DIRECT INGUINAL HERNIA

DEMOGRAPHICS

Name: MRN: Age: 65 Gender: Male

Date of admission:

HISTORY

Chief Complaint:
Right inguinal swelling for 3 days
History of Present Illness:
 Patient came to the OPD complaining of 3 days history of right swelling in the
inguinal area with aching and heaviness sensation on the bulge.
 Pain associated with nausea, vomiting (the vomit contained food but no blood)
and constipation.
 Patient has difficulty in passing urine also.
 No fever and no renal symptoms.
 No weight loss or recent trauma.
 Alleviating factors: None.
 Aggravating factors: None.
ROS:
 CVS: no palpitations, no chest pain.
 Resp: no shortness of breath, no cough, or wheezing
 GU: no dysuria, frequency or urgency only difficulty passing urine
 MUSCULOSKELETAL: no pain in bones, joint or any weakness in muscles
 CNS: no headaches or visual, auditory disturbances
 No weight changes or trauma
PMH: HTN, dyslipidemia and IHD
PSH: angioplasty to the left main coronary artery was done 6 months ago. And previous
surgery for pile under spinal anesthesia many years back
FH: no family history of any chronic diseases.
SH: No smoking or alcohol intake.
Allergies: none.
Meds: Aspirin and Plavix (clopidogrel)
P/E

General appearance Alert and oriented, he seems mildly distressed.

VS: BP 144/80 mmHg MAP: 101 mmHg Pulse 7 bp Resp: 18 br/min
Temp: 36.6 DegC. Oxygen saturation: 98%

pain score

Head and Neck:

 No icterus, pallor, or cyanosis.
 Pupils: PEERLA Pupils equal, round & reactive to light & accommodation
 Mouth: dehydrated.
 Good dental hygiene.
 Normal JVP & no carotid bruits.
 No palpable lymph nodes nor enlarged thyroid.

CVS: Regular rate and rhythm, normal heart sounds with no murmurs.
Lungs: Breath sounds vesicular. No crepitations, rhonchi or rub heard.
Abdomen:
 Inspection: Abdomen not distended with big right inguinoscrotal hernia. No
visible pulsation. No skin discoloration or distended veins
 Palpation: soft and tender, hernia is not reducible.
 No organomegaly
 Coughing increased the pain.
 Percussion: resonant on all four quadrants.
 Bowel sounds are heard.
 Per rectal & genital exam were not done.
 Extremities:
 Inspection: no edema, varicose veins or skin changes.
 Pulses: all peripheral pulses are felt.
Neuro exam: patient is awake, alert and oriented with no focal neurological deficit, alert
and oriented.
Skin: No skin discoloration nor scratch marks or scars.

DIFFERENTIAL DX:

Inguinal Hernia
Inguinal adenitis
Lipoma
Psoas abscess
Femoral fernia

INVESTIGATIONS:

 CT scan of the abdomen, chest and gasrograffen study was done and showed: large
right inguinal hernia formation containing multiple small intestinal loops, with
delayed filling of ileo-cecal junction and cecum up to 36 hours. “no complete
evacuation of jejunal and ileal loops till the end of the study after 66 hours. Picture in
favor of partial intestinal obstruction/ileus.

PLAN OF CARE

 Patient admitted.
 Keep NPO + IV fluids
 dextrose 5% with 0.45% NaCl solution 1500 ml. 120ml/hr.
 sodium chloride 0.9% 500 ml. 250ml/hr
 dexamedetomidine additive 200mcg + sodium chloride 0.9% 50 ml.
 Medications:
o Clopidogerl.
o TNF MED
o Nystatin
o Atorvastatin
o Bisoprolol
o Micronazole toical
o Tramadol
o Herparinoid
o Aspirin
 o Acetaminophen
o Polyethylene glucol 3350 with electrolytes
o Insulin regular
o Budesonide
o Metoclopramide
o Pantoprazole
o Amlodipine
o Enoxaparin
o Sodium biphosphate

FINAL DIAGNOSIS:

Obstructed irreducible Right inguinal hernia

PROGRESS

 Cardiology review assured that the patient need to resume aspirin and clopidogrel
due to recent angioplasty and it was recommended to do the hernia repair surgery
at a center with cath lab.
 Patient discharged in good general condition and recommended to do the surgery in
center with cath lab/ cardiac surgery avaible as soon as possible.
o With Ordered medications:
 Acetaminophen (5 days)
 Domperidone (3days)
 Esmoprazole (maintenance)
 Sodium biphosphate-sodium phosphate
 Patient adviced to remain on soft diet.
 Patient did the surgery (open hernia repair) the day after (27-9-2019).
 2 days Post op progress:
o Patient passed urine and motion
o Drain had 20ml serosanguineous
o NG tube is placed
o Patient had pain at the site of surgery and feel thirsty
o On examination: patient was conscious, oriented, chest was clear and
abdomen was soft and distended mainly in the epigastric region, and
bowel sounds present.

LEARNING POINTS:
  Indirect inguinal hernia is more common in the right side because process vaginalis
close in the left side before the right side, so when we have indirect hernia in the left
side we should suspect hernia in the right side also.
 Umbilical hernia common in peritoneal dialysis patient and ascites.
 Zieman test can be done clinical to determine the site of the hernia.

 Incarcerated hernia when hernia contain hard fecalith material or omentum

adherence.
 Obstructed hernia when hernia contain bowel and present with feature of bowel
obstruction.
 Stargulated hernia when hernia has obstruction and decrease in blood supply.
 Gold standard surgery for hernia is tension free hernioplasty.

LITERTURE REVIEW:

 Inguinal hernia is very common in men, approximately 1 out of 4 men undergo inguinal
hernia repair during their life. it is known that the main cause behind inguinal hernia is
weakness and fibrosis in lower abdominal muscles near the inguinal canal and recent studies
on the exact pathology of muscle weakness showed that the conversion of testosterone to
estradiol by aromatase causes fibrosis and atrophy of lower abdominal muscles as they
express high estrogen receptors on muscle fibroblasts and when estrogen bind it’s receptors it
cause fibroblasts proliferation and fibrosis that result in hernia. And according to these
findings that suggest non-surgical preventative approaches to prevent hernia in high risk
elderly men.
 Most common surgical approach in hernia repair inculde:
o Lichtenstein repair: in which a mesh will be placed between the internal oblique
aponeurosis and external oblique aponeurosis
o Shouldice repair: by suturing the inguinal ligament with internal oblique and
transverse muscles without using a mesh.
o Laproscopic hernia repair which can be divided into:
 Transabdominal preperitoneal repair (TAPP)
 Total extraperitoneal repair (TEP)
o Open hernia repair can also be done in case of complicated hernia, previous
peritoneal surgeries, ascites, contraindicated general anaesthesia, or history of
recurrent hernia.
  Most common complications of hernia repair surgeries include:
o injury to the vas deferens or spermatic vessels
o injury to the femoral nerve, artery or vein
o injury to the bladder
o chronic inguinal pain

References:

 Zhao, H., Zhou, L., Li, L., V, J. C., Chatterton, R. T., Brooks, D. C., … Bulun, S. E. (2018).
Shift from androgen to estrogen action causes abdominal muscle fibrosis, atrophy, and
inguinal hernia in a transgenic male mouse model. Proceedings of the National Academy of
Sciences, 115(44). doi: 10.1073/pnas.1807765115
 Amboss.com