Case Files Surgery, (LANGE Case Files) 4th Ed.

SECTION II. Clinical Cases

CASE 45

A 36-year-old man presents with a 1-day history of right groin pain. The patient indicates that the pain developed during a tennis match the previous evening and on returning home he noticed swelling in the area. His past medical history is unremarkable. The patient denies any history of medical problems or similar complaints. He has not undergone any previous operations. The physical examination reveals a well-nourished man. The results from the cardiopulmonary examination are unremarkable, and the abdominal examination reveals a nondistended, nontender abdomen. Auscultation of the abdomen reveals normal bowel sounds. Examination of the right inguinal region reveals no inguinal mass. There is a 3-cm nonerythematous swelling on the medial thigh just below the right inguinal ligament. Palpation reveals localized tenderness. The lower extremities are otherwise unremarkable. Laboratory findings reveal a WBC count of 6500/mm3 and normal hemoglobin and hematocrit levels. Electrolyte concentrations are within the normal range as are the results from a urinalysis. Radiographs of the abdomen demonstrate no abnormalities.

Images What is the most likely diagnosis?

Images What are the complications associated with this disease process?

Images What is the best therapy?

ANSWERS TO CASE 45: Hernias

Summary: A 36-year-old man complains of a new-onset painful mass in the groin region present since he played tennis the previous day.

• Most likely diagnosis: Incarcerated femoral hernia.

• Complications: Strangulation of the hernia sac contents with resulting sepsis.

• Best therapy: Operative exploration of the right groin to evaluate, reduce the hernia sac contents, and repair the femoral hernia.

ANALYSIS

Objectives

1. Know the presentations of inguinal, femoral, and umbilical hernias.

2. Recognize the anatomic landmarks of the different types of hernias.

3. Learn the pros and cons of the different approaches to hernia repair.

Considerations

The differential diagnosis of groin pain and/or mass includes inguinal hernia, femoral hernia, muscle strain, and adenopathy. Although many patients believe the sudden development of pain or a mass in the groin is the classic and usual presentation for a groin hernia, this particular clinical picture is in fact more suggestive of muscle injury. Patients with inguinal hernias generally describe a long history of intermittent groin pain or “heaviness” that is more prominent when standing and during physical activity. The sudden development of a painful groin mass, such as in a patient with a known hernia, suggests hernia incarceration. In particular, this patient’s presentation is compatible with that for an incarcerated femoral hernia. Because a femoral hernia usually is a small, well-defined anatomic defect, there may be few or no long-term symptoms, and acute incarceration may be the initial presenting symptom. The diagnosis in this case can be established on the basis of the history and the results from a physical examination. In the event of clinical uncertainty, ultrasonography or CT imaging may be helpful in differentiating an incarcerated hernia from lymph nodes, hematomas, or abscesses. Once the diagnosis is made, a patient with an incarcerated hernia should undergo urgent surgical repair to relieve the symptoms and to prevent strangulation of hernia sac contents.

APPROACH TO: Hernias

DEFINITIONS

INDIRECT HERNIA: An inguinal hernia in which the abdominal contents protrude through the internal inguinal ring through a patent processus vaginalis into the inguinal canal. In men, they follow the spermatic cord and may appear as scrotal swelling, whereas in women they may manifest as labial swelling.

DIRECT HERNIA: An inguinal hernia that protrudes through the Hesselbach triangle medial to the inferior epigastric vessels.

FEMORAL HERNIA: A hernia that protrudes through the femoral canal, bounded by the inguinal ligament superiorly, the femoral vein laterally, and the pyriformis and pubic ramus medially. Unlike inguinal hernias, these hernias protrude below, rather than above, the inguinal ligament.

UMBILICAL HERNIA: A hernia resulting from improper healing of the umbilical scar. Eighty percent of pediatric umbilical hernias close by 2 years of age. In adults, defects are often exacerbated by conditions that increase intra-abdominal pressure, such as ascites.

LITTRE HERNIA: A groin hernia that contains a Meckel diverticulum or the appendix.

RICHTER HERNIA: Herniation of part of the bowel wall through a defect in the anterior abdominal wall. Bowel obstruction does not occur, although the constricted bowel wall may become ischemic and subsequently necrotic.

SPIGELIAN HERNIA: A hernia just lateral to the rectus sheath at the semilunar line, the lower limit of the posterior rectus sheath.

OBTURATOR HERNIA: Herniation through the obturator canal alongside the obturator vessels and nerves. This hernia occurs mostly in women, particularly multiparous women with a history of recent weight loss. A mass may be palpable in the medial thigh, particularly with the hip flexed, externally rotated, and abducted (Howship-Romberg sign).

SLIDING HERNIA: A hernia in which one wall of the hernia is made up of an intraabdominal organ, most commonly the sigmoid colon, ascending colon, or bladder.

CLINICAL APPROACH

Abdominal wall hernias are protrusions of abdominal contents through a defect in the abdominal wall. Incarceration occurs if the abdominal contents become trapped. Strangulation occurs when the blood supply to the trapped contents becomes compromised, leading to ischemia, necrosis, and ultimately perforation. Intestinal obstruction can occur in an incarcerated or strangulated hernia. Abdominal wall defects that develop following surgical procedures not related to a hernia are referred to as incisional hernias and addressed elsewhere.

Anatomy

Knowledge of the regional anatomy is essential for the diagnosis and repair of hernias. In the groin, the inguinal ligament divides inguinal hernias from femoral hernias. Inguinal hernias are further divided into indirect and direct hernias based on their relationship to the inferior epigastric vessels. The Hesselbach triangle, defined by the edge of the rectus medially, the inguinal ligament inferolaterally, and the inferior epigastric vessels superolaterally, is the site of direct hernias (Figure 45–1). In this triangle, the peritoneum and transversalis fascia are the only components of the anterior abdominal wall. Indirect hernias are lateral to the inferior epigastric vessels. The Cooper ligament, or the pectineal ligament, extends from the pubic tubercle laterally and passes posteriorly to the femoral vessels.

Images

Figure 45–1. Anatomic location of groin hernias. Direct hernia (A), indirect hernia (B), femoral hernia (right groin from an anterior view) (C).

APPROACH TO AN INCARCERATED HERNIA

Reduction should be attempted in a patient with an incarcerated hernia. This procedure is best accomplished by elongating the neck of the hernia sac while judiciously applying pressure to reduce the hernia. If reduction is unsuccessful, the patient should be prepared for an urgent operation. In a patient with a bowel obstruction, volume depletion and abnormalities in electrolyte levels are common. These conditions should be corrected before operative intervention. Urgent repair requires an incision over the incarcerated hernia, close inspection of any contents, and tension-free reapproximation. For inguinal hernias, the transversus abdominus is sutured to either the Cooper ligament or the shelving edge of the inguinal ligament. For femoral hernias, a Cooper ligament repair must be used. With a compromised bowel, a prosthetic mesh should be avoided because of the infection risk.

Indications for Repair

Symptoms produced by hernias are related to the size and location of the hernias and the activity level of the individual; therefore, it is not uncommon for some patients with small hernias to remain asymptomatic or minimally symptomatic. Until only several years ago, it was the general opinion of the surgical community to recommend that all patients with groin hernias and reasonable life expectancy undergo hernia repairs. This aggressive approach was based on the assumption that these hernias left unattended to would progress to incarceration and/or strangulation. In 2006, the result of the “watchful waiting vs repair” trial was published suggesting that the rate of complications development was low in patients with small, minimally symptomatic, or asymptomatic groin hernias (0.3% over 2 years), and that it was safe and cost-effective to attempt an initial course of nonoperative management.

For individuals with symptomatic hernias, elective repair via an open approach can be performed under local, spinal, or general anesthesia. It can also be done laparoscopically, which requires a general anesthetic. In addition to the elective or urgent/emergent nature of the repair, anesthetic choice, patient preference, and the primary or recurrent nature of the hernia factor into the decision regarding the operative approach. A laparoscopic approach or an open preperitoneal approach is best for recurrent or bilateral hernias (Figure 45–2). For unilateral primary groin hernias, the approaches have similar recurrence rates, similar disability times, and similar costs. Patients who undergo laparoscopy seem to have less pain and may be able to return to work sooner. The recently reported VA Medical Centers Randomized Trial comparing open mesh repairs versus laparoscopic mesh repairs for inguinal hernias found higher complication and recurrence rates for the laparoscopic patients. Although these results are still being debated, the findings seem to suggest no benefits or worse outcome with the laparoscopic approach.

Images

Figure 45–2. Right groin anatomy by preperitoneal view. Operative repair of a direct hernia (A), an indirect hernia (B), and a femoral hernia using a prosthetic mesh in a posterior (preperitoneal) approach (C).

COMPREHENSION QUESTIONS

45.1 A 20-year-old construction worker complains of pain and intermittent bulge in his left groin. He indicates that the symptoms have been worsening over the past 3 months and beginning to affect his activities. On examination, he appears to have a small indirect inguinal hernia. Which of the following is the most appropriate management?

A. Discuss with the patient potential benefits of “watchful waiting” and reevaluate the patient in 1 month.

B. Advise the patient to undergo laparoscopic hernia repair because a large randomized trial showed superior outcome for patients undergoing laparoscopic repairs.

C. Perform open left inguinal herniorrhaphy with primary suture repair.

D. Advise the patients that groin hernias do not need to be fixed.

E. Perform open left inguinal hernia repair with prosthetic mesh.

45.2 A 40-year-old man presents with recurrent bulge in the left groin 2 years following open left inguinal hernia repair with mesh. The physical examination showed a moderately dilated external inguinal ring with a small bulge produced by Valsalva maneuver. Which of the following is the most appropriate treatment approach?

A. Obtain a CT to rule out a femoral hernia, followed by elective hernia repair.

B. Schedule patient for left groin exploration and hernia repair with prosthetic mesh.

C. Advise patient to limit his physical activities and reevaluate in 6 months.

D. Send the patient to an immunologist for evaluation of possible wound healing and tissue collagen defects.

E. Schedule the patient for bilateral inguinal exploration.

45.3 An 80-year-old woman who resides in a nursing home has a several-pound weight loss over the past several months. She presents with a 3-day history of vomiting and anorexia. Her abdominal examination reveals distension and tympany. There is a firm soft tissue mass measuring approximately 4 cm in the medial aspect of her left upper thigh. Her abdominal CT scan reveals fluid-filled dilated small bowel loops and evidence of decompressed ileum and colon. Which of the following is the most appropriate treatment for this patient?

A. Exploration of the left groin and thigh, and repair of her femoral hernia.

B. Exploratory laparotomy.

C. Initial observation of this elderly patient with small bowel obstruction, and, if the process fails to resolve in 5 days, proceed with exploratory laparotomy.

D. Comfort care.

E. Place a long tube to decompress the small bowel.

45.4 Which of the following is the appropriate treatment for the patient in Question 45.3?

A. Schedule her for an elective operation after her symptoms improve.

B. Request a colonoscopy.

C. Take her straight to the operating room.

D. Hospitalize her for volume and electrolyte replacement followed by an urgent operation.

E. Request an MRI to help further determine the cause of her problem.

ANSWERS

45.1 E. Open repair with prosthetic mesh. The study by Neumayer et al (New England Journal of Medicine, 2004) was a randomized comparison of laparoscopic versus open mesh inguinal hernia repair that actually showed increased recurrence rate with laparoscopic repair. There is no definitive evidence to support laparoscopic repair, watchful waiting, or primary open repair in this patient’s case.

45.2 B. This patient has history and physical findings that are compatible with having a recurrent inguinal hernia, and repair for this recurrent hernia is the most reasonable approach. CT evaluation to rule out a femoral recurrence is reasonable only if the patient does not have clinical evidence or history that his recurrent hernia is inguinal in location. “Watchful waiting” is only reasonable if the patient is minimally symptomatic and rerepair of his hernia would not improve his quality of life. Most patients with hernia recurrences do not have definable collagen defects.

45.3 B. This patient has signs and symptoms of high-grade small bowel obstruction. The association of her obstructive symptoms with a newly identified tender medial thigh mass could indicate the presence of an incarcerated femoral hernia or an incarcerated obturator or femoral hernia. In a patient with small bowel obstruction that is likely produced by incarcerated hernia, an initial course of nonoperative management is not appropriate. Comfort care is only reasonable if the patient has extremely limited life expectancy. The patient’s current quality of life is extremely compromised given her bowel obstruction; therefore repair is indicated to correct the condition.

45.4 D. Resuscitation and urgent repair are indicated for patients with a bowel obstruction caused by a hernia.

CLINICAL PEARLS

Images Recent clinical evidence suggests that hernia incarceration and strangulation rate is quite low in patients with small, asymptomatic, or minimally symptomatic inguinal hernias; therefore, an initial trial of nonoperative care is safe and cost-effective.

Images The Howship-Romberg sign refers to obturator neuralgia produced by nerve compression by an obturator hernia. (The sign is produced by thigh extension, adduction, and medial rotation.)

REFERENCES

Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006;295:285-292.

Khaitan L, McKernan JB. Groin hernia. In: Cameron JL, ed. Current Surgical Therapy. 9th ed. Philadelphia, PA: Mosby Elsevier; 2008:561-568.

Millikan KW. Inguinal hernia. In: Cameron JL, Cameron AM, eds. Current Surgical Therapy. 10th ed. Philadelphia, PA: Elsevier Saunders; 2011:491-494.

Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004;350:1819-1827.