Expansion
Examine standing and lying, with a cough impulse and reducibility
Expansion
Examine standing first, since many hernias reduce on lying down and are then invisible.
- Look: site, size, scars, overlying skin, and the effect of coughing and standing
- Feel: temperature, tenderness, consistency, and whether you can get above it, which distinguishes an inguinoscrotal hernia from a scrotal swelling
- Cough impulse: an expansile impulse indicates a communication with the peritoneal cavity. It is absent in an incarcerated or strangulated hernia, which is the point of testing it
- Reducibility: ask the patient to reduce it themselves first
- Deep ring occlusion test: reduce the hernia, occlude the deep ring at the mid-inguinal point, then ask the patient to cough. Controlled suggests indirect, not controlled suggests direct. The test is unreliable and the distinction is usually made at operation
- Auscultate for bowel sounds within
- Examine the other side, the abdomen, and the scrotum
Anatomical distinctions
| Inguinal | Femoral | |
|---|---|---|
| Relation to pubic tubercle | Above and medial | Below and lateral |
| Sex | Commoner in men | Commoner in women |
| Risk of strangulation | Lower | High, narrow neck |
Signs of complication
- Irreducible (incarcerated): cannot be reduced, but still viable
- Obstructed: colicky pain, vomiting, distension, absolute constipation
- Strangulated: tense, tender, irreducible, no cough impulse, overlying erythema, systemic upset. The blood supply is compromised and this requires immediate surgery
- Richter’s hernia: only part of the bowel circumference is trapped, so it can strangulate without obstruction, which makes it easy to miss