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Hernias 7
Key concepts
In order to work through the core clinical cases in this section you will need to understand the following
key concepts.
WHAT IS A HERNIA?
‘An abnormal protrusion of a viscus through the wall of the cavity that usually contains it.’
WHERE DO THEY OCCUR?
Hernias may occur anywhere in the body. Groin hernias are the most common, usually occurring
through the inguinal or femoral canals. Other sites for hernias are where musculofascial weaknesses
may develop (umbilicus, diaphragm, edge of rectus abdominis, lumbar triangle), when abnormally raised
pressure develops (cerebral tumours causing ‘coning’) or as a complication of wound healing (incisional
hernias).
WHAT CAN THEY CONTAIN?
Just about anything. Omentum and small bowel are the most common contents of abdominal wall hernias,
but most organs (including the pregnant uterus) have been described in hernias. Sometimes the organ
within the hernia sac may be pathological, such as Meckel’s diverticulum (the rare Littre’s hernia).
WHY ARE THEY IMPORTANT?
As well as pain from the hernia itself, their main importance relates to the complications arising from
their contents. Fibrosis may lead to irreducibility of the contents (incarceration) and possibly obstruction
of any contained bowel. If the blood supply of the contents is compromised, this may cause ischaemia
(strangulation), necrosis and even perforation.
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8 General surgery
Answers
Clinical cases
CASE 1.1 –
‘I’ve developed a lump in my groin’
A1: What is the likely differential diagnosis?
Inguinal hernia
Femoral hernia
Enlarged inguinal lymph node
Lipoma
Less likely: groin abscess, undescended testis, saphena varix, femoral artery aneurysm, psoas abscess,
tumour
A2: What features of the given history support the diagnosis?
Groin hernias may be caused by heavy exertion, but often this is not the case and no precipitating event
is reported. Tenderness is common, particularly in an acute onset hernia, but may also be a feature of an
enlarged lymph node or psoas abscess (signs of systemic illness would also be expected). The patient’s
young age makes the rarer conditions less likely.
A3: What additional features in the history would you seek to support a
particular diagnosis?
Ask whether the patient has had a hernia before (making future hernias more likely) and about a family
history of hernias. Does he inject into his groin? Has he been otherwise well?
A4: What clinical examination would you perform and why?
Examine the groins and external genitalia. The features characteristic of an uncomplicated hernia are
a cough impulse and reducibility. An inguinal hernia passing through the deep inguinal ring is called
‘indirect’, and one passing through the medial posterior wall of the inguinal canal is called ‘direct’.
Distinguishing between the two types is possible, but makes no difference to treatment.
A5: What investigations would be most useful and why?
Ultrasound to possibly dene clinically unclear entities
Fine-needle aspiration cytology (FNAC) of enlarged lymph nodes
A6: What treatment options are appropriate?
Supportive: hernia trusses have been used in the past but have no role now.
Medical: no role
Surgical: hernia repair is advisable for most patients with a groin hernia in order to reduce the
risks of future complications. The most common approach for repair is still an open operation
through the groin, although laparoscopic repair for recurrent, bilateral and unilateral inguinal
hernias is increasingly common. In both cases a permanent synthetic mesh is implanted.
Laparoscopic repair requires a general anaesthetic, while open repair can be performed under
local anaesthetic.
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Hernias 9
Specically, in the case of this 25-year-old, he should have his hernia repaired urgently on the next
available theatre list.
CASE 1.2 –
‘I can’t push my lump back in anymore’
A1: What is the likely differential diagnosis?
Inguinal hernia
Femoral hernia
Enlarged lymph node (infection, metastatic tumour)
Femoral artery aneurysm
Saphena varix
A2: What features of the given history support the diagnosis?
A previously reducible groin mass which is no longer so is a very clear history of a groin hernia. The
patient’s older age and chronic cough also support this.
A3: What additional features in the history would you seek to support a
particular diagnosis?
Ask about urinary symptoms – benign prostatic hyperplasia (BPH) is common in this age group and
increases the risk of post-operative acute urinary retention.
A4: What clinical examination would you perform and why?
Examine both groins and external genitalia. Perform a digital rectal examination (DRE) to exclude BPH.
A5: What investigations would be most useful and why?
Ultrasound may be useful to differentiate between clinically unclear entities.
A6: What treatment options are appropriate?
Supportive: no role
Medical: no role
Surgical: early elective repair is indicated.
CASE 1.3 –
‘My hernia is sore and I’ve started to vomit’
A1: What is the likely differential diagnosis?
Inguinal hernia, with ischaemia and bowel obstruction
Femoral hernia, with ischaemia and bowel obstruction
Psoas abscess
Infected lymph node
A2: What features of the given history support the diagnosis?
The recent change in the groin lump which has become more painful and the redness of the overlying
skin indicate ischaemia of the hernia contents. Vomiting and constipation would suggest bowel
obstruction. A femoral hernia is more likely to cause ischaemia as a result of the tight neck of the
femoral canal.
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10 General surgery
A3: What additional features in the history would you seek to support a
particular diagnosis?
It is necessary to exclude infections that would drain to the inguinal lymph nodes. Local inammation
could explain the erythema of the skin and tenderness of the lump. Systemic sepsis can secondarily
cause paralytic ileus that would cause vomiting.
A4: What clinical examination would you perform and why?
Examine the groin carefully. Femoral hernias are seen more commonly in women than men, but
an inguinal hernia is still more common in women than a femoral hernia. Femoral hernias are felt
below and lateral to the pubic tubercle. Approximately 40 per cent of femoral hernias present with
strangulation.
A5: What investigations would be most useful and why?
A plain abdominal x-ray will conrm the clinical suspicion of bowel obstruction. An arterial blood gas
(ABG) test may show a metabolic acidosis and raised lactate, suggesting ischaemia. Other investigations
will be directed at readying the patient for emergency surgery.
A6: What treatment options are appropriate?
Supportive: no role
Medical: the patient should be aggressively uid resuscitated with the expectation of going to
theatre urgently. Passing a nasogastric tube reduces the risk of vomiting and aspiration of gastric
contents in addition to improving patient comfort.
Surgical: emergency surgery is needed. This usually consists of a lower midline laparotomy,
although other options are available. Any non-viable bowel will need to be resected, usually with
an anastomosis of the two ends. The hernia itself can be repaired at the same time, either with a
second groin incision, or from within the abdomen.
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Hernias 11
OSCE Counselling cases
OSCE COUNSELLING CASE 1.1 –
‘Should I have my hernia repaired?’
Risks relate to the complications of the underlying condition as well as to the risks of any
treatment.
Risks of surgery may be due to the anaesthetic or the operation.
Risks of an operation may be specic to that operation or general to all surgery.
General risks:
Bleeding – minimized by careful surgical technique, stopping anticoagulation before surgery
Wound infection
Pain
Specic risks:
Hernia recurrence
Scrotal haematoma
Injury to the vascular supply to the testicle (ischaemic orchitis and testicular atrophy)
Chronic pain
Patients can only make informed choices about whether to proceed with surgical treatment if they
are made aware of the risks of any treatment as well as the risks of the underlying condition if left
untreated. There is strong consensus that groin hernias should usually be repaired.
OSCE COUNSELLING CASE 1.2 –
‘Why did my surgeon suggest I see a
urologist rst?’
Q1: BPH is a relatively common condition in elderly men. Similar symptoms of bladder outow
obstruction can also be caused by prostate cancer. Most patients cope well with their
symptoms, which are usually of gradual onset. Occasionally inguinal hernia repair may trigger
acute urinary retention as a result of the combination of anaesthetic drugs, the perioperative
uid load given and pain in the groin. The treatment of acute urinary retention usually
involves a urethral catheter, and may result in a prolonged hospital admission.
Q2: A urologist will take a detailed history, perform complete physical examination including DRE,
and arrange further appropriate investigations. These may include a blood test for Prostate
Specic Antigen (PSA), trans-rectal ultrasound of the prostate (TRUS) including prostate
biopsy if necessary, and cystoscopy to assess the bladder and prostatic urethra. Medications
may be all that are required to manage his symptoms. Trans-urethral resection of the prostate
(TURP) may be appropriate. This assessment and treatment is best performed prior to
uncomplicated elective hernia repair.
REVISION PANEL
Hernias should usually be surgically repaired when present, in order to treat symptoms of
discomfort, and to reduce the risk of serious complications.
Ultrasound is sometimes required to diagnose atypical hernias (or hernias in unusual sites), and to
exclude conditions that may mimic hernia, such as lymphadenopathy.
Hernia repair may be open or laparoscopic. Each method has specic advantages and risks, which
should be discussed with the patient. Neither has a fundamental advantage over the long term.
Patients who present with bowel obstruction should be checked for hernia as a possible cause.
Chronic pain is an under-recognized complication of hernia repair, and may occur in up to 10 per
cent of patients.
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12 General surgery
GALLSTONES
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What features of the given history support the diagnosis?
Q3: What additional features in the history would you seek to support a particular
diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most useful and why?
Q6: What treatment options are appropriate?
CASE 1.4 –
‘My GP tells me my pain is caused by gallstones’
Right upper quadrant pain after fatty meals prompts a 26-year-old woman to see her GP. The pain is felt
under the ribs and in her back. It builds up over an hour and lasts up to 4 hours. It is quite severe. She
feels nauseated, but never vomits. The GP refers her for a surgical opinion, but suggests to her that the
pain will probably turn out to be due to gallstones.
CASE 1.5 –
‘It’s the worst pain ever! It’s not going away, and I’ve got a
fever’
A 31-year-old woman has had typical biliary pain for many months, but has been reluctant to consider
an operation. She now has an episode of constant pain that lasts 18 hours which she says is the worst
ever. She looks ushed and has a temperature of 37.9°C. Nausea, and now vomiting are a feature.
CASE 1.6 –
‘My eyes have gone yellow and my skin is itching’
A 61-year-old man has had niggling epigastric pain for some months. Over the last week his wife has
commented that his eyes are yellow tinged. He has noticed that he is getting itchy skin.
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Gallstones 13
OSCE Counselling cases
OSCE COUNSELLING CASE 1.3 –
‘But I don’t have pain – do I need an
operation?’
During an antenatal scan a 26-year-old woman is noted to have small mobile gallstones. When
questioned she denies pain typical of biliary colic. She is referred by her obstetrician for a surgical
opinion as to whether she should have a cholecystectomy.
Q1: Should she be offered an operation?
OSCE COUNSELLING CASE 1.4 –
‘What is this ERCP thing that you think I
should have?’
Six weeks after delivery the same young woman develops epigastric pain and jaundice. Ultrasonography
conrms the presence of gallstones and shows a dilated common bile duct (CBD) of 11 mm. Endoscopic
retrograde cholangiopancreatography (ERCP) is recommended.
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Key concepts
In order to work through the core clinical cases in this chapter you will need to understand the following
key concepts.
HOW DO GALLSTONES FORM?
Bile consists of water, sodium bicarbonate, bile salts, bile pigments, lecithin and cholesterol secreted
by hepatocytes. Normally these constituents are in solution. Alterations in the relative amounts of
these constituents can render bile ‘lithogenic’ (stone forming). Biliary infection, stasis and changes
in gallbladder function can also cause precipitation around a nucleus of cellular debris or bacteria.
Gallstones are formed.
WHAT CLINICAL PROBLEMS CAN THEY CAUSE?
Consider the problems by where the gallstones are located:
Gallbladder: asymptomatic, biliary pain (colic), inammation (cholecystitis), perforation, malignancy
(75 per cent of gallbladder carcinoma is associated with stones)
Bile ducts: asymptomatic, obstructive jaundice, ascending cholangitis, gallstone pancreatitis
Unusual: stula to duodenum, stomach or colon, gallstone ileus
WHAT OPTIONS ARE THERE FOR IMAGING THE BILIARY TREE?
Ultrasonography is usually the imaging investigation of choice for suspected gallstones. Ten per cent
of gallstones are radio-opaque and visible on plain abdominal x-ray. ERCP gives excellent visualization
of the lumen of the bile ducts, and also allows therapeutic interventions such as sphincterotomy, stone
extraction and stent placement. Magnetic resonance cholangiopancreatography (MRCP) equals the
imaging quality of ERCP but without the risks.
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Gallstones 15
Answers
Clinical cases
CASE 1.4 –
‘My GP tells me my pain is caused by gallstones’
A1: What is the likely differential diagnosis?
Biliary colic
Peptic ulcer disease
A2: What features of the given history support the diagnosis?
Pain associated with gallstones often occurs after fatty meals as the hormone cholecystokinin is released,
causing the gallbladder to contract. As the stimulus is hormonal, the pain is usually of gradual onset but
prolonged duration. Nausea is common. Referred pain is often felt in the back or shoulder.
A3: What additional features in the history would you seek to support a
particular diagnosis?
A family history of gallstones may be present, but this may reect learnt eating behaviours rather than a
genetic tendency to form gallstones. Symptoms of gastro-oesophageal reux and upper gastrointestinal
bleeding should be sought.
A4: What clinical examination would you perform and why?
Abdominal examination should be performed, although often no signs are found. Check the eyes for
jaundice. Note any abdominal scars that might make laparoscopic surgery more difcult.
A5: What investigations would be most useful and why?
Ultrasonography to conrm the presence of gallstones and assess the bile ducts
Blood tests to look for evidence of ductal calculi (raised bilirubin, alkaline phosphatase, amylase)
A6: What treatment options are appropriate?
Supportive: adopting a low-fat diet may reduce the frequency and severity of attacks of biliary colic.
Medical: medical options to dissolve gallstones have been tried unsuccessfully in the past.
Surgical: most patients with symptomatic gallstones should have the gallbladder removed
(cholecystectomy). Laparoscopic cholecystectomy can be performed successfully in 95 per cent of
patients, with 5 per cent requiring open surgery (either planned open surgery, or due to an intra-
operative decision to convert from a laparoscopic technique).
CASE 1.5 –
‘It’s the worst pain ever! It’s not going away, and I’ve got a
fever’
A1: What is the likely differential diagnosis?
Acute cholecystitis
Ascending cholangitis (obstructed CBD with infection ascending into the liver)
Right lower lobe pneumonia
Less likely: acute appendicitis, pyelonephritis, perforated peptic ulcer
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16 General surgery
A2: What features of the given history support the diagnosis?
Her past history of typical biliary pain, now superseded by constant prolonged pain and systemic upset
suggest infection and inammation of the gallbladder.
A3: What additional features in the history would you seek to support a
particular diagnosis?
Exclude symptoms of any other infections – cough, urinary frequency. Ask about dark urine, pale stools
and itching which suggest jaundice is present and makes ascending cholangitis a possibility.
A4: What clinical examination would you perform and why?
Abdominal examination may reveal tenderness and even peritonism in the right upper quadrant.
Murphy’s sign – the cessation of inspiration as the inamed gallbladder descends onto the examining
ngers in the right upper quadrant – is tested. Charcot’s triad (jaundice, fever with rigors and right
upper quadrant pain) indicate ascending cholangitis.
A5: What investigations would be most useful and why?
Blood tests: elevated white cell count (WCC) is likely to be present. Electrolytes should be normal
unless there is dehydration or prolonged vomiting present. Liver function tests (LFTs) may be mildly
out of range, but high bilirubin or amylase suggests diagnoses other than acute cholecystitis.
Ultrasonography: will conrm gallstones, and may identify features of acute cholecystitis – thickened
gallbladder wall, pericholecystic uid, the sonographic Murphy’s sign. An abscess or gallbladder
perforation should also be evident. In a severely ill patient, computed tomography (CT) may be more
appropriate.
A6: What treatment options are appropriate?
Supportive: uid resuscitation and analgesia, including non-steroidal anti-inammatory drugs
(NSAIDs), are available.
Medical: antibiotics have traditionally been used to resolve acute cholecystitis. Often a prolonged
course (10 to 14 days) is required.
Surgical: early laparoscopic cholecystectomy has been shown to be as safe as initial medical
management with elective laparoscopic cholecystectomy 6 weeks later. The advantage of surgery
during the initial admission is reduced hospital admissions and elimination of the risk of further
complications while waiting for surgery.
Other: in very sick patients, or those with signicant comorbidity, percutaneous image-guided
drainage of an empyema (pus-lled gallbladder) in addition to antibiotics is an option.
CASE 1.6 –
‘My eyes have gone yellow, and my skin is itching’
A1: What is the likely differential diagnosis?
Obstructive jaundice due to gallstones
Obstructive jaundice due to malignancy (e.g. pancreatic carcinoma, enlarged metastatic lymph
nodes, liver metastases)
Jaundice from other causes
A2: What features of the given history support the diagnosis?
Pain from stones within the ductal system is often intermittent and difcult to characterize. Obstructive
jaundice classically results in yellowing of the sclera and skin, dark urine and pale stools and intense
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