this chapter discuss the symptoms & signs of variant inguinal hernias

1. Clinical Manifestations of
Inguinal Hernia
History:
The groin hernia can present in a variety of ways, from the
asymptomatic hernia to frank peritonitis in a strangulated hernia.
Many hernias are found on routine physical examination or on a
focused examination for an unrelated complaint. These groin hernias
are usually fully reducible and chronic in nature. Such hernias are
still referred for repair since they invariably develop symptoms, and
asymptomatic hernias still have an inherent risk of incarceration and
strangulation (David and Brooks 2007).
A congenital inguinal hernia may be present at birth or may
appear shortly afterward, but in adults the development is usually
more insidious. The exception to this is the rapid onset, even within
hours or a day or two, of an "acute" inguinal hernia, usually indirect,
following sudden unexpected and unusual exertion and accompanied
by pain and even occasionally by ecchymosed in the inguinal region.
In the usual case, the patient may feel some discomfort in the groin or
pain referred to the testicle and notices a small bulge above the
inguinal crease when coughing or straining, which immediately
subsides. As the hernia develops, it appears when the patient stands
and reduces when he lies down. As it grows larger, it may not reduce
spontaneously when he is lying down and the patient learns to reduce
it manually (Abrahamson, 1997).
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Clinical Manifestations

2. The most common presenting symptomatology for a groin
hernia is a dull feeling of discomfort or heaviness in the groin region
that is exacerbated by straining the abdominal musculature, lifting
heavy objects, or defecating. These maneuvers worsen the feeling of
discomfort by increasing the intra-abdominal pressure forcing the
hernia contents through the hernia defect. Pain develops as a tight
ring of fascia outlining the hernia defect compresses intra-abdominal
structures with a visceral neuronal supply. With a reducible hernial
feeling of discomfort resolves as the pressure is released when the
patient stops straining the abdominal muscles. The pain is often
worse at the end of the day and patients in physically active
professions may experience the pain more often than those who lead
a sedentary lifestyle (Javid and Brooks 2007).
A. General Examination:
(1) Cardiovascular and respiratory assessment:
The cardiovascular and respiratory systems should be assessed
with the patient's fitness for operation in mind. Also, look for the
common causes of a raised intra-abdominal pressure e.g. chronic
bronchitis and coughing (Browse, 1997).
(2) Abdominal examination:
The common causes of a raised intra- abdominal pressure are
looked for such as a large bladder, an enlarged prostate, ascites, intra-
abdominal masses and chronic intestinal obstruction. Also, any signs
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Clinical Manifestations

3. of intestinal obstruction are looked for such as distension, increased
bowel sounds, and visible peristalsis (Browse, 1997).
B. Local Examination:
The clinician examines the patient from the front with the
patient standing with legs apart. The patient is instructed to look at
the ceiling and cough. If the hernia will come down, it usually does.
The examiner looks for the impulse and feels for the impulse and
then addresses the following questions:
Is the hernia right, left or bilateral? Is it an inguinal or femoral
hernia? Is it a direct or an indirect hernia?
Is it reducible or irreducible (the patient may have to lie down
for this to be ascertained)?
Is the inguinal hernia incomplete or complete?
What are the contents? (Russell et al., 2004).
Features of indirect inguinal hernia.
1. Can (and often does) descend into & scrotum.
2. Reduces upwards, then laterally and backwards.
3. Controlled, after reduction, by pressure over the internal
inguinal ring.
4. After reduction, the bulge reappears in the middle of the
inguinal region and then flows medially before turning down to the
neck of the scrotum.
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Clinical Manifestations

4. Features of Direct inguinal hernia.
1. Usually does not go down into the scrotum.
2. Reduces upwards and then straight backwards.
3. Not controlled, after reduction by pressure over the internal
inguinal ring.
4. The defect may be felt in the abdominal wall above the
pubic tubercle.
Figure (15) An indirect hernia (Brose, 2008)
5. After reduction, the bulge reappears exactly where it
was before.
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Clinical Manifestations

5. These signs are not always clear cut; a longstanding large
indirect hernia will stretch the internal ring until it occupies most of
the transversalis fascia and will appear no different from direct
hernia. A small direct hernia protruding through a narrow tear; of the
transversalis fascia will appear clinically like an indirect hernia
(Abrahamson, 1997).
Internal ring test can be done to differentiate between an
indirect from a direct inguinal hernia. After reduction of the hernia,
the thumb obliterates the internal ring, with the thumb in place, the
patient asked to cough. If the hernia does not appear, then this is an
indirect hernia, hernia descends and is above the inguinal ligament in
case of direct hernia, or the hernia descends below the inguinal
ligament, this occurs in femoral hernia (Abrahamson, 1997).
If the scrotum is invaginated with the index finger and the tip
of the finger is placed through the external inguinal ring into the
canal, and the patient is then asked to strain, an indirect hernia will
push against the fingertip, whereas a direct hernia will push against
the pulp of the finger. It should be noted that the accuracy of this
clinical assessment is questioned (Richard et al., 2006).
The contents of the hernial sac will be enterocele or
omentocele:
Enterocele: It is soft, with gurgling sensation; its first part is
difficult for reduction, and resonant on percussion.
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Clinical Manifestations

6. Omentocele: It is doughy and its last part is difficult for
reduction because of adhesion of sac and omentum (Lawerance et
al.,1997).
Complications of Inguinal Hernia
The majority of patients who are admitted as emergencies with
complicated hernias have not previously sought medical attention or
been diagnosed with the condition in the outpatient department. This
observation implies that most hernias that develop complications do
so within a relatively short time in the natural history of the disease
(Cuschieri et al., 2002).
I. Irreducibility (Incarceraion):
Incarcerated means "trapped" or "imprisoned." Clinically, an
incarcerated hernia is an irreducible hernia. Incarceration does not
denote obstruction. The contents of the hernia may be omentum, non
obstructed bowel, or ovary, and its irreducibility is associated with
adhesions to the hernial sac (Richard et al., 2006).
The recommended treatment of an incarcerated hernia is
surgical, but there is no urgency because there is no life threatening
complication presents (Fitzgibbons et al., 2005).
II. Obstruction:
This occurs in irreducible hernias due to occlusion of lumen of
contents from without or from within (the blood supply is still
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Clinical Manifestations

7. unaffected). There are symptoms of intestinal obstruction as
vomiting, distension, colics, and constipation. The picture simulates
strangulation but is less severe. Locally the hernia becomes
distended, irreducible, but it is still soft. Distinction between
obstruction and strangulation in hernias may be difficult, thus it is
safe to treat it as strangulation and early surgery should be performed
(Fuzun et al., 1991).
III. Inflammation:
It can occur from inflammation of the contents within the sac
e.g. acute appendicitis or salpingitis, also from external causes e.g.
from a sore caused by an ill-fitting truss. The hernia is tender but not
tense, and the overlying skin becomes red and edematous. Operation
is necessary to deal with the cause (Rains et al., 1992).
IV. Strangulation:
This is the most serious complication. It means constriction of
contents leading to interruption of their blood supply. If not relieved,
gangrene may occur within 4-6 hours (Fuzun et al., 1991).
The constricting agent may be:
1. A resistant structure outside the sac as the superficial or deep
inguinal ring or the Gimbernat's ligament.
2. The neck of the sac.
3. Bands of adhesions within the sac.
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Clinical Manifestations

8. If the contents are intestine, the intestine proximal to the
strangulated loop will be obstructed with progressive distension and
hyperperistalsis. The intestine distal to the strangulated loop will be
collapsed. The strangulated loop will suffer the following sequelae:
• Impeded venous return.
• Later, the arterial supply becomes impaired.
• Finally, gangrene occurs.
• Peritonitis is the terminal event, as infection spreads
From the sac to the peritoneum. Neglected cases die from
septic shock and dehydration (Fuzun et al., 1991).
In addition to having an irreducible hernia and intestinal
obstruction, the patient is toxic, dehydrated, and febrile. Examination
of the abdomen reveals the signs of an intestinal obstruction, with
distention and increased bowel sounds. Absolute constipation and
vomiting are other manifestations. The hernia itself is tense,
irreducible, and very tender, and the overlying skin may be
discolored with a reddish or bluish tinge. No bowel sounds are heard
within the hernia itself. The patient commonly manifests a
leukocytosis with a predominance of polymorphonuclear leukocytes.
Blood gases may reveal metabolic acidosis (Richard et al., 2006).
Rapid resuscitation with intravenous fluids is essential, along
with electrolyte replacement, antibiotics, and nasogastric suction.
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Clinical Manifestations

9. Urgent surgery is indicated once resuscitation has taken place.
(Fitzgibboris et al., 2005).
V. Maydl 's hernia:
Maydl's hernia is a complication of large hernial sacs,
especially right scrotal hernias in Africans, when a W-loop of small
gut lies in the sac. The intervening loop is strangulated within the
main abdominal cavity by the constriction of the neck of the sac
(Delvin and Kingsnorth. 1998).
VI. Strangulated Littre's hernia:
Littre's hernia is an oddity and rarity, a hernial sac containing a
strangulated Meckel's diverticulum. Littre's hernia can resolve
spontaneously with gangrene, suppuration and formation of a local
fistula. An inflamed Meckel's or appendix within the hernial sac can
give similar signs (Delvin and Kingsnorth, 1998).
VII. Richter's hernia:
In this interesting complication, part of the bowel wall
herniates through the defect and may become ischemic and
gangrenous. However, intestinal obstruction does not occur. The
overlying skin may be discolored. (Richard et al., 2006).
Differential Diagnosis
The diagnoses of inguinal hernia is usually not difficult, but
occasionally it may have to be differentiated from
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Clinical Manifestations

10. I. In the male:
1. Vaginal hydrocele
2. An encysted hydrocele of the cord
3. Spermatocele
4. A femoral hernia
5. An incompletely descended testis in the inguinal canal. An
Inguinal hernia is often associated with this condition
6. A lipoma of the canal
7. Enlarged inguinal lymph node
8. Saphena varix
9. A subcutaneous lipoma
10. A tuberculeous psoas abscess may point in the groin and be
confused with hernia
11. Rupture of adductor longus tendon hematoma
(Abrahamson, 1990)
II. In the female
1. A hydrocele of the canal of Nuck is the commonest
differential diagnostic problem
2. A femoral hernia. (Abrahamson, 1990) .
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Clinical Manifestations
Figure (16) femoral hernia (Browes,2008(

11. 68
Clinical Manifestations