Link to the Podcast: https://podcasters.spotify.com/pod/sh..
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Link to my YouTube channel: youtube.com/c/surgicaleducator
Embedded Podcast you can hear here itself
The Script for the Podcast:
Podcast- Script for Inguinal Hernia
Introduction: Hello and welcome to our Surgical Educator podcast. I am
your host/ master of ceremony for today’s episode. You can call me as
MC is the Master of the ceremony. We are going to discuss the surgical
problem of Groin swellings in the forthcoming weeks. Today in this episode
we are going to discuss the commonest cause for groin swellings-
the inguinal hernia. We will be discussing the definition, various causes
for groin swellings, applied anatomy, epidemiology, etiology, pathology,
clinical features, complications, treatment, and postoperative
complications associated with inguinal hernia. In the subsequent
episodes, we will discuss the other causes of the groin swellings. Our
expert Surgeon Prof Dr. Selvaraj is here to answer all our questions. So,
let us dive deep into the topic.
Q1. What is an inguinal hernia doctor?
Hi, MC good morning. An inguinal hernia is a protrusion of the whole or
part of a viscus through a weak point or defect in the cavity which
contains it. Hernia has four parts- mouth, neck, body, and fundus. The
inguinal canal is a passage through the lower abdominal wall that allows
structures such as blood vessels, nerves, and the spermatic cord in
males and the round ligament in females to pass from the abdomen to the
scrotum and labia respectively.
Q2. What are the different causes of groin swellings?
You must think of different structures or organs lying in the groin area. They
are lymph nodes, spermatic cord, round ligament, Femoral vein, femoral
artery, and femoral nerve. Think of pathologies in these structures.
The commonest cause is an Inguinal hernia. Other causes are Femoral
hernia, encysted hydrocele, lipoma of the cord, undescended testis,
saphena varix, femoral artery aneurysm, femoral nerve neuroma and
cold abscess.
Q3. What applied anatomy the students must know in Inguinal hernia?
Well, to be a successful surgeon, you must know the underlying
anatomy thoroughly. You must know the anatomy of the anterior surface of
the lower abdominal wall to do a successful open surgery for a hernia and
to do a successful laparoscopic surgery you must know the anatomy of
the posterior surface of the same area. Regarding the anterior surface, you
must know about the inguinal canal and its boundaries. The inguinal canal is
a 4cms passage between the deep inguinal ring which is a defect in
transversalis fascia and the superficial inguinal ring which is a defect in
external oblique fascia. The inguinal canal is anteriorly related to external
oblique aponeurosis and the origin of the internal oblique, posteriorly related to
transversalis fascia, superiorly by internal oblique muscle and conjoint
tendon and inferiorly related to inguinal ligament. Myopectineal orifice of
Fruchaud is a well-defined weak area in the anterior lower abdomen which
is divided into supra inguinal and infra inguinal part by inguinal ligament.
In suprainguinal part both direct and indirect inguinal hernias can occur
whereas in infra inguinal part femoral hernia results.
The posterior surface anatomy you should learn ideally with a diagram.
You must know about the various structures lying there like the various
muscles, blood vessels, nerves, and the orifices like an internal inguinal ring
and femoral ring. You should also know about the triangle of doom,
a triangle of pain, and circle of death. This is something like teaching about
elephants- however good I am going to explain about elephants verbally,
showing a picture of an elephant instead will have a great impact.
Because it’s an audio podcast, I can’t do that. So, I request my audience
to refer to a standard Surgical anatomy atlas to understand this anatomy
very well. Knowledge of the anatomy of the posterior surface of the lower
abdominal wall is important to master laparoscopic repair of groin
hernias.
Q4. What is the epidemiology of inguinal hernia?
Inguinal hernias are common and affect both men and women.
However, they are more common in men, with a lifetime risk of up to
27%. Inguinal hernias also tend to occur more frequently in the elderly. More
common on the right side and in premature babies.
Q5. What are the etiological factors of inguinal hernia?
1. General factors like aging, male gender, family history, obesity,
and smoking.
2. In pediatric patients persistence of processus vaginalis is the
cause for hernia.
3. Increase intra-abdominal pressure caused by Chronic cough,
constipation, dysuria, and heavy weight lifting resulting in indirect
inguinal hernia.
4. Direct inguinal hernia is common in the elderly due to weakness of
anterior abdominal wall muscles.- Malgagne’s bulging
5. Injury to iliohypogastric nerve due to surgery in RIF like
appendicectomy or open ureterolithotomy resulting in direct
inguinal hernia
Q6. What is the pathology of inguinal hernia?
Inguinal hernias occur when the abdominal contents, such as the
intestine or omentum, protrude through a weak point or defect in the
myopectineal orifice of Fruchaud or because of increased intra-
abdominal pressure. The protrusion can be either indirect, where the
hernia sac passes through the internal inguinal ring, travels down the
inguinal canal, and exits the abdominal wall through superficial inguinal
ring, or direct, where the hernia sac won’t pass through inguinal canal
but appears as a bulge in the groin area and comes out through
Hessebach’s triangle.
Q7. What are the clinical features of inguinal hernia?
1.The most common clinical feature of an inguinal hernia is a bulge or
swelling in the groin area that may or may not be associated with pain.
Other symptoms include a dragging sensation in the groin because of
the pull on mesentry, discomfort or pain during physical activity, and a
feeling of heaviness in the scrotum.
2.Expansile cough impulse in an uncomplicated hernia. If it becomes
complicated like irreducible,obstructed or strangulated hernia there won’t
be any cough impulse.
3.Swelling is partially or completely reducible.
4. Get above the swelling is not possible because indirect inguinal hernia
is an inguinoscrotal swelling.
5. Deep ring occlusion test positive in indirect inguinal hernia but
negative in direct inguinal hernia.
6. Zieman’s three finger’s test: Index finger-IIH, Middle finger- DIH, Ring
finger- Femoral hernia
Q8. What are the three types of indirect inguinal Hernia?
1. Bubonocele
2. Funicular
3. Complete scrotal
Q9. How will you differentiate indirect inguinal hernia from direct inguinal
hernia?
Q10. What are the complications of inguinal hernia?
1. Irreducible- internal ring is tight.
2. Obstructed- Lumen is obstructed. Can’t happen in omentocele only
in hollow viscera
3. Strangulated- blood supply is cut off , peritonitis, perforation. Can
happen in enterocele and omentocele
4. Incarceration- here internal ring is normal but irreducibilty is
because of adhesion between the content and sac of hernia or
solidified fecal matter
5. Reduction-en-mass- Because of forcible reduction the hernial sac
get invaginated without proper reduction.
Q11. What are the special types of hernias?
1. Dual/Pantaloon/Saddle Hernia: Both direct and indirect sacs +
2. Sliding Hernia: (Hernia-en-glissade) Retroperitoneal organ is part
of hernial sac.
3. Richter’s Hernia: only part of circumference of the small gut is
obstructed. Common in femoral hernia.
4. Maydl’s Hernia: “W” shaped hernia
5. Littre’s Hernia: Meckel’s diverticulum as content
6. Amyand’s Hernia: Appendix as content
Q12. What is the treatment for inguinal hernia?
1. The treatment for inguinal hernia is surgical repair, which can be
performed either through an open or laparoscopic approach. The
type of surgery depends on the patient's individual needs and the
surgeon's preference. The most common surgical technique is the
Litchtenstein’s tension-free mesh repair.
2. In pediatric inguinal hernia do just herniotomy that’s high ligation of
sac
3. In young adults ideally herniorrhaphy- that’s suturing together
patients own tissue to strengthen the posterior wall of inguinal
canal. Bassini’s, Shouldice, Maloney’s, Desarda are few examples.
There are numerous types of herniorrhaphys.
4. In elderly we do hernioplasty- that’s using synthetic material to
strengthen the posterior wall of inguinal canal. Litchtenstein’s
tension free mesh repair, Gilbert’s sutureless Prolene hernia
system, Stoppa’s preperitoneal mesh repair.
5. Laparoscopic/Robotic hernia repair- for recurrent and bilateral
inguinal hernias. If it’s primary unilateral hernia there is no
indication for Lap hernia repair. 2 types of Lap hernia repair- TAPP
& TEP
Q13. What are the postoperative complications associated with inguinal
hernia repair?
1.The commonest complication now in the mesh era is nerve
entrapment neuropathy. That’s when we are fixing the mesh to the
inguinal ligament or the conjoint tendon we shouldn’t include the
ilioinguinal nerve or genital branch of genitofemoral nerve in our ligature
otherwise nerve entrapment neuropathy happens which can be treated
symptomatically.
2. The commonest complication in the pre mesh era was recurrence
which has gone down considerably after the introduction of mesh repair.
3. Other complications are seroma/hematoma, SSI, urinary retention,
Testicular atrophy due to injury to testicular artery.
In most cases, these complications can be managed with medications
and close follow-up with the surgeon.
Q14: Thank you doctor for sharing your knowledge regarding the
theoretical aspect of the inguinal hernia. Can you share your experience
of some real inguinal hernia cases managed by you?
Thank you for the question MC! However knowledgeable you are
theoretically, you should apply that knowledge to treat a real patient
successfully. I will share 3 case scenarios of inguinal hernia to reinforce
the theoretical knowledge gained.
Case No 1: A 25-year-old builder suddenly develops a golf-ball-sized,
slightly tender lump in his right groin after lifting a 20-kg bag of sand. He
states that he felt a tearing sensation as it happened. He attends the
accident and emergency department.
Case No 2: A 7-month-old baby was brought to surgical outpatient clinic
with a inguino-scrotal lump. He has had the lump for the past 2 months,
but previously it appears only on crying. Over the last 2 days has
descended into scrotum and was unable to reduce. Baby started
vomiting for one day.
Case No 3: 73-year-old man has had a groin lump for some time which
he ignored. Over the last 3 days it has become progressively more
painful, with redness of the overlying skin. He has not opened his bowels
during this time and yesterday he started to vomit.
Q15.In Conclusion what you want to sum up regarding inguinal hernia?
In conclusion, I want to tell inguinal hernia is a common condition that
can cause significant discomfort and lead to serious complications. It is
important to seek medical attention if you experience any symptoms of
an inguinal hernia. Surgical repair is the most effective treatment for
inguinal hernia, and patients should discuss their options with their
surgeon to determine the best approach for their individual needs.
Q16. Before going to close this episode do you want to tell anything to
our audience doctor?
Yeah. Good. I told in the first episode itself and want to reinforce it once
again.
1. I request my audience to hear these podcasts ideally with a
headphone.
2. Don’t mechanically listen these podcasts instead visualize what I am
discussing as a real patient and see all the symptoms and signs in that
patient. In other words, you should not just hear the podcast but should
run a mental movie along what you are hearing regarding the patient
under discussion.
3. You can hear these podcasts while commuting or driving, walking,
jogging, cooking, or just before going to sleep. But don’t forget to use a
headphone.
4. Just allow my words and the mental movie you are visualizing to
permeate into your mind so that it will get imprinted in your subconscious
mind. Then the recall of the information needed is easier.
5. If you think these educational podcasts are very effective learning
tools kindly spread this message to your friends or students.
6. If you want to learn more, kindly follow me in my YouTube channel
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the YouTube search engine.
Question Remark: Thank you doctor for your clear and impactful
answers. Bye---Bye
Answer Doctor: Thank you very much MC. I wish you all happy learning
and listen your way to mastery of surgery.
Bye---Bye. See you all in the next episode.
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