Updated: 7/30/2018

Hernias

Topic
Review Topic
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Questions
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Evidence
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Snapshot
  • A 35-year-old man presents to the general surgeon's office with pain in his right groin. He recently noticed a bulge in this region after performing heavy weight lifting at the gym. The pain and bulge comes and goes sporadically and he thinks it is associated with his workouts. He denies any change in bowel or bladder function. 
Overview

 
 
Introduction
  • Clinical definition
    • a protrusion of peritoneum through an opening or weakness into another body cavity
  • Increased risk with structural weakness or increased intra-abdominal pressure
  • Classification based on the anatomy of Hesselbach's triangle
    • borders
      • lateral - inferior epigastric artery
      • medial - lateral border of rectus abdominis
      • inferior - inguinal ligament
  • Types
    • indirect inguinal
      • travels the entire length of the inguinal canal following descent path of the testes
        • enters internal inguinal ring lateral to inferior epigastric artery and exits external inguinal ring
        • may enter scrotum
      • covered by all 3 layers of spermatic fascia
      • most commonly seen in male infants
        • due to patent processus vaginalis
          • peritoneal connection between inguinal canal and tunica vaginalis
    • direct inguinal 
      • bulges through the inguinal (Hesselbach's) triangle
        • directly through abdominal wall through the external inguinal ring
        • medial to inferior epigastric artery
      • covered only by external spermatic fascia
      • most commonly in older men
    • femoral
      • protrudes below inguinal ligament through femoral canal
        • lateral to pubic tubercle
      • more common in women
    • umbilical
      • most commonly in adults
        • associated with pregnancy, ascites, and obesity
    • incisional
      • occurs at previous surgical sites 
Treatment
  • Indirect and direct inguinal hernia
    • surgical placement of mesh over Hesselbach's triangle/inguinal canal and reinforce abdominal wall 
  • Femoral
    • surgical joining of Cooper's ligament to transversalis fascia
  • Incisional 
    • associated with previous incision through the fascia 
    • goal is to achieve primary fascial closure with mesh reinforcement 
    • number of different repairs are possible including mesh underlay, inlay, overlay or bridging repairs 
Prognosis, Prevention, and Complications
  • Incarceration and strangulation
    • seen in all hernia types where hernia contents get stuck within the defect
    • the larger the hernia defect the smaller risk of incarceration
      • femoral hernia has greatest risk
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.GI.62) A father brings his 1-year-old son into the pediatrician's office for a routine appointment. He states that his son is well but mentions that he has noticed an intermittent bulge on the right side of his son's groin whenever he cries or strains for bowel movement. Physical exam is unremarkable. The physician suspects a condition that may be caused by incomplete obliteration of the processus vaginalis. Which condition is caused by the same defective process? Review Topic

QID: 106455
1

Femoral hernia

13%

(17/134)

2

Hydrocele

69%

(92/134)

3

Varicocele

11%

(15/134)

4

Diaphragmatic hernia

1%

(2/134)

5

Testicular torsion

4%

(5/134)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M1.GI.40) A 68-year-old man presents to his primary care physician complaining of bulge in his scrotum that has enlarged over the past several months. He is found to have a right-sided inguinal hernia and proceeded with elective hernia repair. At his first follow-up visit, he complains of a tingling sensation on his scrotum. Which of the following nerve roots communicates with the injured tissues? Review Topic

QID: 106254
1

L1-L2

39%

(7/18)

2

L2-L3

0%

(0/18)

3

L4-L5

6%

(1/18)

4

S1-S3

17%

(3/18)

5

S2-S4

28%

(5/18)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M1.GI.39) A 72-year-old man presents to his primary care physician complaining of pain and bulging in his groin. He is otherwise healthy and has never had surgery. He is referred to a general surgeon, and is scheduled for an elective hernia repair the following week. On closer inspection in the operating room, the surgeon notes a hernia sac that protrudes through the external inguinal ring, bypassing the inguinal canal. Which of the following accurately describes this patient's condition? Review Topic

QID: 106249
1

Direct hiatal hernia

0%

(0/6)

2

Indirect femoral hernia

0%

(0/6)

3

Direct incisional hernia

0%

(0/6)

4

Isolated rectus diastasis

0%

(0/6)

5

Direct inguinal hernia

67%

(4/6)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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