the testicle, uh reaches the testicle at birth and then it sort of obliterates. But in some people that remains patent so they will have

an innural hernia and it'll be an indirect hernia. So hernias in children are pretty much always indirect. In adults it's about two thirds indirect, one third So on the basis of that, uh that's you know, that's that's the sort of story I suppose for indirect versus direct. Now indirect of course has got a slightly greater propensity to strangulate and incarcerate, so uh but we sort of fix everything up pretty much.

So there is a theory about uh collagen makeup and there's no doubt that people with Marfans or Elas Danlos syndrome have a higher incidence of inginal hernia. And I guess y you brought up the topic of raised intra abdominal pressure and of course that's very important. And this goes back to uh you know, the basic of all uh you know, answering any question or seeing any patient.

It's uh you gotta get your history right. So within the history, um it's you know, with every history for anything, whether it's orthopedic or general surgical or medical, you always have to ask what occupation uh does this person do? And obviously if they're lift lifting, you know, sacks of cement into a uh truck every day and heavy physical labour that well they might be more Prone to getting a hernia. But the questions that people often forget to ask in respect to intra abdominal pressure.

is uh what are their bowels like? Because once in a while you will pick up that somebody has had increase in constipation. And then they go, Well actually yes, my bowels have been abnormal for a while and oh yes actually I have had some rectal bleeding and um you know it may well be that you can unmask uh a a more serious problem.

uh than a hernia. So somebody might have a uh sigmoid carcinoma that's causing a incomplete large bowel obstruction and that's why they're straining. And of course in men is questions with related uh related to the prospect. So, you know, how many times do you get up at night? What's your stream like? Do you have feelings of incomplete empty? And it'd be s you'd be surprised how many cases of prosthetism or benign BPH or even carcinoma get diagnosed because somebody's presented

with a hernia. So you must ask all those questions, apart from all the usual things like you know, pass suit medications, allergies and all that sort of thing. But those those three particular questions, so occupation, bow habit and urinary habits are pretty important. And it's often useful to get a time frame You know, when did you first get your symptoms? A lot of people just notice a lump when they're in the shower and they go, My God, what's that?

Gotta see the doctor quickly. Quick quick quick. But for a lot of people it's a pain. It's it's just pain or an ache. That's probably one of the biggest things that we have to differentiate as surgeons is, you know, what's causing that pain. So uh you know, it's very important to get that that exact history and then when do you get the pain? If somebody has

pain, um, you know, after exerting themselves or doing their daily activities or occupation. Well, sure, that might uh that might well be a hernia. If people only have pain perhaps going up and down stairs or getting

in and out of cars, well it might possibly be an osteoitis pubus. So um Yeah, the history is is important.

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Um now that tends to cause a little bit of uh uh tingling down the inner aspect of the thigh. Uh the genital branch of the genito femoral nerve also goes through there. You've got sympathetic fibers. So yes, often you get a uh Uh you'll get a referred pain sort of thing and um uh you'll get that just before the uh hernia pops out. But our biggest problem is what if we can't actually feel anything? If it's just a pain, where do we go?

So I guess that segues nicely into uh um examination. So we're taking our history examination and here, you know, students just have to remember get the patient to stand up. It's one of those absolute things you have to get them to do. So it's like examining for varicose veins. You're not going to see much when they're long. You must get them to stay. So get them to stand up. They uh you know, have to uh uh disrobe adequately so that you can

seeing feeling everything. And of course at this point I hasten to add, always get a chaperon. or ask the patient if, you know, they want a chafferone present. So get them to stand up and um then put your Uh, after you've washed your hands of course, uh get them to cough first of all, see if you can see anything. See if you can see any difference in the scrotum from one side to the other.

And uh and then uh palpate. So I think most people these days would probably wear gloves, which is a good thing. Um now remember a lot of people think uh inguinal and they put their hands over the hip flank. That's not the inguinal region. It's it's higher than you think. So go back to your landmarks, feel for the pubic tubercle and feel for the anterior superior spine.

And there's your imaginary line which is the inguinal ligament. So you just want to put your fingers just above the midpoint of that and uh get them to cough and then slide your fingers down a little bit more to where the superficial uh femoral ring is get them to cough and then you can invaginate the scrotum into the uh superficial ring get them to cough now look

It's difficult feeling for hernia. Some of them are obvious, they they pop out, some of them you get the thrill, so that's the little uh tickly feeling I guess when uh they cough was raised intra abdominal pressure.

But they can be very, very difficult to feel. So after you've got them to stand up, then get them to lie down and repeat the procedure.

Now of course um if I was studying for my if I was sitting for my fellowship exam, I'd say I'd do a full abdominal examination to check for any masses, and I'd also in the mail I'd also suggest doing a for the reasons that we sort of talked about before because it may be that they've got a massive uh prostate or you may even find blood on your glove after you've done it.

So that's the way I'd approach um, you know, examination. Take your time but get them to stand up, get them to lie down and uh see where it goes from there. So after history and examination It's either obvious or it isn't. Uh if it isn't, then then we go to uh uh investigation. Now it would be fair to say that one of the biggest problems we have with hernias, an assessment of hernia.

is the young you know, thirty year old person that comes in, they've got groin pain, they're clutching an ultrasound that their GP has organised that says there's a small indirect hernia. They come to you and they go, I want this hernia fixed. You take a history, it doesn't sound like a hernia, you examine them, you can't feel a hernia, but they're determined that they need an operation.

Because they've got an ultrasound. Now I love our radiological fellows. They're fantastic and they help us out many, many times. But unfortunately with ultrasound, it tends to overcall earnings. You can imagine if you've got the ultrasound probe and you ask somebody to cough or strain. Now anything that bulges into that inguinal canal uh can get interpreted as a hernia. Now is that a real hernia? Is it just a radiological hernia?

Um, for many of us we would take that all with a with a grain of salt and would say, Look, if we can't feel anything, then we shouldn't be doing an operation because really we haven't fully explained um your pain. Now hernia pain If it's a severe pain then something is incarcerated or caught or obstructed. Um it doesn't tend to cause sort of nagging pain all the time. So you have to be very, very circumspect when somebody comes with an ultrasound.

Um now, ultrasound of course, as we all know, is very operator dependent. So some you know, some people are just absolute guns with this sort of thing and you stake your life on the fact that if they said there's a hernia there must be a hernia. But in general, you know, unless we can feel a hernia, then uh uh we'd perhaps look in other areas for the pain.

And uh I've used that on many occasions and uh uh I've never regretted using it and uh that can certainly sort out uh um you know whether there's uh there's a musculoskeletal problem there as opposed to a True Hernia.

Um, you know, sometimes you can see hernias on C T scans just as a incidental finding, but of course C T scans not a dynamic scan, so you can't sort of get the patient to cough and strain while you're doing a C T. I guess what has changed in the last ten years or so has been the uh uptake of uh laparoscopic versus opening little hernia. And for a lot of people now, if they're confronted By someone who's got a uh

uh an ultrasound that says that yes there are hernias there. Um you know, if they're proficient at laparoscopic repair they might go, well, you know what, we'll stick the laparoscope in and have a look and if there's a hernia there we'll fix it up.

And you know, it it depends on the person. A lot of them say, look, just fix up the symptomatic side and that's fine. As long as they know what the risks of uh uh or what to look out for in the future with the other And I guess it's a good it's a good time to talk about the the two different approaches. Um certainly uh the open repair or the Liechtenstein repair uh is where we make uh incision in the skin, uh probably about Six to eight centimeters in length.

or two fingers breadths above your inguinal ligament and we uh open up the external B capineurosis, we find the spermatic cord and isolate that and then we can say okay well there's a sac associated directly with the chord which comes from the deep ring, so it's an indirect or we find a sack that's coming straight out from the posterior wall and that's a direct

With direct sacks we don't tend to open them up and push everything back in, we just tend to reduce the sack. With the indirect sacks that go down the cord, we tend to open the sack up, reduce the contents and then uh respect the sack at the level of the deep in and all ring. With both indirect and direct the the way we fix it is exactly the same. Uh we usually plicate the posterior wall. That's just putting a few stitches in the posterior wall, and then we put some onlay mesh, nylon mesh.

putting nylon suture sort of backwards and forwards a little bit. That's about the only situation where we wouldn't use mesh. Now of course this mesh has been tried through tested and uh look you know, the amount of times that we have to remove pieces of mesh in the inguinal region at least for uh infection it's very, very very s very So um um no we'd always use mesh. So that's an open repair and that usually takes

you know, forty five minutes to an hour. It can be done as a day case. It can be done under local if the patient, you know, is really that unwell. We tell people don't do any heavy physical activity for about four weeks, but We've probably been a bit conservative with that. I think we're sort of getting people to go back into things a little bit sooner than they used to. Um the laparoscopic repair can be uh

Uh done one of two ways. It can be done via an extraparate approach. So that where we make a cut in the skin and we find the uh plane between the peritoneum and the uh and the muscles and we sort of go through that or into that plane. Uh we uh there's various devices that open that plane up, various balloons. And we so we're looking at the inguinal canal and the inguinal structure from behind and that's the big difference.

uh with along with a big piece of mesh. The TAMP approach, so that's the trans abdominal approach, doesn't get used so much anymore. There have been various uh uh changes to that approach over the years. Initially the uh uh mesh was just applied to the peritoneum and uh staples were used to fix it. Uh but unfortunately um adhesions can occur to the mesh and uh cause you know strangulation, gangrene. Fistulas. So these days if people do do the test they tend to

pull the perit uh make a cut in the peritoneum, pull it down like a leaf and put the mesh in between the muscle and the peritoneum. So Uh that's the difference. That the tap approach you might do if you've got the patient but um you're not sure if there's a hernia there and all the investigations a bit up in the air, you can do the tap approach to look underneath to see if there's actually a hernia there. That's probably its real uh real benefit these days.

can be a problem as well. And there's always the risk of strangulation. So that's when the contents of the hernia are unable to be reduced. and uh there's compromise of the uh blood supply to whatever's trapped in that hernia. Now that's usually just a bit of momentum, but it can be bowel, usually small bowel, but it can be large bowel, can even be bladder.

So that's what the emergency is. And certainly if you were uh had a hernia that you knew about and you were about to embark on your round the world trip, you wouldn't want to get strangulated hernia, you know, on the top of the Andes or anywhere silly like that. So look the exam question answer is that we'd still repair it now.

when the patient is elderly and perhaps you know, it's not causing them too much in terms of symptoms and it's been noticed by a family member or somebody at the nursing home or whatever. then we would perhaps say, look, you know, I think the the risks of a hernia repair probably outweigh the benefit and certainly with some of the smaller unbelievable hernias, you know, people are quite happy to watch But generally speaking we'd say that uh uh most true legitimate

if you can't push it back then it is irreducible. Now that doesn't necessarily mean that it's uh obstructed or in or incarcerated, it just means that you can't get it back at that point in time. If it's been out for a while and it's a little bit tender, then that starts going into the category of uh incarcerated. And then on from that, if there's a lot of tenderness

Then there's the whole question of ischemia and that becomes strangulation. So strangulation implies uh that the blood supply is in trouble. So they're the basic casual.

So things are much more likely to strangulate. And that's the problem with a femoral hernia. And because it's in an awkward position, so it's below the f so if we go back to our inguinal ligament, pubic tubercle, Into your superior. femoral hernia has always got to be below that line. So if there's a if there's a tender lump that is below the inguinal ligament and kind of medial to the pubic tubercle, you're talking about um

A possible femoral uh hernia. And it's a great exam question. How do you tell the difference between an inguinal and a femoral hernia on examination? Or inguinal hernia is going to be above the inguinal ligament and it comes out sorry it comes out medial to the pubic tubercle. Ephemeral hernia will be below the inguinal ligament and be just lateral to the pubic.

So um but look, in reality it can be very difficult to uh determine and sometimes the best thing uh best way to determine is to do an operation. So the femoral hernia is much more of an a emergency procedure than an inguinal hernia. and there are various approaches for it but often um you know there can be a little knuckle of incarcerated uh bow.

Especially if any of our listeners are ever faced with the situation of the little old lady that comes in with a small bowel obstruction. They've never had uh any major medical conditions nor have they had uh any surgery in the past, make sure that you look in the groin. Looking in the groin should be part of every standard abdominal

Because if you look in the groin you might find that tender little nodule which will tell you ah there's a femoral hernia. So that's a surgical emergency and should be fixed up uh post.

and then, you know, take things from there. But uh, you know, it is a tricky uh a tricky area and if you can uh have the opportunity to uh to go and see an open hernia and assist in an open hernia, uh please grab it with both hands because uh things start to make a little bit of sense once you've actually, you know, had a look at