Incisional hernia

Definition

Classification

1. Etiological classification

1. Primary incisional hernia
   • First hernia occurring through a previous operative scar.
2. Recurrent incisional hernia
   • Hernia recurring after a prior operative repair.
3. Port-site hernia
   • Incisional hernia through a laparoscopic trocar site.
4. Parastomal hernia
   • Incisional defect adjacent to an intestinal or urinary stoma. Usually classified separately.

2. Classification by anatomical site

A. Midline incisional hernia

• Upper midline
• Epigastric
• Umbilical
• Infraumbilical
• Suprapubic

B. Lateral incisional hernia

• Subcostal
• Flank
• Iliac
• Lumbar
• Oblique scar
• Transverse scar
• Pfannenstiel scar

3. European Hernia Society (EHS) classification of incisional hernia

1. Site of defect
2. Width of defect
3. Recurrence status

A. Midline location: M classification

B. Lateral location: L classification

C. Defect width: W classification

D. Recurrence: R classification

Other useful clinical classifications

4. Classification according to reducibility and complications

• Reducible
• Irreducible or incarcerated
• Obstructed
• Strangulated
• Inflamed or ulcerated

5. Classification by contents

• Omentocele
• Enterocele, containing small bowel
• Colocele, containing colon
• Richter-type hernia, where only part of bowel circumference is entrapped
• Sliding hernia, where a viscus forms part of sac wall

6. Classification by size

• Small: < 5 cm
• Medium: 5-10 cm
• Large: > 10 cm
• Giant or loss-of-domain hernia: very large defect with a substantial proportion of viscera permanently residing outside the abdominal cavity.

Incisional Hernia Case Proforma

A. Identification data

• Name:
• Age:
• Sex:
• Occupation:
• Address:
• Hospital number:
• Date of admission:
• Date of examination:
• Informant and reliability:

B. Chief complaints

1. Swelling over previous abdominal operative scar for ___ months/years.
2. Pain or dragging sensation over swelling for ___ duration.
3. Swelling increasing on coughing or straining for ___ duration.
4. Difficulty in reducing swelling for ___ duration.
5. Vomiting, abdominal distension, constipation, or inability to pass flatus for ___ duration.
6. Ulceration, skin discoloration, or discharge over swelling for ___ duration.

C. History of present illness

1. Onset and progression

• When was the swelling first noticed?
• Did it appear soon after surgery or after an interval?
• Was onset sudden or gradual?
• Has it progressively increased in size?
• Is it related to coughing, lifting weights, straining during defecation, micturition, or physical work?
• Does it reduce spontaneously on lying down?

2. Pain

• Site and nature: dull dragging pain, aching, colicky pain, severe continuous pain.
• Relation to exertion, standing, meals, cough, and posture.
• Sudden severe pain may indicate incarceration, obstruction, or strangulation.

3. Reducibility

• Is the swelling completely reducible?
• Does it reduce on lying down?
• Is manual pressure needed?
• Any history of irreducibility?

4. Features of intestinal obstruction

• Colicky abdominal pain
• Vomiting
• Abdominal distension
• Constipation
• Obstipation, inability to pass flatus or stool

5. Features suggesting strangulation

• Sudden severe continuous pain
• Tender irreducible swelling
• Fever
• Tachycardia
• Vomiting
• Skin erythema or discoloration over swelling
• Toxic appearance

6. Previous operation details

• Indication for prior surgery:
• Date of surgery:
• Type of surgery:
• Elective or emergency:
• Open/laparoscopic/robotic procedure:
• Type and site of incision:
  • Midline
  • Paramedian
  • Transverse
  • Subcostal
  • Pfannenstiel
  • Port site
  • Stoma site
• Any re-laparotomy?
• Any postoperative wound infection?
• Wound dehiscence or burst abdomen?
• Serosanguineous discharge around postoperative day 5-8?
• Prolonged wound discharge?
• Resuturing or secondary suturing?
• Drain through the main wound?
• Previous hernia repair?
• Type of previous repair: anatomical repair, onlay mesh, sublay/retrorectus mesh, intraperitoneal mesh, laparoscopic IPOM, component separation.
• Number of prior repairs and recurrence interval.

7. Predisposing factors

• Obesity and recent weight gain
• Smoking
• Diabetes mellitus and glycaemic control
• Malnutrition or hypoalbuminaemia
• Anaemia
• Chronic renal failure
• Malignancy
• Steroid use, chemotherapy, immunosuppressive treatment
• Connective-tissue disease or collagen disorder
• Advanced age

• Chronic cough, COPD, tuberculosis, bronchiectasis
• Constipation
• Prostatism or stricture urethra causing straining
• Ascites
• Repeated vomiting
• Heavy manual work
• Pregnancy

• Surgical-site infection
• Poor fascial closure
• Emergency surgery
• Peritonitis or intra-abdominal sepsis
• Repeated abdominal operations
• Tissue ischemia or excessive tension on closure.

D. Past history

• Diabetes mellitus
• Hypertension
• COPD, asthma, tuberculosis
• Chronic cough
• Constipation
• Urinary obstructive symptoms
• Chronic liver disease, ascites
• Renal disease
• Malignancy
• Previous tuberculosis
• Previous abdominal surgeries
• Previous hernia surgeries
• History of wound infection or burst abdomen

E. Personal history

• Appetite and weight loss
• Bowel habits and constipation
• Micturition and straining
• Smoking, tobacco, alcohol
• Occupation involving heavy lifting
• Nutritional history

F. Drug and allergy history

• Corticosteroids
• Immunosuppressive drugs
• Chemotherapy
• Anticoagulants or antiplatelet agents
• Antidiabetic treatment
• Drug allergies

G. Family history

• Hernias in family members
• Known collagen vascular or connective-tissue disorders

Examination

1. General physical examination

• General condition and nutritional status
• Body mass index
• Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
• Hydration
• Pulse, blood pressure, temperature, respiratory rate
• Signs of diabetes or chronic steroid use
• Features of COPD or chronic cough
• Evidence of chronic liver disease or ascites

2. Abdominal examination

A. Inspection

• Site of previous scar
• Scar type, length, direction, and quality
• Location of swelling in relation to scar
• Size and shape of swelling
• Single or multiple swellings
• Skin changes:
  • Scar
  • Dilated veins
  • Erythema
  • Ulceration
  • Excoriation
  • Pigmentation
  • Thin, shiny, atrophic skin
• Visible peristalsis
• Cough impulse
• Whether swelling becomes prominent on standing, coughing, or raising the head and shoulders from supine position
• Other scars, stomas, drain sites, sinuses, or fistulae
• Divarication of recti

B. Palpation

• Local temperature
• Tenderness
• Consistency
• Surface and margins
• Cough impulse
• Expansile impulse on coughing
• Reducibility:
  • Complete or partial
  • Spontaneous or manual
  • Gurgling on reduction suggests bowel
• Defect:
  • Site
  • Number
  • Shape
  • Maximum transverse width in cm
  • Vertical length in cm
  • Margins, especially lower margin
• Contents:
  • Omentum: doughy, non-gurgling
  • Bowel: soft, gurgling, may be resonant
• Whether defect is narrow or wide
• Whether there are multiple defects along the scar

C. Percussion

• Resonant: likely bowel-containing sac
• Dull: likely omentum or fluid-containing sac

D. Auscultation

• Bowel sounds over swelling may indicate bowel content.
• High-pitched or exaggerated sounds may suggest intestinal obstruction.
• Absent sounds with severe tenderness is concerning for strangulation or ileus.

E. Tests

• Cough impulse: place fingers over swelling and ask patient to cough.
• Head-raising test: with patient supine, ask them to lift head and shoulders. A hernia becomes more prominent due to contraction of abdominal muscles.
• Reducibility test: gently attempt reduction only if there is no suspicion of strangulation.
• Finger invagination test: not routinely useful in large incisional hernia, but may help identify a small scar defect.

F. Examination of other systems

• Respiratory system for COPD/chronic cough
• Cardiovascular assessment
• Per rectal examination if constipation, bleeding, or obstruction is present
• Digital rectal examination in elderly men with urinary symptoms
• Examine all other hernial sites

Provisional diagnosis

“A ___ year old male/female has a reducible/irreducible, uncomplicated/obstructed/strangulated incisional hernia through a previous ___ incision, with a defect measuring ___ cm × ___ cm, containing probable ___, classified as EHS ___, associated with ___ risk factors.”

“A 58-year-old obese woman with diabetes has a reducible infraumbilical midline incisional hernia following lower midline laparotomy, with a 7 cm transverse and 9 cm vertical fascial defect, containing bowel and omentum, without obstruction, classified as M4 W2 R0.”

Differential diagnosis

• Divarication of recti
• Lipoma of abdominal wall
• Seroma
• Chronic postoperative hematoma
• Abdominal wall abscess
• Stitch granuloma
• Desmoid tumour
• Abdominal wall neoplasm
• Parastomal hernia
• Spigelian hernia, depending on location

Investigations

Routine preoperative tests

• Complete blood count
• Blood group and cross-match if indicated
• Blood glucose and HbA1c
• Renal function tests and electrolytes
• Liver function tests, especially if ascites or malnutrition suspected
• Serum albumin
• Coagulation profile when indicated
• Urine routine and culture where appropriate
• ECG and chest radiograph based on age/comorbidity
• Pulmonary function assessment if COPD is suspected

Hernia-specific investigations

1. Ultrasonography

• Small, clinically equivocal defects
• Dynamic assessment with Valsalva
• Identifying superficial collections

2. CT abdomen and pelvis with Valsalva if feasible

• Fascial defect width and length
• Number of defects
• Hernial contents
• Bowel adhesions or obstruction
• Muscle quality
• Previous mesh position
• Loss of domain
• Operative planning

3. MRI

Brief management outline for case presentation

Initial approach

• Determine whether the hernia is uncomplicated, obstructed, or strangulated.
• Correct dehydration, electrolyte imbalance, hyperglycaemia, anaemia, malnutrition, and respiratory infection.
• Encourage smoking cessation and weight reduction where feasible.
• Treat chronic cough, constipation, urinary obstruction, and ascites.
• An abdominal binder may provide temporary symptomatic support but does not repair the defect.

Indications for urgent operation

• Strangulation
• Intestinal obstruction
• Irreducibility with pain or tenderness
• Peritonitis
• Skin necrosis or impending rupture

Elective repair

• Pain or activity limitation
• Progressive enlargement
• Recurrent obstruction
• Cosmesis affecting quality of life
• Large defect or poor skin condition

History

History Case Presentation

Chief complaints

• Swelling in the right lumbar region for 6 months.

History of presenting illness

Past history

• History of right nephrectomy for renal infection, details not available.
• No known history of diabetes mellitus, hypertension, tuberculosis, chronic respiratory illness, or chronic liver disease.
• No previous history of hernia repair.

Personal history

• Appetite: Normal.
• Bowel habits: Regular. No constipation.
• Bladder habits: Normal. No straining during micturition.
• No history of smoking, alcohol intake, or heavy manual work.

Family history

• No similar illness in family members.

Provisional diagnosis

Right lumbar incisional hernia following right nephrectomy, uncomplicated, with a swelling more than 5 cm in size.

Points to confirm on examination

• Presence and site of right flank/lumbar operative scar
• Size and exact location of swelling
• Cough impulse and expansile nature
• Reducibility and contents
• Defect size and margins
• Evidence of obstruction, strangulation, or associated abdominal-wall weakness
• Examination of the left kidney and other hernial sites

History Case Presentation

Chief complaint

• Swelling in the right lumbar region for 6 months.

History of presenting illness

Past history

• Right nephrectomy 1½ years ago for right renal infection, details not available.
• Diabetes mellitus, poorly controlled.
• Possible constipation.
• No past history of hypertension, chronic respiratory disease, chronic liver disease, ascites, or tuberculosis.
• No history of previous hernia repair.

Personal history

• Appetite: Normal.
• Bowel habits: History suggestive of constipation with occasional straining.
• Bladder habits: No difficulty or straining during micturition.
• Sleep: Normal.
• No history of smoking, alcohol consumption, or heavy manual work.

Family history

• No family history of similar swelling or hernia.

Provisional diagnosis

Right lumbar incisional hernia following right nephrectomy, uncomplicated, in a patient with uncontrolled diabetes mellitus and constipation.

Risk factors in this patient

1. Previous right flank/lumbar incision for nephrectomy
2. Poorly controlled diabetes mellitus, which can impair wound healing
3. Possible chronic straining due to constipation, causing raised intra-abdominal pressure

Points to be elicited/examined further

• Exact site, type, and length of nephrectomy scar
• Whether swelling has an expansile cough impulse
• Reducibility and contents of swelling
• Size of fascial defect and number of defects
• Presence of bowel sounds over the swelling
• Evidence of obstruction or strangulation
• Glycaemic status: random blood sugar, fasting/postprandial glucose, HbA1c
• CT abdomen for confirming defect, contents, and planning repair

There is a history of lifting heavy weights regularly as part of her daily household/occupational activities. This may have contributed to increased intra-abdominal pressure and enlargement of the swelling.

There is a possible history of constipation with occasional straining during defecation, and a history of regular heavy weight lifting. There is no history of chronic cough or straining during micturition.

Updated risk factors

1. Previous right nephrectomy through a lumbar/flank incision
2. Poorly controlled diabetes mellitus
3. Constipation with straining
4. Regular lifting of heavy weights

The patient underwent a right nephrectomy 1½ years ago for a right renal infection. The surgery was performed through a transverse incision extending from the umbilical region to the right flank. However, she is unable to give further details about the exact renal disease, operative procedure, or postoperative period.

Revised relevant portion of history

Revised provisional diagnosis

Right lateral incisional hernia through the lateral end of a previous transverse umbilico-flank incision, following right nephrectomy, uncomplicated, in a patient with poorly controlled diabetes mellitus, constipation, and a history of heavy weight lifting.

Final History Case Presentation

Chief complaint

• Swelling over the right lumbar/flank region for 6 months.

History of presenting illness

Past history

• History of right nephrectomy 1½ years ago for renal infection, with details not available.
• Known case of diabetes mellitus, poorly controlled.
• Possible history of constipation.
• No history suggestive of chronic respiratory disease or chronic cough.
• No history of chronic liver disease or ascites.
• No history of previous hernia repair.

Personal history

• Appetite: To be elicited.
• Bowel habits: Possible constipation with occasional straining.
• Bladder habits: No history of difficulty or straining during micturition.
• Sleep: To be elicited.
• Diet: To be elicited.
• History of heavy weight lifting is present.
• Smoking and alcohol history: To be elicited.

Family history

• No relevant family history of hernia or similar illness is available.

Summary

Provisional diagnosis

Right lateral incisional hernia through the lateral end of a previous transverse umbilico-flank incision following right nephrectomy, uncomplicated, in a patient with poorly controlled diabetes mellitus, constipation, and a history of heavy weight lifting.

Risk factors in this patient

1. Previous transverse abdominal incision extending to the right flank
2. Poorly controlled diabetes mellitus, with impaired wound healing risk
3. Possible constipation and straining
4. Regular lifting of heavy weights, causing repeated rises in intra-abdominal pressure

Important points to confirm on examination

• Exact location, length, and condition of the operative scar
• Site and size of swelling and fascial defect
• Cough impulse and expansile nature
• Reducibility and likely contents
• Presence of bowel sounds over the swelling
• Number of defects and status of abdominal wall musculature
• Evidence of obstruction or strangulation
• Examination of other hernial sites
• General assessment, including BMI and diabetic status.

Final Case Presentation

Chief complaint

• Swelling over the right flank/lumbar region for 6 months.

History of Presenting Illness

Past History

• History of right nephrectomy 1½ years ago for right renal infection.
• Known case of diabetes mellitus, poorly controlled.
• History suggestive of constipation.
• No history of hypertension, chronic cough, chronic obstructive pulmonary disease, tuberculosis, chronic liver disease, or ascites.
• No history of previous hernia repair.

Personal History

• Appetite: Normal.
• Bowel habits: Occasional constipation with straining during defecation.
• Bladder habits: Normal. No straining during micturition.
• History of regular lifting of heavy weights is present.
• Sleep: Normal.
• No history of smoking or alcohol consumption.

Family History

Physical Examination

The following findings are appropriate for this case presentation. Replace the exact measurements and examination findings with those found in your patient.

General Physical Examination

• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, or pedal edema.
• Pulse: ___/minute, regular.
• Blood pressure: / mmHg.
• Temperature: Afebrile.
• Respiratory rate: ___/minute.
• No clinical features of dehydration or sepsis.
• Body mass index: ___ kg/m².
• Features of poorly controlled diabetes such as skin infection, neuropathy, or diabetic foot should be specifically looked for.

Local Examination of Abdomen and Swelling

Inspection

• Abdomen moves normally with respiration.
• A healed transverse operative scar is present, extending from the umbilical region towards the right flank, consistent with the history of right nephrectomy.
• A visible swelling is noted at the lateral end of this scar in the right flank/lumbar region.
• The swelling is approximately more than 5 cm in maximum dimension. Record exact dimensions as ___ cm × ___ cm.
• The swelling becomes more prominent on standing, coughing, and straining.
• The overlying skin is normal, with no redness, ulceration, dilated veins, sinus, discharge, or visible peristalsis.
• No other abdominal scars, sinuses, or visible swellings are noted.

Palpation

• Local temperature is not raised.
• The swelling is non-tender.
• It is soft in consistency, with smooth surface and indistinct margins.
• An expansile cough impulse is present.
• The swelling is reducible completely or partially on gentle pressure in the supine position. If bowel is present, reduction may produce a gurgling sensation.
• On reduction, a fascial defect is palpable at the lateral aspect of the scar. Its exact transverse and vertical dimensions should be recorded: ___ cm × ___ cm.
• The defect margins are palpable and non-tender.
• There is no local guarding, rigidity, or tenderness.

Percussion

• The swelling is resonant if it contains bowel.
• It may be dull if it predominantly contains omentum.

Auscultation

• Bowel sounds may be audible over the swelling, suggesting bowel as a content.
• No high-pitched bowel sounds are heard.
• There are no findings suggestive of intestinal obstruction.

Rest of the Abdominal Examination

• Abdomen is soft and non-tender.
• No distension, organomegaly, ascites, or free fluid.
• No other palpable abdominal mass.
• All other hernial sites, including inguinal, femoral, umbilical, and previous scar sites, should be examined and documented as normal.
• Per rectal examination may be done to assess constipation and exclude fecal loading, if indicated.

Systemic Examination

• Respiratory system: Normal, with no evidence of chronic cough or COPD.
• Cardiovascular system: Normal.
• Central nervous system: Normal.
• Left renal system: To be assessed clinically and by renal function tests, as the patient has a solitary left kidney.

Case Summary

Provisional Diagnosis

Uncomplicated, reducible right lateral incisional hernia through the lateral end of a previous transverse umbilico-flank incision following right nephrectomy, in a patient with poorly controlled diabetes mellitus, constipation, and history of heavy weight lifting.

Investigations to Plan

1. Complete blood count and urine routine examination
2. Fasting blood glucose, postprandial blood glucose, and HbA1c
3. Renal function tests and serum electrolytes, especially important because she has one remaining kidney
4. Serum albumin and nutritional assessment
5. Ultrasound abdomen and abdominal-wall defect assessment
6. CT abdomen and pelvis for defining the fascial defect, contents, number of defects, and operative planning
7. ECG and chest radiograph if required for preoperative assessment

Clinical Tests for Right Lateral Incisional Hernia

1. Cough impulse test

• Place the palm or fingertips over the swelling.
• Ask the patient to cough.
• Positive test: An expansile impulse is felt, supporting a hernia.
• In this case, it is expected to be positive.

2. Valsalva manoeuvre

• Ask the patient to take a deep breath and strain as if passing stool.
• Observe and palpate the swelling.
• Positive test: Swelling becomes more prominent and tense.
• Useful in demonstrating a small or partially reducible hernia.

3. Reducibility test

• Examine with the patient supine and relaxed.
• Gently apply pressure over the swelling towards the defect.
• Positive finding: Swelling reduces completely or partially.
  • A gurgling sensation suggests bowel content.
  • Smooth, doughy reduction suggests omental content.
• After reduction, palpate the fascial defect and measure its transverse and vertical dimensions.

4. Head-raising or partial sit-up test

• With the patient lying supine, ask her to raise her head and shoulders without using her arms.
• This contracts the abdominal musculature and increases intra-abdominal pressure.
• Positive finding: The swelling becomes more prominent, and the defect may be easier to define.
• It also helps look for associated divarication of recti.

5. Defect palpation after reduction

• Once the swelling is reduced, place fingertips over the scar defect.
• Ask the patient to cough or strain.
• Assess:
  • Number of defects
  • Size of each defect
  • Shape and margins
  • Whether margins are firm or tender
  • Impulse transmitted through the defect

6. Auscultation over the swelling

• Listen for bowel sounds.
• Presence of bowel sounds supports bowel as a hernial content.
• High-pitched, frequent bowel sounds with distension and vomiting may suggest obstruction.
• Absence of bowel sounds alone does not diagnose strangulation.

7. Percussion

• Resonant note: bowel-containing hernia.
• Dull note: omentum, thick sac, or fluid-containing lesion.
• This is supportive only and does not replace imaging.

8. Examination in different positions

• Examine in:
  • Standing position
  • Supine position
  • During cough and Valsalva
• A hernia generally becomes more evident on standing/straining and decreases or reduces when supine.

Examination Statement for Your Case

On local examination, a swelling of more than 5 cm is present at the lateral end of the healed transverse umbilico-right flank scar. It becomes prominent on standing, coughing, and Valsalva manoeuvre. The swelling is non-tender, has a positive expansile cough impulse, and is reducible on lying down. Following reduction, a fascial defect can be palpated at the lateral end of the scar. Percussion may be resonant and bowel sounds may be audible over the swelling, suggesting bowel content. There are no clinical signs of obstruction or strangulation.

Differential Diagnoses

• Right lateral incisional hernia, most likely
• Primary lumbar hernia
• Postoperative flank bulge due to denervation or muscle paralysis, also called pseudohernia
• Lipoma of the abdominal wall
• Seroma or chronic postoperative collection
• Chronic hematoma
• Cold abscess, including tuberculous abscess
• Abdominal-wall tumour, including desmoid tumour

Inguinal Hernia: Complete Exam Case Presentation

Use right or left according to the patient.

Chief Complaints

1. Swelling in the ___ inguinal region for 6 months.
2. Pain over the swelling for 6 months.

History of Presenting Illness

• Chronic cough, COPD, or smoking
• Constipation and straining during defecation
• Difficulty or straining during micturition, especially in elderly males with prostatism
• Heavy weight lifting or strenuous work
• Ascites
• Previous abdominal surgery
• Previous hernia repair
• Family history of hernia

Past History

• No past history of similar swelling or hernia repair.
• No history of tuberculosis, chronic cough, COPD, or asthma.
• No history of diabetes mellitus, hypertension, chronic liver disease, ascites, or malignancy.
• No history of abdominal or pelvic surgery.

Add positive illnesses if present.

Personal History

• Appetite: Normal.
• Bowel habits: Regular/no constipation.
• Bladder habits: Normal/no straining during micturition.
• Sleep: Normal.
• History of heavy weight lifting: Present/absent.
• Smoking and alcohol history: Present/absent.

Family History

• No family history of hernia or similar illness.

Physical Examination

General Physical Examination

• Pulse: ___/minute, regular.
• Blood pressure: / mmHg.
• Temperature: Afebrile.
• Respiratory rate: ___/minute.
• No pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, or pedal edema.
• Look specifically for chronic cough, obesity, ascites, and features of chronic liver disease.

Local Examination of Groin

Inspection

• A swelling is seen in the ___ inguinal region.
• Record its size: approximately ___ cm × ___ cm.
• It may extend towards the scrotum in a complete indirect inguinal hernia.
• The swelling becomes more prominent on coughing, standing, and straining.
• The overlying skin is normal, without redness, edema, ulceration, or dilated veins.
• Look for scars of previous operation and examine the opposite groin.

Palpation

• Local temperature: Not raised.
• Tenderness: Mild tenderness may be present because the patient has pain.
• Consistency: Soft.
• Surface: Smooth.
• Margins: Usually well-defined, except at its base.
• Cough impulse: Expansile cough impulse is present.
• Reducibility: The swelling is reducible completely/partially on lying down with gentle pressure.
• A gurgling sensation during reduction suggests bowel as content.
• A doughy reduction suggests omentum as content.
• After reduction, assess the superficial inguinal ring, posterior wall, and deep ring.

Percussion

• Resonant if bowel is present as content.
• Dull if the sac contains omentum.

Auscultation

• Bowel sounds may be audible over the swelling if it contains intestine.
• High-pitched bowel sounds in association with pain, vomiting, and distension suggest obstruction.

Examination of External Genitalia

• Examine both testes separately.
• Note whether the swelling can be got above.
• Look for hydrocele, varicocele, epididymo-orchitis, and testicular tumour.
• In an inguinoscrotal hernia, it may not be possible to get above the swelling.

Clinical Tests

1. Cough impulse test

2. Reducibility test

3. Deep ring occlusion test

1. Reduce the hernia completely.
2. Identify the deep inguinal ring, about 1.25 cm above the midpoint of the inguinal ligament.
3. Apply firm pressure over the deep ring.
4. Ask the patient to cough or stand.

• Swelling does not reappear while pressure is maintained: suggests an indirect inguinal hernia.
• Swelling reappears despite deep ring occlusion: suggests a direct inguinal hernia.

4. Invagination test

• Invaginate the scrotal skin with the little finger and advance it upwards along the spermatic cord towards the superficial inguinal ring.
• Ask the patient to cough.

• Impulse felt on the pulp of the finger may support an indirect hernia.
• Impulse felt on the side of the finger may support a direct hernia.

5. Zieman's three-finger test

• Index finger over the deep inguinal ring
• Middle finger over the superficial inguinal ring
• Ring finger over the femoral canal

• Impulse under index finger: indirect inguinal hernia
• Impulse under middle finger: direct inguinal hernia
• Impulse under ring finger: femoral hernia

6. “Get above the swelling” test

• In an inguinal or inguinoscrotal hernia, it may not be possible to get above the swelling if it extends into the scrotum.
• In a hydrocele, one can usually get above the swelling.

Rest of Abdominal Examination

• Abdomen is soft and non-tender.
• No abdominal distension, organomegaly, free fluid, or palpable mass.
• Examine the umbilicus, femoral regions, opposite inguinal region, and all previous surgical scars for other hernias.
• Per rectal examination should be considered in older patients or those with constipation and urinary symptoms, to evaluate fecal loading or prostatic enlargement.

Systemic Examination

• Respiratory system: Assess for chronic cough/COPD.
• Cardiovascular system: Routine preoperative assessment.
• Per abdomen: Look for ascites and abdominal masses.
• Genitourinary system: Assess for urinary obstruction/prostatism if relevant.

Case Summary

Provisional Diagnosis

Uncomplicated, reducible ___ inguinal hernia, likely indirect/direct, with pain for 6 months.

Differential Diagnosis of Inguinal Swelling

1. Femoral hernia
   • Usually below and lateral to the pubic tubercle.
   • More common in females.
2. Hydrocele
   • Scrotal swelling.
   • Usually fluctuant and transilluminant.
   • No expansile cough impulse.
   • Usually possible to get above the swelling.
3. Varicocele
   • “Bag of worms” sensation.
   • More prominent on standing and decreases when supine.
   • No cough impulse.
4. Epididymo-orchitis
   • Painful, tender scrotal swelling with fever or urinary symptoms.
   • Testis may not be separately palpable.
5. Testicular tumour
   • Firm, painless intratesticular mass.
   • Testis not separately palpable.
   • No cough impulse or reducibility.
6. Inguinal lymphadenopathy
   • Multiple discrete nodules.
   • Non-reducible and no cough impulse.
7. Lipoma of the spermatic cord
   • Soft, non-reducible swelling.
   • No expansile cough impulse.
8. Saphena varix
   • Compressible swelling at the saphenofemoral junction.
   • May have a cough impulse and disappear on lying down.
   • Associated varicose veins may be present.
9. Psoas abscess
   • Fluctuant swelling below the inguinal ligament.
   • May be associated with fever, tuberculosis, hip flexion deformity, or spinal disease.

Investigations

Routine preoperative investigations

• Complete blood count
• Blood group and cross-match, if indicated
• Blood glucose
• Renal function tests and serum electrolytes
• Liver function tests if clinically indicated
• Urine routine microscopy and culture, if urinary symptoms are present
• ECG in older patients or those with cardiac risk factors
• Chest radiograph when clinically indicated

Hernia-specific investigations

• Ultrasonography of groin with Valsalva manoeuvre: Useful if the diagnosis is uncertain, for occult hernia, or to differentiate hydrocele, lymph nodes, and other groin masses.
• CT abdomen/pelvis or MRI: Usually not needed for a clinically obvious inguinal hernia. Consider for recurrent, occult, complex, or diagnostically uncertain groin swelling.

Additional investigations according to risk factors

• HbA1c in known diabetes
• Pulmonary function testing if COPD is suspected
• Prostate assessment in elderly males with lower urinary tract symptoms
• Stool assessment and treatment for constipation where indicated.