One-page cheat sheet
Abdominal wall hernias
Anatomy, risks and repair
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Groin anatomy
- Deep ring: midpoint of the inguinal ligament, lateral to the inferior epigastric vessels
- Superficial ring: above and medial to the pubic tubercle
- Hesselbach’s triangle: inferior epigastric vessels, rectus edge, inguinal ligament
- Femoral canal: inguinal ligament, lacunar ligament, pectineal ligament, femoral vein
Types
- Indirect inguinal: through the deep ring, lateral to the epigastric vessels; commonest at all ages
- Direct inguinal: through Hesselbach’s triangle
- Femoral: below and lateral to the pubic tubercle; high strangulation risk
- Others: umbilical, epigastric, incisional, Spigelian, obturator, Richter’s, Littre’s, Amyand’s
Examination
- Examine standing and lying, both sides, with a cough impulse
- Direct vs indirect is not reliable clinically: it is decided at surgery
- Ultrasound if the diagnosis is uncertain; CT for complex or incisional hernias
Management
- Symptomatic inguinal: mesh repair, open Lichtenstein or laparoscopic TEP/TAPP
- Laparoscopic preferred for bilateral and recurrent hernias, and in women (occult femoral)
- Minimally symptomatic men: watchful waiting is reasonable
- Femoral: repair promptly
- Children: herniotomy without mesh; soon in infants. Umbilical hernias in children usually close by 4–5
Strangulation
- Tense, tender, irreducible, red skin, obstruction, systemically unwell
- Emergency surgery: do not force reduction (reduction en masse)
- Richter’s hernia can strangulate without obstruction
Exam pearls
- Obturator hernia: thin elderly woman, medial thigh pain (Howship-Romberg)
- After repair: chronic groin pain in up to 1 in 10, recurrence, seroma, testicular ischaemia
- Incisional hernia follows up to 1 in 5 laparotomies