Introduction

DefinitionInguinal hernias occur when soft tissue — usually part of the intestine — protrudes

through a weak point or tear in your lower abdominal wall. The resulting bulge can be painful — especially when you cough, bend over or lift a heavy object. An inguinal hernia occurs when tissue pushes through a weak spot in your groin muscle. This causes a bulge in the groin or scrotum. The bulge may hurt or burn.

CauseMost inguinal hernias happen because an opening in the muscle wall does not close as it

should before birth. That leaves a weak area in the belly muscle. Pressure on that area can cause tissue to push through and bulge out. A hernia can occur soon after birth or much later in life.

You are more likely to get a hernia if you are overweight or you do a lot of lifting, coughing, or straining. Hernias are more common in men. A woman may get a hernia while she is pregnant because of the pressure on her belly wall.

Sign and SymptomThe main symptom of an inguinal hernia is a bulge in the groin or scrotum. It often feels

like a round lump. The bulge may form over a period of weeks or months. Or it may appear all of a sudden after you have been lifting heavy weights, coughing, bending, straining, or laughing. The hernia may be painful, but some hernias cause a bulge without pain.

A hernia also may cause swelling and a feeling of heaviness, tugging, or burning in the area of the hernia. These symptoms may get better when you lie down.

Sudden pain, nausea, and vomiting are signs that a part of your intestine may have become trapped in the hernia. Call your doctor if you have a hernia and have these symptoms.

Risk FactorsYou're far more likely to develop an inguinal hernia if you're male. Nearly 10 times more

men than women have inguinal hernias, and the vast majority of newborns and children with inguinal hernias are boys.

Other risk factors include:

Family history. Your risk of inguinal hernia increases if you have a close relative, such as a parent or sibling, with the condition.

Certain medical conditions. Having cystic fibrosis, a life-threatening disorder that causes severe lung damage and often a chronic cough, makes it more likely you'll develop an inguinal hernia.

Chronic cough. A chronic cough, such as occurs from smoking, increases your risk of inguinal hernia.

Chronic constipation. This leads to straining during bowel movements — a common cause of inguinal hernias.

Excess weight. Being moderately to severely overweight can put extra pressure on your abdomen.

Pregnancy. This can both weaken the abdominal muscles and cause increased pressure inside your abdomen.

Certain occupations. Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia.

Premature birth. Infants who are born sooner than normal are more likely to have inguinal hernias.

History of hernias. If you've had one inguinal hernia, it's much more likely that you'll eventually develop another — usually on the opposite side.

ComplicationMost inguinal hernias enlarge over time if they're not repaired surgically. Large hernias can

put pressure on surrounding tissues — in men they may extend into the scrotum, causing pain and swelling.

But the most serious complication of an inguinal hernia occurs when a loop of intestine becomes trapped in the weak point in the abdominal wall (incarcerated hernia). This may obstruct the bowel, leading to severe pain, nausea, vomiting and the inability to have a bowel movement or pass gas.

It can also diminish blood flow to the trapped portion of the intestine — a condition called strangulation — that may lead to the death of the affected bowel tissues. A strangulated hernia is life-threatening and requires immediate surgery.

TreatmentA doctor can usually know if you have a hernia based on your symptoms and a physical

exam. The bulge is usually easy to feel.

If you have a hernia, it will not heal on its own. Surgery is the only way to treat a hernia.

If your hernia does not bother you, you most likely can wait to have surgery. Your hernia may get worse, but it may not. In some cases, hernias that are small and painless may never need to be repaired.

Most people with hernias have surgery to repair them, even if they do not have symptoms. This is because many doctors believe surgery is less dangerous than strangulation, a serious problem that occurs when part of your intestine gets trapped inside the hernia.

But you may not need surgery right away. If the hernia is small and painless and you can push it back into your belly, you may be able to wait.

Babies and young children are more likely to have tissue get trapped in a hernia. If your child has a hernia, he or she will need surgery to repair it.

Exam: Whole Abdomen 08/20/09Clinical DataReports:

Result Normal SignificanceGB intraluminal

diameter2.3cm 4.0cm

GB wall thickness 0.3cm 0.4cmCommon duct 0.2cm 0.6cm

Liver span 16.5Spleen 10.6X5.5cm

Pancreas 2.1X1.4X2.6cmPancreatic duct 0.2cm

Right Kidney 10.9X5.5X4.3cm LWHCortical thickness 1.9cm

Left Kidney 11.5X5.8X5.8cm LWHCortical thickness 1.7cm

Uterus __cmRight Ovary 2.5X2.7cmLeft Ovary __cm

Elaborations: (Abnormal findings/Areas of concern)

The liver is mildly enlarged. Configuration & lobar proportion are within physiologic range. Parenchymal echogenicity is mild to moderately increased. Parenchymal ecotexture is homogenous with no solid masses or cystic lesions. The hepatic are of normal course and caliber. The structure and left ovary are surgically absent. The right ovary is physiologic in appearance. No definite abnormal solid masses or cystic lesions are noted in the pelvic cavity.

The bulging in the right anterior perineal region labeal level is d/t a blind ending saccular structure with mildly echogenic, approximately the appearance of fatty tissue. This finding is also seen in the left, but it is less pronounced. Compression study shows reduction of the herniated fatty lesions possibly emental fat.

Conclusion:>Consider bilateral anterior perineal hernia, labial level, more pronounced in the right composed of non-specific fatty tissue.>Unremarkable GB, CBD & biliary radicles.> Mild to moderate degree of fatty changewith resultant mild increase in liver dimensionsEssentially normal kidneys, spleen & pancreasS/P TAHLSO; physiologic appearance of the right ovary

>structurally unremarkable urinary bladder>structurally unremarkable aorta with no evidence of aneurismal dilatation of significant atheroslerostic plaque formation

Exam: Whole Abdomen 01/08/08Clinical DataReports:

Result Normal ValueGB intraluminal diameter 2..24cm 4.0cm

GB wall thickness 0.10cm 0.4cmCommon duct 0.29cm 0.6cm

Pancreas 2.01X0.81X1.30Pancreatic duct 0.2cm

Liver Span 13.04cmSpleen 8.06X7.97cm

Right Kidney 9.98X3.89X6.47

Left Kidney 9.85X4.13X5.14cm LWHCortical thickness RR:1.06cm

LR:1.30cmRight Ovary Observed by

overloading bowel gasLeft Ovary Observed by

overloading bowel gasAbdominal Aorta 148cm

System/Organ ______

GB, biliary is normalLiver – The liver is normal in size. Configuration and lobar proportion are ____ physiologic range. Parenchymal echogenicity is mildy and diffusely increased with resultant increase alternation. Echotexture in fairly homogenous. No definite abnormal _______ ____ or cystic lesions are seen which the ____ parenchymal. Hepatic veins are non elastic.

Pancreas NormalSpleen NormalKidney Normal

Urinary Bladder NormalUterus The uterus is surgicallyOvaries The uterus is surgically

-observed by ____ bowel-no gross pelvic masses seen

Chemical Chemistry Test 05/27/09 9:59am

Result Normal Value SignificanceGlucose 89 60-110 Within normal

limitsCreatinine 0.6 0.6-1.5 Within normal

limitsCholesterol 219 150-240 Within normal

limitsTriglycerides 143 45-150 Within normal

limitsVLDL 28.6 0-40 Within normal

limitsLDL 139.3 0-150 Within normal

limitsHDL 51.1 30-90 Within normal

limits

CBC 01/08/08 3:18pm

TEST Result Normal Value SignificanceWBC 10.70 4.8-10.8 Within

normal findings

RBC 3.98 4.2-5.4 anemiaHemoglobin 11.9 12-16 Polycythemia

dehydrationHematocrit 36.5 37-47 Polycythemia

dehydrationMCV 92 81-99 Within

normal findings

MCH 29.9 27-31 Within normal findings

MCHC 32.6 33-37 Intravascular hemolysis

Platelet 360 130-400 Within normal

findingsRDW 13.1 11-16 Within

normal findings

PDW 12.5 9-14 Within normal findings

MPV 7.8 7.2-11.1 Within normal findings

Date:October 27, 2004

Operation: Total Abdominal Hysterectomy Left Salphingo – OophorectomyPostop - Total Abdominal Hysterectomy Left Salphingo – OophorectomyTime: 11:55 Ended:1:45Technique of Operation:Epidural Spinal Anesthesia inducted and maintained. Patient was then placed on dorsal spine position operative field aseptically prepared & draped. An intraumbilical midline incision was done on the skin using a knife. This was deepened down to the subcutaneous fat & fascia. Peritoneum was tented & entered. Pathology indentified.

Intra-op Findings:Uterus: Regularly enlarged to 16 weeks. Size A 10X10cm intramural myomatous mass was noted deviating the uterus towards the left. On section, the endometrium is thin and smooth.Cervix: grossly normal Left Ovary: grossly normal; adherent to the fundusRight Ovary: grossly normal Right and Left: grossly normalAppendix: Grossly normal

Urinary Analysis 01/08/2008

MacroscopicResult Normal Values Significance

Color light yellow Straw/amber Within normal findings

Character clear clear Within normal findings

pH 6.4 4.6-8.0 Within normal findings

Specific Gravity 1.014 1.005-1.030 Within normal findings

Albumin Negative negative Within normal findings

Macroscopic (per hpf)WBC: 0-1 0-5 Within normal

findingsRBC: 0-1 0-5 Within normal

findingsEpithelial Cells: 0-2 rare

Bacteria: none rare

Urinary Analysis05/27/2008

Physical CharacteristicsResult Normal Values Significance

Color yellow Straw/amber Within normal findings

Transparency: blazy clear Within normal findings

pH 5.0 4.6-8.0 Within normal findings

Specific Gravity 1.025 1.005-1.030 Within normal findings

01-28-09Reports:

The bulging in the right perineal region/labial level echoes within which approximates the appearance of fatty tissues. This findings is also see in the left, but to a lesser degree. Compression study shows reduction of the herniated fatty tissue/mental fat.

Conclusion:Consider bilateral anterior perineal hernia, labia level, more pronounced in the right

size, composed of non specific fatty tissue.

Ultrasound Report 01/08/08Conclusion:

Normal sized of liver with mild degree of diffuse fatty change.Unremarkable GB, CBO and biliary radicles.Essentially normal kidneys, pancreas and spleen.S/P TAHUnremarkable Structurally unremarkable urinary bladder.Normal abdominal aorta

The Anatomy of HERNIA

The most common location for hernia is the abdomen. The abdominal wall - a sheet of tough muscle and tendon that runs down from the ribs to the legs at the groins - acts as 'nature's corset'. Its function, amongst other things, is to hold in the abdominal contents, principally the intestines.

If a weakness should open up in that wall, and it does not really matter how or why it happened (more on this later), then the 'CORSET EFFECT' is lost and what pushes against it from the inside (the intestines) simply pushes through the 'window'. The ensuing bulge, which is often quite visible against the skin, is the hernia.

These 'windows of weakness' commonly occur where there are natural weaknesses in our abdominal wall - such as where the 'plumbing' goes through it. Examples of these are the canals (inguinal and femoral) which allow passage of vessels down to the scrotum and the legs, respectively. The umbilical area (navel) is another area of natural weakness frequently prone to hernia. Another area of potential weakness can be the site(s) of any previous abdominal surgery.

How do Hernias happen?The wall of the abdomen, comprising muscle and tendon, performs several functions, one of which is to provide strong support to the internal organs which are exerting significant outward pressure. The opening of a gap in the tissue can occur of its own accord at a point of natural weakness, or by over-stretching a part of the tissue. Overexertion can cause it, but so could a simple cough or sneeze.

The occurrence of the gap in the abdominal wall is not normally, of itself, a problem. The problems result from the ensuing bulge of intestine through the gap. The effects felt by the patient can range from being perfectly painless, through discomfort, to being very painful indeed.

Almost every movement we make puts additional pressure on the internal tissues which, in turn, push out through the opening a little more each time. This also enlarges the opening itself. If unchecked, this process can continue even to the extent of allowing much of the intestine to hang down through the hernia.