Bookmark:           

Symptoms of inguinal hernia

The patient may complain of:

1. A lump in the groin
2. A dragging sensation in the groin
3. Discomfort in the groin on coughing and lifting

Signs of inguinal hernia

You may find on examination:

1. A lump in the groin
2. A visible cough impulse in the lump (increase in size of the lump when the patient coughs)
3. A palpable cough impulse (increase in size of the lump felt when the patient coughs)

Complications of inguinal hernia

1. Incarceration: From the Latin "to imprison" - hence incarcerate. The hernia is normally reducible, i.e. the lump can be pushed gently back into the abdominal cavity. Sometimes the hernia becomes too large to push back through the small hole in the abdominal wall through which it came and is said to be irreducible or incarcerated. This is rather like putting a hand when flat through railings and then making a fist and being unable to get the hand back through. There are no serious sequelae of incarceration itself but other more serious complications below may be more likely.
2. Obstruction: The opening the abdominal wall through which the hernia protrudes (neck of the hernia) is too small to allow bowel contents through into the loop of bowel in the hernia. Thus the contents of the bowel accumulate upstream of the blockage (rather like stepping on a hosepipe). The blocked bowel is invariably small bowel and so the patient presents with symptoms and signs of small bowel obstruction (colicky central abdominal pain, abdominal distension, vomiting and absolute constipation (no faeces or flatus passed through the rectum)). There will be an irreducible hernia in the groin on examination also.
3. Strangulation: The opening the abdominal wall through which the hernia protrudes (neck of the hernia) is too small to allow adequate drainage of blood from the contents of the hernia (rather like tying a tourniquet around a finger). The occlusion of venous drainage leads in turn to decreased arterial supply of blood. Both of these produce ischaemia (too little blood supply for metabolic needs of the tissue) and then infarction (cell death) of the contents of the sac. The hernia becomes painful, the skin over the lump may become red and the lump is very tender to touch. Strangulation occurs in 0.3-2.9% of inguinal hernias per annum. The risk is greatest within 3 months of the hernia first appearing.

Most hernia repairs are perfromed as elective procedures. However, 4.8% of primary hernias and 8.6% of recurrent hernias are repaired as an emergency with a complication.

Plain supine X-ray of a patient with small bowel obstruction secondary to an obstructed inguinal hernia. The bowel is distended and can be identified as small bowel by its central position and the lighter lines on the X-ray passing completely across the loops of bowel. These are the radiological appearances of the valvulae conniventes. The patient needs resuscitation with fluids and oxygen and when fit enough, operation to reduce the obstructed bowel and repair of the hernia.

Two examples of infarcted bowel found within a strangulated inguinal hernia. There has been insufficient blood supply to the bowel stuck in the hernia. Cell death (infarction) of the tissue has occurred. The patient needs resuscitation with fluids and oxygen and when fit enough, operation to excise the dead bowel and repair the hernia. If not operated upon the dead bowel would perforate, leak and cause peritonitis. Mortality if this occurs is high.

Return to Main Menu