Groin Hernia

You are the general surgery CT1 asked to see a 40-year old body builder with 2-hour history of pain and a discoloured swelling in his right groin. Then pain started after a heavy gym session. His nauseous and has vomited twice. His respiratory rate is 25 and his heart rate is 115. How would you proceed? 

Example answer introduction

In this scenario I would be most worried about a strangulated inguinal hernia, although my differentials will include testicular torsion, strangulated femoral hernia and groin aneurysm/psuedoaneurysm. I would assess this patient using an A-E approach, take a focused history and perform an abdominal examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, Trop I, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications 

  • Past medical history, including previous abdominal surgery

  • Last meal

  • Events leading up to this point - nature of pain, nausea and vomiting, diarrhoea, constipation, weight loss, PR bleeding

Abdominal examination

  • Inspect – Distention, surgical/traumatic scars, hernia appearance – overlying discolouration

  • Auscultate – bowel sounds

  • Palpate – Tenderness, hernia – attempt reduction only if no suspicion of strangulation or bowel obstruction

  • Percussion – Normal or hyper-resonant

  • Digital rectal examination – obturator hernia, malignant masses, blood 

  • External genitalia – hernia, testicular torsion

Example questions to progress the station

Q1 What do you see in this picture?

 

​Strangulated inguinal hernia.

 

Q2 What are the complications of anterior abdominal wall hernias?

Incarcerated hernia

Stangulated hernia

Perforation

Q3 Would you arrange any imaging?

Further imaging is not generally required for uncomplicated hernias, but an ultrasound of the groin can be useful to differentiate inguinal and femoral hernias in obese patients. Thin-slice CT or MRI also has a role. In patients with signs of bowel obstruction or toxicity and CT abdomen and pelvis should be performed for further evaluation of bowel status. 

Q4 There are no overlying skin changes and x-rays are normal. Your attempt at reduction fails. What would you do next?

Initial management

This patient will need to go to theatre for surgical exploration and repair and I would inform the surgical registrar immediately. 

  • IV crystalloids and catheter to maintain urine output of 0.5ml/kg/hr   

  • Analgesia according to WHO ladder

  • Keep nil by mouth

  • Inform general surgery registrar 

  • Prep for theatre - P-Possum score, Anaesthetist, Emergency theatres, Keep nil by mouth 

  • Keep patient and any relatives informed

  • Document, document, document!!!

 Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct.
Discussion with theatres and anaesthetics +/- ICU will be required. 
Useful Resources

International guidelines for groin hernia management, The HerniaSurge Group

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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