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INGUINAL HERNIA

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DEFINITION

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EPIDEMIOLOGY

• Most common hernia in both males and females
• 10 times more common in males than females
• Accounts for approximately 75% of all abdominal wall hernias
• Indirect inguinal hernia comprises more than 80% of all inguinal hernias
• Almost all hernias in children and women are of the indirect (oblique) type
• Direct hernia is more common above 40 years of age (acquired, degenerative)

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ANATOMY OF THE INGUINAL CANAL

The Inguinal Canal

• An oblique passage through the lower part of the anterior abdominal wall
• Approximately 4 cm long in adults
• Runs from the deep inguinal ring to the superficial inguinal ring
• Directed downwards, medially and forwards

Deep Inguinal Ring (Internal Ring)

• A defect in the transversalis fascia
• Lies midway between the anterior superior iliac spine (ASIS) and the pubic tubercle
• Located approximately 2-3 cm above and just lateral to the femoral artery pulse
• Inferior epigastric vessels lie just medial to the deep ring
• This relationship is the key to distinguishing indirect from direct hernia

Superficial Inguinal Ring (External Ring)

• An inverted V-shaped defect in the external oblique aponeurosis
• Located just superolateral to the pubic tubercle
• The testis/spermatic cord emerges here to descend into the scrotum

Walls of the Inguinal Canal

Conjoint Tendon

• Formed by the fusion of the internal oblique and transversus abdominis muscles
• Arches over the deep inguinal ring from lateral to medial
• Descends to attach to the pubic tubercle
• Below this arch, the posterior wall has NO muscle - only transversalis fascia + external oblique aponeurosis = area of weakness

Contents of the Inguinal Canal

• Spermatic cord (testicular artery, pampiniform venous plexus, vas deferens, lymphatics)
• Cremasteric muscle fibres around the cord
• Three nerves: ilioinguinal nerve, iliohypogastric nerve, and genital branch of genitofemoral nerve

• Round ligament of uterus (ends in labia majora)
• Ilioinguinal nerve

Hesselbach's Triangle (Triangle of Weakness)

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CLASSIFICATION

A. ANATOMICAL TYPES

• Bubonocele - hernia does not come out of the superficial inguinal ring
• Incomplete hernia - comes out through the ring but does not reach the bottom of the scrotum
• Complete hernia - reaches the bottom of the scrotum (inguinoscrotal hernia)

• Enterocele - contains intestine; elastic in consistency, resonant on percussion, reduces with a gurgle, reduction is difficult at first but easy at end
• Epiplocele (Omentocele) - contains omentum; doughy and granular feel, dull on percussion, reduces without gurgle, easy at first but difficult towards the end
• Cystocele - contains urinary bladder; occurs only in direct or sliding hernia

B. CLINICAL TYPES (Based on Complications)

• Contents can be returned to the abdominal cavity
• Sac remains in its position
• Uncomplicated hernia - normal state

• Contents cannot be returned to the abdomen
• No compromise of blood supply
• Causes: adhesions of contents to each other, adhesions to sac, large scrotal hernia, sliding hernia
• NOT tender, NOT tense (important distinction from strangulation)

• Hernia is irreducible + features of intestinal obstruction (colicky pain, vomiting, distension, constipation)
• NO interference with blood supply to intestine
• Important caveat: strangulation also causes all these features plus vascular compromise - do not delay treatment assuming it is "only" obstructed

• Contents are constricted such that blood supply is cut off
• May or may not have intestinal obstruction (e.g., Richter's hernia, Littre's hernia, omentocele - no obstruction)
• Clinical features: irreducible hernia + no cough impulse + extremely tense and tender + overlying skin may be red/oedematous
• Followed by features of acute intestinal obstruction and systemic toxicity
• Indirect inguinal hernia strangulates more commonly than direct (narrow neck)

• Occurs when contents (appendix, Meckel's diverticulum, fallopian tube) become inflamed inside the sac
• Signs of local inflammation present
• Differentiating point from strangulated hernia: this hernia is NOT tense

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SPECIAL TYPES OF INGUINAL HERNIA

1. Indirect (Oblique) Inguinal Hernia

• Due to persistence of the processus vaginalis (patent peritoneal process)
• Normally, after testicular descent, the funicular process obliterates - only the scrotal part remains as the tunica vaginalis
• If the entire process remains patent - content of peritoneal cavity can descend all the way to the scrotum = congenital vaginal hernia (complete)
• If patent only up to the top of the testis = congenital funicular hernia
• Note: Although named "congenital," it is usually first noticed/clinically apparent in adults

• Does not protrude into a pre-formed sac
• Progresses gradually
• Clinically: does not become complete immediately, unlike congenital type
• Occurs later in life due to stretching of the deep inguinal ring under chronic raised intra-abdominal pressure

2. Direct Inguinal Hernia

• Always acquired - due to weakening and stretching of the abdominal wall within Hesselbach's triangle
• More common in elderly men above 40 years
• Frequently incomplete; rarely reaches the scrotum unless untreated for years
• Hernia comes out as soon as the patient stands and disappears immediately on lying down
• Swelling is more spherical in shape
• Rarely strangulates because the neck is wide

3. Sliding Hernia (En Glissade)

• Type of acquired indirect hernia
• Retroperitoneal fat is pushed into the inguinal canal, dragging peritoneum with it - thus the sac forms secondarily
• Part of the wall of the sac is formed by a viscus (sigmoid colon on left, caecum on right, or urinary bladder in direct type)
• Surgical danger: if the bowel forming the sac wall is cut during dissection, serious injury occurs
• The sac cannot be excised in the usual manner; it must be reduced en masse

4. Pantaloon Hernia (Saddle-bag Hernia)

• Both an indirect (lateral) and a direct (medial) hernia are present simultaneously on the same side
• The inferior epigastric vessels lie between the two sacs - hernia straddles the vessels like a pantaloon

5. Richter's Hernia

• Only part of the circumference of the bowel (anti-mesenteric border) is caught in the hernial sac
• Intestinal obstruction may NOT be present (lumen not completely occluded)
• Strangulation of the bowel wall can occur silently without obvious obstruction - hence dangerous
• Inguinal and femoral hernias are the common sites

6. Littre's Hernia

• Hernia containing a Meckel's diverticulum within the sac

7. Maydl's Hernia (Hernia-in-W or Hernia-en-W)

• Two loops of bowel lie in the hernial sac with the intervening segment (the middle limb of W) remaining inside the abdomen
• The intra-abdominal loop strangulates first - strangulation occurs without obvious abnormality in the externally visible hernia
• Very dangerous: a patient can develop gangrene of an intra-abdominal loop not visible in the sac

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CAUSES AND PREDISPOSING FACTORS

Anatomical / Congenital Factors:

• Patent processus vaginalis (main cause in children and indirect hernia)
• Inherent weakness in the abdominal wall musculature
• Poor development of the conjoint tendon

Raised Intra-Abdominal Pressure (Chronic):

• Chronic cough (COPD, smoking)
• Chronic constipation and straining
• Benign prostatic hyperplasia (straining at micturition)
• Ascites
• Pregnancy
• Obesity
• Heavy manual labour

Weakness of the Abdominal Wall (Acquired):

• Old age - muscle atrophy, loss of tissue elasticity
• Malnutrition
• Previous surgery/scars
• Collagen disorders

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CLINICAL FEATURES

Symptoms

• Swelling in the groin: painless lump that appears on standing, coughing, or straining; disappears on lying down (reducible hernia)
• Pain or discomfort: dragging ache or dull pain, especially after prolonged standing or exertion
• Patients refer to it as a "rupture"
• If irreducible: persistent lump that cannot be reduced
• If strangulated: sudden severe pain, tender lump, vomiting, signs of intestinal obstruction and toxaemia

Signs - Physical Examination

• Position: examine standing and lying down
• Site: above and medial to the pubic tubercle (inguinal hernia lies medial to pubic tubercle and above inguinal ligament)
• Swelling visible on standing/coughing
• Extends toward or into the scrotum in complete hernias

• Cough impulse: an expansile impulse felt when patient coughs - hallmark of a hernia
• Reducibility: can the contents be pushed back?
• Consistency: soft and compressible (enterocele) vs. doughy (epiplocele)
• Tenderness: absent in uncomplicated hernia; severe in strangulation

• Index finger is invaginated into the scrotum and up into the superficial inguinal ring
• Patient is asked to cough
• In indirect hernia: impulse is felt at the fingertip as the hernia comes obliquely downwards and laterally along the canal
• In direct hernia: impulse is felt at the pulp/side of the finger as the hernia pushes directly forwards, and the finger goes directly backwards instead of upwards, backwards and laterally

• Reduce the hernia completely
• Occlude the deep inguinal ring with a finger (midpoint of inguinal ligament)
• Ask patient to cough or stand
• If hernia does NOT come out: indirect hernia (hernia has been stopped at its point of origin)
• If hernia comes out MEDIAL to the occluding finger: direct hernia (hernia arises medial to the ring)

• Enterocele: resonant on percussion; bowel sounds may be heard
• Epiplocele: dull on percussion

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DIFFERENTIAL DIAGNOSIS

In the Groin:

1. Femoral hernia - below and lateral to the pubic tubercle, below the inguinal ligament; inguinal canal is empty on invagination test
2. Lymph node enlargement - firm, multiple nodes, no cough impulse
3. Encysted hydrocele of the cord - transilluminates, no cough impulse, does not change size with coughing
4. Lipoma of the cord - no cough impulse, soft, lobulated
5. Saphena varix - below the inguinal ligament, disappears on lying down, cough impulse present (can mimic hernia), blue tinge, thrill on coughing, disappears on pressure
6. Psoas abscess - fluctuant, no cough impulse, cross-fluctuation with lumbar swelling
7. Undescended testis - firm, testis absent from the scrotum

In the Scrotum:

1. Hydrocele - transilluminates, can get above the swelling (upper limit definable)
   • Key distinction: with large scrotal hernia, you CANNOT get above the swelling (it extends back into the inguinal canal and peritoneal cavity)
2. Epididymo-orchitis - tender, inflamed, systemic features
3. Testicular tumour - hard, non-tender, heavy feeling

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INVESTIGATIONS

• Ultrasonography: useful in obese patients, occult hernias, or equivocal cases. May miss hernias in supine position as they reduce spontaneously.
• CT scan: useful for large or complex hernias, differentiating from other groin masses, and diagnosing sliding or complications
• MRI: provides excellent soft tissue detail; occasionally used for athletes or occult groin pain
• Herniography: injection of contrast into peritoneal cavity under fluoroscopy - largely obsolete now

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MANAGEMENT

Conservative Management

• Truss (external support device): NOT recommended. It does not cure the hernia, may cause adhesions making subsequent surgery more difficult, and is associated with poor compliance and skin complications.
• Watchful waiting is acceptable for:
  • Elderly patients with minimal symptoms
  • Early, asymptomatic direct hernia
  • Patients with high surgical risk
  • These patients must be warned to seek early advice if hernia enlarges or becomes symptomatic (strangulation risk)

Surgical Management

• All symptomatic hernias
• All irreducible hernias
• Emergency: strangulated or obstructed hernia

HERNIOTOMY (Sac Excision Only)

• Used in children
• Simply dissect, open, reduce contents, and close (ligate) the sac at its neck - no repair needed
• Rationale: the canal walls are strong in children; simply closing the patent processus vaginalis is sufficient
• High recurrence rate if done alone in adults

HERNIORRHAPHY (Sac Excision + Repair of the Posterior Wall)

1. Bassini's Repair (1890) - The Original Repair
   • Open the inguinal canal through the external oblique aponeurosis
   • Spermatic cord is retracted
   • Sac of indirect hernia is dissected, opened, contents reduced, ligated at the neck
   • Key step: sutures placed between the conjoint tendon (above) and the inguinal ligament (below), from the pubic tubercle to the deep inguinal ring
   • Strengthens the posterior wall of the inguinal canal
2. Shouldice Repair (Modification of Bassini)
   • Transversalis fascia is opened by a central incision from the deep inguinal ring to the pubic tubercle
   • Then closed in two layers (double breasting - overlapping technique)
   • Creates a strong two-layered posterior wall
   • Expert centres report lifetime failure rates of less than 2%
   • Technically demanding; most commonly performed in Shouldice Hospital, Toronto
   • Currently considered the best non-mesh (tissue) repair
3. Maloney's Darn Repair
   • Uses a continuous, non-absorbable nylon or polypropylene suture darned between the conjoint tendon and inguinal ligament
   • Most common tissue repair in resource-limited settings
4. Desarda Repair
   • A strip of external oblique aponeurosis (1-2 cm) is isolated, left attached medially and laterally
   • Sutured to the conjoint tendon and inguinal ligament to reinforce the posterior wall
   • Considered equivalent to Shouldice repair

1. Lichtenstein's Tension-Free Mesh Repair (MOST COMMON OPEN REPAIR)
   • Described by Lichtenstein in the 1980s
   • Initial steps identical to Bassini (open canal, handle sac)
   • A flat polypropylene mesh (approximately 8 × 15 cm) is placed over the posterior wall, behind the spermatic cord
   • Mesh is slit to wrap around the spermatic cord at the deep inguinal ring, creating a new ring
   • Held in place with loose sutures to the inguinal ligament and conjoint tendon
   • Advantages: lower recurrence rates, faster recovery, tension-free
   • Currently the most common operation for inguinal hernia in resource-rich countries
   • Main long-term complication: chronic groin pain (up to 20% of patients)
2. Mesh Plug Repair
   • A shaped mesh cone/plug is inserted into the deep inguinal ring or defect
   • Simple to insert, requires little fixation
   • Complication: plug can become solid (meshoma) and migrate/erode into bladder or adjacent structures
   • NOT recommended by 2018 European Hernia Society guidelines
3. Preperitoneal Mesh Repair (Open - Stoppa)
   • Mesh is placed in the preperitoneal space through a midline incision
   • Useful for recurrent hernias after multiple failed repairs
   • Largely superseded by laparoscopic approach

1. TAPP - Trans-Abdominal Pre-Peritoneal Repair
   • Approach via the peritoneal cavity
   • A large mesh is placed in the preperitoneal space and secured with tacks
2. TEP - Total Extraperitoneal Repair
   • Entire procedure performed in the preperitoneal space - peritoneal cavity is NOT entered
   • Preferred technique as it avoids entering the peritoneum

• Less chronic post-operative pain
• Faster return to normal activity
• Better visualization of anatomy
• Bilateral repairs possible through the same ports (major advantage)
• Useful for recurrent hernias (virgin tissue plane)

• Requires general anaesthesia
• Technically more demanding
• Higher cost
• Risk of injury to iliac vessels and urinary bladder

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EMERGENCY SURGERY FOR INGUINAL HERNIA

• Approximately 5% of inguinal hernias present as emergencies (strangulation)
• Time is critical - ischaemic bowel requires urgent intervention
• Approximately 20% of emergency cases require bowel resection
• Bowel resection may require conversion to midline laparotomy (increases morbidity and mortality)
• Mesh can still be used in emergency cases provided there is no gross contamination and appropriate antibiotics are given
• If bowel is gangrenous and contaminated: primary mesh repair is avoided; tissue repair preferred

Principles of Emergency Management:

1. IV fluid resuscitation + correction of electrolyte imbalance
2. Nasogastric decompression
3. IV antibiotics
4. Urgent surgical exploration
5. Assess viability of contents
6. Resect non-viable bowel with anastomosis or stoma
7. Repair of hernia defect

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COMPLICATIONS

Complications of the Hernia Itself:

1. Irreducibility
2. Intestinal obstruction
3. Strangulation with possible bowel gangrene
4. Inflammation (rare)

Complications of Hernia Surgery:

• Bleeding and haematoma (from subcutaneous vessels or, rarely, the inferior epigastric or iliac vessels)
• Urinary retention (requires catheterisation)
• Femoral nerve block (from local anaesthetic infiltration) - transient, resolves in hours

• Pain, bruising, scrotal swelling
• Seroma (fluid collection in sac remnant) - usually resolves spontaneously; may need aspiration; more common when sac is left in situ
• Wound infection (uncommon despite groin location and mesh use)
• Ischaemic orchitis (from damage to testicular blood supply during cord dissection) - can lead to testicular atrophy

• Recurrence (most important long-term complication)
  • Mesh repairs have lower recurrence than suture repairs
  • Target recurrence: less than 5% at 5 years in specialist centres
  • Causes: surgical error (inadequate repair), poor technique, persisting raised intra-abdominal pressure, wound infection
• Chronic groin pain (defined as pain persisting more than 3 months after surgery)
  • Affects up to 20% of patients after open mesh repair
  • Less common after laparoscopic repair
  • Due to: nerve injury (ilioinguinal, iliohypogastric, or genital branch of genitofemoral nerve), chronic irritation by mesh or sutures, meshoma
  • Neuralgic pain is the most severe type
  • Specialist hernia surgeons have lower rates of both recurrence and chronic pain
• Injury to the vas deferens - risk of infertility
• Injury to femoral vessels
• Intestinal injury
• Mesh complications: infection, migration, meshoma (plug becoming solid), chronic pain

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KEY DIFFERENCES: INDIRECT vs DIRECT INGUINAL HERNIA

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KEY DIFFERENCES: INGUINAL vs FEMORAL HERNIA

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IMPORTANT MNEMONICS AND EXAM TIPS

• M - Medial border: Lateral border of rectus abdominis
• I - Inferior border: Inguinal ligament
• L - Lateral border: Inferior epigastric artery

• M - Medial = superficial ring
• A - Anterior = external oblique aponeurosis
• L - Lateral = deep ring
• Roof = Conjoint tendon (arching internal oblique + transversus)
• T - Floor = inguinal ligament

• Reducible → Irreducible → Obstructed → Strangulated
• (Each stage adds more urgency)

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SUMMARY TABLE: SURGICAL REPAIRS AT A GLANCE

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HERNIA COMPLICATIONS

Quick Clinical Reference Guide for Exam Preparation

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SECTION 1: THE COMPLICATION SPECTRUM (PROGRESSION LADDER)

REDUCIBLE  →  IRREDUCIBLE  →  OBSTRUCTED  →  STRANGULATED  →  INFARCTED
(Normal)      (Trapped)       (+Obstruction)  (+Ischaemia)    (Gangrene)

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SECTION 2: FIVE CLINICAL TYPES IN DETAIL

1. REDUCIBLE HERNIA

• Contents freely move in and out of the sac
• Appears on standing/coughing, disappears on lying down
• Has a positive cough impulse
• Normal, uncomplicated state
• Sac remains in position even after contents are reduced

Exam Point: Only the CONTENTS reduce, not the sac itself.

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2. IRREDUCIBLE HERNIA

1. Adhesions of contents to each other
2. Adhesions of contents to the sac
3. Adhesions between parts of the sac wall
4. Sliding hernia (viscus forms part of sac wall)
5. Very large scrotal hernia (scrotal abdomen - too large to reduce)

• Persistent lump that cannot be reduced
• May be mildly uncomfortable
• NOT tense, NOT severely tender, NO redness of overlying skin
• Cough impulse may still be present

Exam Point: Irreducible does NOT mean ischaemic. The dangerous trap for beginners is confusing irreducible with strangulated. Remember: irreducible = trapped but alive; strangulated = trapped AND dying.

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3. OBSTRUCTED HERNIA (Incarcerated Hernia)

• Irreducible hernia
• Colicky abdominal pain
• Vomiting (bilious initially, faeculent later)
• Abdominal distension
• Absolute constipation (no flatus, no faeces)
• Tinkling bowel sounds
• Tense swelling at hernia site

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4. STRANGULATED HERNIA

• Narrow neck of sac acts as a constriction ring
• Venous occlusion occurs first (veins are thin-walled, occluded easily)
• Venous congestion → oedema → increased pressure → arterial occlusion
• Arterial occlusion → ischaemia → gangrene → perforation → peritonitis → septicaemia → death

• Hernia is irreducible
• NO cough impulse (absent or reduced - tense contents cannot expand further)
• Extremely tense and tender
• Overlying skin: red, oedematous, later purplish/dusky discoloration
• Signs of acute intestinal obstruction (if bowel is content)
• Systemic: fever, tachycardia, dehydration, shock

Exam Point: Intestinal obstruction is NOT always present in strangulation - absent in omentocele, Richter's hernia, and Littre's hernia.

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5. INFLAMED HERNIA (Rare)

• Appendix (most classic - appendix within a hernial sac)
• Meckel's diverticulum
• Fallopian tube / ovary

• Local signs of inflammation: redness, oedema, warmth, tenderness of the swelling
• Constitutional symptoms (fever, malaise)
• Swelling is painful and tender but NOT tense
• No intestinal obstruction

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SECTION 3: SPECIAL / EPONYMOUS HERNIA COMPLICATIONS

RICHTER'S HERNIA

• Only the anti-mesenteric border (part of the bowel circumference) enters the sac
• The lumen is NOT completely occluded, so intestinal obstruction may be ABSENT
• However, the bowel wall undergoes strangulation and gangrene silently
• Gangrene and perforation can occur WITHOUT obvious signs of obstruction
• Most dangerous: patient can have a gangrenous bowel with equivocal clinical signs
• Common sites: femoral ring, inguinal canal, obturator foramen

Exam Favourite: "A hernia that can strangulate WITHOUT causing intestinal obstruction"

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LITTRE'S HERNIA

• The hernia sac contains a Meckel's diverticulum
• Can strangulate without causing complete obstruction (same principle as Richter's)
• Important because Meckel's diverticulum is the only content

Exam: Littre's hernia = Meckel's diverticulum in the sac

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MAYDL'S HERNIA (Hernia-en-W / W-hernia)

• Two loops of bowel are present in the sac
• The connecting loop between them (middle of the W) lies INSIDE the abdomen
• The intra-abdominal loop strangulates first
• The external hernia appears normal or reducible - no warning sign
• Gangrene of the intra-abdominal segment occurs while the sac contents look viable
• Very dangerous: resecting only the visible loops without checking the abdominal segment leads to missed gangrene

Exam: "Strangulation of a loop that is NOT in the sac" - always check the intra-abdominal loop at surgery

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SLIDING HERNIA (Hernia-en-Glissade)

• Retroperitoneal viscus slides into the hernia - the viscus forms part of the WALL of the sac
• Left side: sigmoid colon / pelvic colon
• Right side: caecum
• Either side: urinary bladder
• The sac CANNOT be excised in the usual manner - the viscus will be injured
• Surgical danger: inadvertent incision into the bowel wall during sac dissection

Exam: Sac wall = part of viscus → must not excise the sac blindly

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PANTALOON (SADDLE-BAG) HERNIA

• Simultaneous indirect (lateral) + direct (medial) hernia on the same side
• Inferior epigastric vessels lie BETWEEN the two sacs
• Hernia straddles the vessels like a pantaloon/saddle-bag

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SECTION 4: WHICH HERNIAS STRANGULATE MORE READILY?

Key Rule: Risk of strangulation is inversely proportional to the size of the neck. Narrow neck = high risk; Wide neck = low risk.

Exam Favourite: "Direct inguinal hernia rarely strangulates" - because the neck is wide. "Femoral hernia strangulates most commonly" - because of the rigid lacunar ligament.

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SECTION 5: PATHOLOGY OF STRANGULATION (Step by Step)

1. Constriction at the neck - pressure begins at the narrow ring
2. Venous occlusion (first to occur - veins thin-walled, easily compressed)
3. Venous congestion - blood accumulates in the hernial contents
4. Oedema and swelling of the contents - increases pressure further
5. Arterial occlusion (occurs later - arteries are thick-walled, require more pressure)
6. Ischaemia of the wall of the bowel
7. Venous gangrene - characteristic appearance (bluish-black bowel)
8. Perforation of the bowel wall
9. Release of infected, toxic contents into surrounding tissues and peritoneal cavity
10. Peritonitis → septicaemia → multi-organ failure → death if untreated

Exam: Veins occlude FIRST in strangulation (not arteries). This is why early strangulation can be reversible - if released before arterial occlusion occurs.

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SECTION 6: ASSESSMENT OF BOWEL VIABILITY AT SURGERY

Signs of Viable Bowel (KEEP IT):

• Normal pink/red colour returns after release of constriction
• Normal glistening serosa
• Peristaltic movement returns
• Pulsation visible in the mesenteric vessels

Signs of Non-Viable Bowel (RESECT IT):

• Persistent dark blue/black or green discoloration
• No peristalsis despite warming with warm packs (5 minutes waiting time)
• No visible mesenteric vascular pulsations
• Dull, non-glistening, flaccid bowel wall

Rule: If in doubt after 5 minutes - resect. "When in doubt, take it out."

• ~5% of inguinal hernias present as emergencies
• ~20% of emergency hernia cases require bowel resection
• Bowel resection may necessitate midline laparotomy (increases morbidity significantly)

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SECTION 7: COMPLICATIONS OF HERNIA SURGERY

Immediate (Within 24 Hours):

Early (First Week):

Late (Weeks to Years):

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SECTION 8: EMERGENCY MANAGEMENT OF STRANGULATED HERNIA

Pre-Operative (Resuscitation - "DRIP AND SUCK"):

1. IV access + aggressive fluid resuscitation (correct dehydration and electrolytes)
2. Nasogastric tube insertion (decompress the bowel)
3. IV antibiotics (broad-spectrum: cover gram-negatives and anaerobes)
4. Urinary catheter (monitor urine output)
5. Analgesics
6. Blood investigations: FBC, U&E, LFT, clotting, cross-match, lactate

Intra-Operative Steps:

1. Open the hernial sac
2. Reduce the strangulated contents carefully
3. Assess bowel viability
4. If viable: return to abdomen
5. If non-viable: resect bowel + anastomosis (or stoma in contaminated field)
6. If bowel resected + contaminated: avoid synthetic mesh; use tissue repair
7. Repair the hernia defect

Post-Operative:

• Continue IV antibiotics
• Monitor for anastomotic leak, ileus, wound infection
• DVT prophylaxis

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SECTION 9: HIGH-YIELD EXAM COMPARISON TABLES

Obstructed vs Strangulated Hernia

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Irreducible vs Strangulated Hernia

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Special Hernias Quick Comparison

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SECTION 10: MUST-KNOW EXAM POINTS (QUICK FIRE)

• First structure occluded in strangulation = Veins (not arteries)
• Richter's hernia = partial circumference, obstruction may be absent, strangulation can occur silently
• Direct inguinal hernia = wide neck → rarely strangulates
• Femoral hernia = rigid ring → strangulates most commonly among groin hernias
• Littre's hernia = Meckel's diverticulum in the sac
• Maydl's hernia = W-shaped, intra-abdominal loop is the one that strangulates
• Sliding hernia = viscus is the sac wall → cannot excise blindly
• Cause of irreducibility = adhesions, sliding hernia, large scrotal hernia
• Inflamed hernia is NOT tense (unlike strangulated which IS tense)
• In strangulation, pain is NEVER completely absent
• 20% of emergency hernia repairs require bowel resection
• Chronic pain after hernia repair = affects up to 20% after open Lichtenstein
• Mesh use in emergency = acceptable if no gross contamination + antibiotic cover
• Best tissue repair = Shouldice (double-breasting of transversalis fascia)
• Most common open repair worldwide = Lichtenstein (flat polypropylene mesh)
• Preferred laparoscopic approach = TEP (total extraperitoneal, peritoneum not entered)

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