MRCS Teaching: Hernias



Join Dr. Manic, a surgical registrar from South Mead Hospital in Bristol, in this talk on abdominal wall hernias tailor-made for MRC S level medical professionals. The session will cover both exam-specific content and clinically relevant material, ensuring that you walk away with comprehensive knowledge and understanding of the topic. The main objective is highlighting clinically relevant anatomy, particularly focusing on groin hernias. The talk breaks down the various aspects to consider when dealing with abdominal hernias: history, exam differentials, investigations, and management strategies. The discussion further delves into the anatomy of a hernia, highlighting its components— a mouth, a neck, a body, and a fundus. You will also get to examine various case studies, and participate in Q&A sessions, ensuring that you're well-equipped to handle any hernia-related situation in real-time clinical practice. This course will help you to demystify the concept of abdominal hernias, irregardless of your level of medical proficiency.
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Teaching on abdominal hernias aimed at the level of MRCS.

Learning objectives

1. Learn to identify the key anatomical structures relevant to abdominal hernias, focusing specifically on groin hernias, and their clinical significance. 2. Understand the pathophysiology of abdominal hernias with an emphasis on the main causes and risk factors, including both anatomical and lifestyle factors. 3. Develop skills to assess and diagnose different types of abdominal hernias including understanding the difference between complicated and uncomplicated hernias. 4. Acquire the ability to order and interpret the appropriate investigations for suspected hernias, considering such factors as patient risk, urgency, and cost-effectiveness. 5. Develop a structured approach to the management of abdominal hernias including the understanding of when it is appropriate to resuscitate, investigate, and escalate.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Oh, well, welcome to this talk on abdominal wall hernia. My name's Manic. I am one of the surgical registrars uh currently working with the seven in South Mead Hospital in Bristol. Um This is obviously aimed towards um MRC S level. Um So we will uh cover hopefully what is relevant to the exam and what is clinically relevant. So, learning objectives wise um to familiarize yourself with the clinically relevant anatomy uh especially for groin hernia. Um and that is a topic that comes up quite frequently in the M RT S. Um It is easy to test because there's a lot of uh both uh anatomy and technical factors as well as just how people present clinically. So hopefully it will be useful in your day to day jobs as well. Um And consider the following with regards to abdominal hernia. So, history exam differentials, investigations and management and I like to think of management as um in terms of answering exam technique, a lovely way to start would be say my, my goals here are to resuscitate, investigate and escalate appropriately. Um And that buys you time at the very least. Um It's generally the answer to any emergency. Um And we can put together all this knowledge, uh build it up into understanding and finally you can apply it. Um So it's again, MRC S, any exam. Uh It's really important to have definitions if someone asks you what is a hernia, um you should have a very generic general answer just at the tip of your tongue. So uh what I like is the protrusion of tissue through a defect in its containing cavity. And uh a couple of things can be added. So some people talk about it in terms of protrusion of a viscous or part of a viscous, that being said it can be just fat that's come through a hernia defect. Um So I think tissue is a, a good gene general term um and through a defect in its containing cavity, and you could add in a normal or abnormal defect as well. So, for instance, a hiatus, hernia that is through a normal defect uh in the abdominal cavity. Uh You get the, the, the diaphragmatic hiatus. Uh obviously, things aren't things that are not meant to go through it. Um For instance, you know your stomach uh through your where your esophagus comes through. Um However, that that's an additional thing you could add. Um and then you can break it, break it down by site. So, groin, uh ventral, which just means anterior abdominal wall, really uh pelvic and posterior abdominal wall and um lots of people haven't heard of posterior abdominal wall, hernias, thankfully, they're quite rare. Uh, but we'll cover those as well briefly. So, uh, again, now talking about hernias in general, a hernia has a, a mouth, a neck, a body and a fundus. Um, and that is the anatomy of the hernia within itself. Um, the other thing that I think it, it's important to appreciate is that abdominal hernia have a peritoneal sac. So, or when you get a hernia through the abdominal wall, the peritoneum, which lines the inside of the abdomen, uh we also, it'll come out in layers and finally, you'll have uh like a little balloon like sac uh which surrounds everything. And it's important from a technical point of view, uh how you fix it. Um Then the other thing to clarify is whether hernia is complicated or uncomplicated. Um So again, definitions are important here. So, uncomplicated hernia uh are generally reducible. So you can push it back in, into the cavity. It's meant to be in uh you get a transmitted coughing pulse. So when someone coughs, they get a rise in transient, rise in intraabdominal pressure, uh which then gets transmitted to your hand uh when they cough. So you feel it, uh they are tend to be asymptomatic and non tender uh complicated her. On the other hand, maybe uh irreducible. So you try to push it in, you can't. Um And that's usually because it's been out for, it's got stuck. So it's got, got to the point where it's, there's too much of it to push back in. Um, and the other things to note are whether it's obstructed or strangulated and, or strangulated. So these definitions are important. So, obstructed is only really in the context of bowel. So if there's bowel in it and they put a bowel obstruction on the back of it, then that is a obstructive hernia. Uh You don't use obstructed hernia in any other context. It's, it's in terms of bowel obstruction, it's the third commonest cause of small bowel obstruction, um, strangulated. On the other hand, is could happen to any tissue. Uh It might be bowel that's in it might not. But the, the key is that what's happened is the contents of the hernia have, um, because usually because it's been irreducible, uh has led to venous or has got swollen. Uh, venous congestion is usually what happens. And eventually that leads to a lack of arterial, well, blood supply, capillary inflow. Uh and that uh is called ischemia. If you get uh, ischemia of the, of the contents, what you normally get is redness, uh very tender, uh, swelling and, and, and the answer is both of these things usually require an operation unless you can push the contents back in. So, uh for those who are here at the moment, uh, there are some questions via ment timeter. Uh So we will uh, give you a moment to uh use the QR code to get in on that and then I will change the presenting tab uh so that you guys can answer questions. Yeah, if you, I just on the chat, if you could make a note when you've um when you've got onto the meter, it would be useful just to share that. Otherwise we can, we can just use the the usual, right? So I'm not gonna get an answer on the chat. So we'll, we'll just use what I've written before. So question number one, the most common hernia in females is which of these? And I can, we, we'll come back to having spoken about it. So even if you don't answer here, that's fine. Let's see people. OK. Actually, let's just stop presenting a second cause people are answering. So a tab meantime, there you go. Hopefully you can see that now. Perfect. OK. So a few different answers there and that's fine. Uh We will go to the next question. Not one of the, which of these structures is not one of the borders of the Femoral Ring. Two people think that is the England alignment. Fine. Uh Hopefully we can see more on there. So let's see if people can answer this. We'll come back to answer these questions fully. But I'd like to know what the people who are logged in at the moment and what they think before we talk about these things. I'm not seeing any answers. But the, the so I'll just read out the, the question if you can't see it. So, a 40 year old woman presents to her GP with a lump in the right groin, which has been present on and off for a few months, but it's now persistent. No other symptoms of note on examination. There's a grape sized lump below and lateral to the pubic tubercle lump is not tender. There is no cough and belt be. What is the most likely diagnosis? So, you've got incarcerated, femoral hernia, incarcerated inguinal hernia, obstructed, femoral hernia, a strangulated femoral hernia in the senno pax. No answers. So we'll skip through to that for the next question. Uh which is, you know, the on call surgical fy one, Doctor Clark, a 37 year old man with a severely tender lump in his left groin. Uh He's an IVD U is associated with nausea and vomiting is pyrexial and tachycardic. The lump is natural and inferior to pubic tub. It is irreducible, fluctuant PASAT and the overlying skin is erythematous. Which of the following do you write in your management plan? So one person's suggested we initiate sepsis. Six, you can do well, there's a couple of correct answers here. Uh Everyone's a bit shy to, to try that one. which uh So this hernia has two parts, either each line, either side of the inferior gastropar. So we've got an answer here but pantaloon hernia, fine, fair enough let's go back to the uh slide. Perfect. All right. Well, what I can suggest from that is that when to be honest, we'll uh having talked about this, I suspect some of you will change your answers. Let's see. Um So the basics of inguinal anatomy. So, understanding this will lead to understanding groin hernias generally. So, um this is AAA nice sort of schematic of it. So the inguinal canal is actually a potential space. It is in men. Uh the testicle started in the abdomen, the gubernaculum dragged it down, dragged the testicle from the abdomen into the scrotum. And the path it took is basically the inguinal canal. That's a nice thinking about it. So it's, it's a space which has borders. Uh but those borders are uh what the borders will define how the, how you approach the uh fixing it technically. Um So in front is the external oblique aponeurosis. So that starts with muscle on the, on the lateral border of the uh abdominal, what's the lateral abdominal wall uh thins out and becomes an aponeurosis. Um and it conde that apsis condenses into what is the inguinal ligament. So it curves round and that forms the floor to the bottom of the inguinal behind the inguinal canal is the con joint tendon. So that is medially, the conjoint tendon. The conjoint tendon is, is basically a a condensation of the internal oblique and transverse abdominis, which is otherwise when you go more lateral is the lateral is the posterior border of the inguinal canal. Um And in the inr is the uh systematic cord in men. And it basically follows that line from the deep uh from the deep ring to the superficial ring. So that's the entrance of the spermatic cord into the, into the abdominal wall, into the inguinal canal. And it comes out of the superficial ring and then carries on down to the, the scrotum. Uh You've also got some anatomical landmarks which we'll talk about surface anatomy, some vessels that uh define the deep R and the superficial. So uh clinical case number one. So uh a 70 year old man has a background of CO PD and he continues to smoke and he's got uh B PH uh I think which he is on medical treatment for. Uh and it, when it comes to exam questions, II mean part B is also when you're being tested you or, you know, be able to have an open conversation whereas an MC, everything in front of you on paper, but they don't usually give information that is extraneous. Um So the relevance of the CO PD and the B PH is basically straining. So when CO PD, you cough a lot and that will lead to transient, rises in intra pressure, uh which can lead to hernia, same with B PH. So straining uh to pass urine, uh the previous open appendicectomy. Uh There is a suggestion that uh having an open appendicectomy may affect nerves in the uh an adominal wall which lead to weakness and may lead to hernias in the groin. Uh He's an active gardener. So again, he's presumably doing heavy lifting for instance. And he's referred by his GP for uh right, groin swelling, swelling disappears on lying down. So that suggests it reduces by itself and a testicular examination is normal. So your differential diagnosis could include all of these. Um by far, the most common is an inguinal hernia. Uh And we'll talk about whether direct or indirect is the underlying cause. But w when you think about it, it could be inguinal lymphadenopathy, cryptorchid testes. So that is why examining the testes uh is important. Uh a lipoma uh which is a fatty lump, uh nothing more complicated fe arterial is, is generally unlikely but obviously to be considered especially in intravenous drug users. Um s in Avax, which is a varicus vein um of the um uh well, the the vessel, the sa vein, the great sa um and the c abscess and hydrocele hydrocele being usually a a surrounded testicle, but uh that can be also be in the groin. So this is what matters really for exams usually uh and also just for general examination. So the relevant landmarks to be aware of uh guide whether it's likely that the inguinal hernia is um direct or indirect. So, first thing is the uh anterosuperior iliac spine. Uh which is uh the most lateral point. Uh and then your pubic tubercle which is medial. And what goes between those two things is the inguinal ligament uh which is remember the condensation of the internal oblique aponeurosis at the midpoint of that is a landmark called the midpoint of the inguinal ligament. So that's fairly straightforward and that is where you have your deep ring. So the entrance of your, the intraabdominal entrance of your um uh inguinal canal, uh then you have something called the mid inguinal point, which is uh the point between the aces, the anterosuperior iliac spine and the pubic symphysis. So that's medial to the, that's the right and the midline. So um medial to your pubic tubercle. So the midpoint of the in ligament is uh the, the mid inguinal point is between the ass and the pubic synthesis. And that is where you get your inferior epigastric artery. So to put it simply the deep ring is later right, natural to the knitting part. I hope that makes sense. Uh And this is a demonstration of that just with the pelvis. So, malignant point, pubic synthesis to asy midpoint thing with pubic tubercle to ASIS uh hassle. So the the reason this is relevant is you can judge whether someone has an indirect or indirect inguinal hernia uh as an indict hernia follows the line of the pubic uh oo of the inguinal canal. So it starts at the deep ring. Whereas a direct inguinal hernia comes out at uh hassel back's triangle and Hassleback triangle is, is demonstrated here. Uh that is uh bordered by the rectus abdominis, the lateral border, the rectus abdominis, the inguinal uh ligament uh and the inferior gastric vessels which if you remember uh mid the little point. And that is to say that uh direct inguinal hernia breaks through that, that area of weakness in Hassleback triangle and, and protrudes out of the superficial inguinal ring uh which is just uh medial and above the pubic tubercle. Uh And this is, this is what you get. So um a nor well normal patient, a patient without a hernia, you have the inguinal canal and the infer the inferior gastric vessels. Hi, when someone has an indirect inguinal hernia, you get uh the start of the hernia being at the deep ring, which is lateral to the pediatric vessels follows the root of the uh pubic of the inguinal canal and projects through the superficial inguinal ring as well. So it can uh make its way down into the scrotum. Um a direct of the hernia as you can see in the, in the other picture projects through the uh abdominal wall and nasa back angle uh medial to the epigastric vess. Uh And this is, this is basically a summary of all that and and actually indirect hernia are the commonest in both men and women. So it, it's a via the normal um uh defect in the abdominal wall, which is the deep brain follows that. Uh and it is more common in males than females. However, it's still the commonest in, in both categories. Uh A di ting, a hernia is usually uh a bulge in, in elderly men, usually fat containing, uh sometimes contains bowel, but it comes through a normal defect. So how do you examine knowing the anatomy? Uh You can find, uh using surface anatomy, you can find the deep ring which is to reiterate at the midpoint of the inguinal ligament. Uh and close that well, feel for a hernia. So you get them to uh stand up, turn their head away and cough while your hand is on there and you might feel a transmitted coughing bells. Uh You check if it's reducible and if it's reducible, is it reducible through that through the deep brain? Or does it, can you just reduce it through uh just the whole groin, which would suggest that it's a uh uh coming out by Hassleback triangle. Uh If it's an enterocele ie containing bowel, it might gurgle. Uh And if it's an ao sele, which just means it contains omentum or just fat, uh it is more likely for globular. Uh And if it's in England or scrotal, you, you can't get above the lump. So, if you, if you feel the um uh a common question is, oh, well, uh how do you define a, a hernia for dis swelling that, uh, say a hydrocele. And, uh, for a hernia, you, you have to get all the way up to the groin to get above it. Uh, whereas a hydrocele is usually contained, uh in the scrotum, other types of hernias, you can actually get both at the same time, a direct and an indirect hernia that would be called a panto hernia. So it's a natural concurrent, direct and indirect inguinal hernia. So I can see a few questions and some quite complicated ones. I think I'm gonna her a communist in both sexes. Correct. Yes. Uh Our femoral hernia is more common in females than men. Correct. Well, so you have to remember. So it's a bit of a trick question. So if someone says, what's the commonest hernia in women, the answer is an indirect women hernia just like it is for men. However, when you compare men and women, men, uh women have a, it's a 10 to 1 ratio of femoral hernia, wo women tend to get femoral hernia. Uh When counseling a patient, a pregnant person who wants an elective C section, that what would you say is a POSTOP risk of an incisional hernia, postpartum. Uh I am, I'm not sure about that. That is way beyond the scope of MRC S. Um However, it would be, I mean, you would consent them for the risk of incisal hernia. But it's to be honest, I it's ha I personally haven't seen that many of those. Um And that would, yeah, II wouldn't, I wouldn't consider myself off about that at the moment. Fine. So moving on, uh clinical case number two, so a 52 year old female uh has had a recent intentional weight loss uh and is par. So again, if we're gonna go through this, uh thinking about why they're giving you the information. So a 52 year old female is uh usually perimenopausal. They're a female just going off. Um What we were um discussing just a second ago from the question from the audience. Recent intentional weight loss or hold that thought will come back to why that's relevant Marty Paris. So they have had several Children tens A&E with a tender right, groin lump, uh vomiting, abdominal distension and absolute constipation for the last two days. Um Right. So clinically, um what does that suggest? It suggests that they've got a small, well, they've got a bowel obstruction. So you've got the cardinal features of a bowel obstruction which are vomiting, abdominal distension, uh usually pain and absolute constipation, meaning that they are not passing plat or stool. Um On examination, the lump in the groin is irreducible. The lump is below and lateral to the people too. So there you go. So going back to anatomy, which is really what this is about the clinical diagnosis are instructed from her. This is the femoral triangle. It's a subsartorial space in the upper medial third of the thigh. Uh and it is bordered by the sartorius in ligand and the adductor longus. Why do we care? The contents are there on the other side of the other picture? Which is the uh femoral nerve artery and vein. Uh and the uh femoral ring or the femoral canal. So easy way to remember is from lateral to medial navy. So nerve artery vein yb um and the femoral ring is uh relevant here. So the Femring is an opening into the femoral canal. The femoral canal uh doesn't contain much. It contains fat and a lymph node or some lymph nodes. One of them, in particular called the lymph node of Cloquet. And why we, why that, why it's relevant. It's the opening of the femoral canal, which is where you have this potential space for hernias to enter and that's called the femoral hernia. Uh It's particularly tight. Uh Why is it tight? Because three of the four borders of the femoral ring are um ligamentous. Uh Only the femoral vein is nice and soft. Otherwise you have the uh inguinal ligament, anterior pectineus ect ect a ligament uh posteriorly, the lacunar ligament medially and then we've got femoral vein. So if something gets in there, uh the only thing that's kind of compressible is the vein. So if, if something gets stuck, then it's hard to get out. Um Why is that? So just going back to that question. So recent, intentional weight loss. Um Remember what was in the con what was the content of the femoral canal usually fat. Uh So lose the fat in the femoral canal. Potential space, things can drop into it. Um And it does tend to be post menopausal women, men who present with this kind of thing. Uh Right case number three. So for 26 year old male, they're obese. Um they have had a long standing lump just above the umbilicus which has become tender and irreducible. There's erythema of the lump and they are systemically. Well. Uh and the bowels are open or so, what are we thinking here? Um Real. So they've got, remember what we discussed at the start. So he has a strangulated hernia. Um And that just means that uh it's lost its blood supply. It is reassuring that he remains systemically well. And his bowels are normally. However, you've gotta be a bit cautious. You can't rule out the fact that there's uh that it's only fat in, in the hernia. It might be that he's got uh some bowel in it. Uh And he's got something like a Richter's hernia if you've heard of that, so that we'll show you a picture later on, but there, it just means part of the bowel is in it, um and might be compromised, uh but not enough for it to cause an obstruction. So, initial investigation management, uh pretty straightforward stuff. So, anergies and antiemetics, uh usually they blood in can uh keep the mil by mouth if they're gonna end up having an operation, if they're clinically TED and NG two, sometimes, especially if you grow a bit more. Uh Right. It's simply a or you might be able to reduce it easier. Um If there is evidence of strangulation, uh usually um and then discuss whether they need imaging and definitely escalate to see you if, if you think they, they need an operation. So, reducing a hernia is one a judgment goal. So if you've got a floridly very clear cut, um strangulated tissue, uh then you'd question whether pushing that back into the abdomen is just going to make them worse. Uh in terms of physiologically, they might become more unwell. Um However, if it's, you know, just being stuck for a little bit and, and A&E haven't been able to push it back in, there's no reason that we can't try it because that would get them out of trouble and then they can have a outpatient repair sort of semi elective basis. Uh How do you do it? Uh a lot of it is a bit of a, it's a bit of an art. So you, you need to calm everything down. Uh These patients tend to be quite worried, obviously, um and worrying and being stressed will lead to them tensing up their abdominal musculature, which makes pushing in a potentially uncomfortable hernia harder for them and harder for you um, so you just need to, you know, get them to chill out, lie down flat and warm up your hands so that they're not jumping off the bed. But if you've got cold hands, lots of, you know, you can give them a shot of them off just before, uh, you let that kick in and then just get gradual. It's not, it, it is pretty obvious when it has gone back in. Um, But you can, you got to sort of take some time, try and push it, massage it in, especially if it's a uh indirect hernia, then remember that it's coming out, it's coming along the whole inguinal canal. So you need to push in that direction. And that's why, again, that's why the anatomy is relevant. So you understand how to manipulate this kind of thing. Uh So summary of risk factors for, for hernias. So, in 22 broad categories and, and it's a good way of answering questions is being able to categorize. So if someone asks you, what are the risk factors for, for developing an abdominal wall, hernia, increased intra pressure and weakness of the musculature. So lots of things can increase intra abdominal pressure, chronic cough, straining, uh for whatever reason, um uh ascites and uh tumors on the inside weakness of the musculature. So the damage to the collagen uh with just age smoking, um local nail damage, like we discussed with previous open appendicectomy on the right side and having uh organic connective tissue disorders such as X animals. So how do you electively when you see these patients in clinic, how do you manage it? So the ideas are the, the the initial thing is essentially health promotion. So, improve that tissue health, nothing is going to there. It's not a cure for hernias to tell them to do these things. However, it might set them up for a future operation in a better state and minimize the risk of complications including recurrence of the her. So, um yes, these are, these are not cures for the hernia, but we stop, it may stop it getting bigger. And uh there's a, there's a quote here. So most emergency operating in future neglected elective operating room um at a slightly higher level. Uh a lot of it is to do with when you see a patient in clinic uh with a hernia, uh which is otherwise uncomplicated. The, the biggest thing is how is this affecting their quality of life? Uh And that shouldn't be documented and very much sort of the reasoning for whether you operate or not uh alongside whether they're fit for an operation, of course, but um you should have that very clear what the goals of this are. Hopefully to alleviate any symptoms, obviously fix the anatomy. Uh But there is a risk of them still having discomfort in that area or just not being happy with the results. So, the nuance of that is important. So that brings us on to the operation. So complicated hernia or those of the narrow neck, for instance, a, a femoral hernia uh should be surgically repaired. Um So uh a femoral hernia, like you said, tend to tend to get stuck faster or, or they, if you find an incarcerated femoral hernia, um you would generally recommend an operation on an urgent outpatient basis unless they are, you know, really in pain and we've seen them on call might fix it um as an emergency. Um And the basis of any hernia repair to have minimal tension. So you don't want to the edges of what the hernia defect was to be pulling apart and trying to recur basically. And these are some sort of broad definitions. So herniotomy opening, excising the hernia, sac hernia roughly is a suture repair and hernioplasty is a mesh repair. Mesh has become much more common one day. So if we're going to stick to inguinal hernia, hernia, and femoral hernia, so, inguinal hernia, there's a few different repairs. So there's Lichtenstein tension free repair or modified Lichtenstein because I'm sure we're doing things slightly differently from what when it was first described. Um But it is, the concept is trying to get into theater and see these, uh they take a little bit of time to get your head around. But again, it is down to appreciating anatomy and then being able to translate it in, in real life. So it's a, it's a lovely operation when and done nicely where you see all the anatomy you um identify the tissue that's, that's herniated, push that back in and you sort of buttress the abdominal wall with a mesh polypropylene mesh, um, a shoulder repair. There's tissue repairs. So there's the shoulders technique. Uh, there's a shoulders clinic in the US where they do this and, and that's, that's very anatomical. So you're finding each layer of the abdominal wall and putting it back together with stitches. Um And then now you've got laparoscopic repairs as well. So there's the tap and the tap. So the tap is a franz abdominal preperitoneal depend. Uh Again, these things are unlikely to come up in your MRC S the details of it. But you should be aware that there's open and laparoscopic methods. And nowadays, there's robotic methods which are essentially a um the same as a laparoscopic in terms of approach. Um a femoral hernia uh can also be managed in different ways. These uh e eponyms might come up. But you can just say low approach in low approach and high approach. Uh The relevance of the high approach is that you generally do that when uh it's an emergency and it's stuck. And you're worried that there's an important, there's bowel, for instance, that's stuck in which and the high approach just means that you essentially do a little laparotomy via the, the groin, enter the abdomen enter the peritoneum and pull out the hernia and do whatever you need to do in bowel resections via the groin. Uh And that they, these can also be fixed laparoscopically. Um And I got a few pictures later on. There you go. So the laparoscopic approach, the idea is arguably there's better cosmesis uh because you have two laparoscopic incisions and no big incision in the groin. Uh And there is some evidence to suggest that they might return to work sooner as well as this idea that there is, um there are lower rates of chronic pain and that's something we'll talk about in a second. Um And especially if they've got a bilateral, so bilateral groin hernias. Um you, it is recommended in fact to do laparoscopic repairs because you can fix them. Uh You can fix both sides uh via the same operation. So you don't need two groin incisions, um, recurrent cases as well. So if they've had a previous laparoscopic repair and that they've got a recurrent hernia, then the idea is that you do an open repair, uh because you're going through new fresh tissue, which isn't scarred and the opposite history. If they had a previous open repair, you might uh offer them a uh laparoscopic repair. And again, the anatomy, you can see some pictures here uh is relevant. So it's, it's a bit confusing because it's kind of the opposite, you know, you're seeing things from the inside. Uh But it's, it's a, it's a nice way of appreciating the anatomy from different views. Uh, which just means that you're, you're really familiar at, which is a totally extraperitoneal repair is a very interesting operation, um, because you never enter the abdomen. So you, you enter, you put this balloon into the, uh, uh, retro rectus space. So you're, you're staying, uh, in front of the, uh, in front of the posterior sheath. Um, and you do some dissection with this balloon, make space and then it's, it's laparoscopic and that you've got some gas insulation, but you're, you're fixing the hernia and within the abdominal wall, hope that makes sense. You might have to, there's some good videos on youtube. Uh So, complications. So again, uh in terms of answering questions, uh uh it's important to have a structure. So you, you might talk about uh intraoperative complications, early and late. Um And intraoperative complications might include bleeding. That's the main thing. Um And for example, aberrant arteries. So sometimes the lacunar ligament, which we talked about, which is kind of the medial um medial border of the femoral hernia defect, um sometimes contains an aberrant obturator artery and you might put a stitch through that and cause some bleeding. Uh you get early and late. So early uh postoperative might be a recurrence. So I say medial because that's where they tend to come. Uh And so from a technical point of view, we talk about having good medial coverage uh with the mesh. Um So that, that, that's the, the highest, uh the point of the, the highest chance of recurrency is covered, uh hematoma or seroma. So, seroma is simply sort of tissue fluid, inflammatory fluid that builds up usually and it'll occur in almost every operation because that's, it's tissue fluid that your body overproduces and fills up a space. They tend to not be if they, they might be uncomfortable. And as long as they're not um really big or infected, you tend to leave them alone and your body reabsorbs them uh infection. Uh and including mesh infection and, and remember that mesh is for a body for all intents and purposes. Uh And you've got to be cautious about um uh infection here because uh antibiotics, they can fes though because antibiotics might not work uh as well as it with uh your their own body tissue. Uh urinary retention fairly well, it might happen again, you're, you're digging around in the groin. Um They usually get a catheter uh if need to be and they can come back a few weeks later for a talk. Uh late postoperative um complications include testicular atrophy. So you might get uh damage to the testicular vessels during the dissection which leads to uh ischemic atrophy, basically, uh chronic pain, supposedly up to one in 10 patients. Uh And that's important to counsel patients about preoperatively. Um uh There's that up to one and 10 is what the evidence suggests. Um And you can get hydroceles um afterwards as well. Uh So more kind of eponyms and weird and wonderful. So, um there are different funny types of hernia. So Mandel hernias where you get this, as you can see in the picture, W shaped a double loop of loop of bowel herniating. Ali's hernia contains Meckel's diverticulum arm's hernia contains appendix uh with or without inflammation. Um They're quite interesting. They're almost, they are exclusively on the right side, obviously, because that's where you get your appendix. Uh Richter's hernia, which is we touched on briefly where you get only part of the circumference of the bowel in the hernia and therefore, you can get strangulation without obstruction. So there's still a lumen for things to get through. Um But you have this uh the wall and the bowel uh stuck and you know, eventually that if it is truly strangulated, it can uh necrose perforate and then you're, you've got a true emergency. Uh Spigelia has a a hernia defect in the linear semilunaris, which is the lateral lateral border of the rectus abdominis or where the uh internal uh the, the external oblique, uh the the oblique muscles fuse the aponeurosis fuses with the anterior posterior sheath. Uh And then you've got other things, it, the pantaloon hernia where you get concurrent ipsilateral and indirect inguinal hernia, uh sliding hernia where you part of the hernia sac is made up of a viscous. So, uh like I said, you normally get a peritoneal sac. Uh But when you get, uh and that's why it's important to understand uh the sort of peritoneal attachment and the peritoneal relations of different organs. For instance, the bladder can make up part of a hernia sac because it, it doesn't have a peritoneal covering in some, in uh some aspects of it. And an obturator hernia comes down through the obturator canal which is in the pelvis. And that again is more common in women. Uh And a significant point in the history taking is medial thigh pain. So you get a burning medial thigh pain because of um, the nerve being irritated, irritated, other weird and wonderful hernias. Uh Again, people aren't really aware of these kind of things because they're relatively rare. You can get gluteal hernia and sciatic hernia which come out through the sciatic foramina. Um And other funny ones, lumbar hernias, Greenfeld hernia and petite hernia. Again, this is very interesting, certainly, uh incredibly unlikely to come up in uh MRC S. Um So if we actually go back to, ok, that's a good idea. Let's see. No. Yeah. Yeah. Close. Um Right. If we go back to the mm um Sorry, that's my son in the background. Um So if you go back to the um um stop presenting, you know, back to the temperature change the other one. And let's see what you guys think. Now, I wonder if you can try again. So most common in females, I don't know if this has kept your old answers. The answer here is an indirect, the hernia because that is by far the most common, 75% of all uh abdominal wall hernia are in and of those significant proportion are indirect. And, and the tripping up point here is that um people think femoral because that's what they think women get and they certainly do get it compared to men but not, not in the grand scheme of things. Uh which of these uh structures not form on the border of the femoral. So the answer here is the lymph node. Ok. Uh That is uh within the femoral canal which the femoral ring is the entrance of uh all the others. Uh The three ligaments of the femoral, they are uh make up the femoral ring. Uh This one. So um my answer here is an incarcerated femoral hernia. So why is it incarcerated? So, it's a lump in the right groin present on and off for a few months. So it sounds like it's been going in and out, but it's now persistent, it's stuck. So there's no other symptoms. So it's, it's a painless nontender lump which is irreducible and it's below and lateral to fever tubercle is that's where the surface anatomy of where you get from the hernia is. Um Whereas an hernia usually will pop out uh in hernia especially will be uh medial and uh above the pubic cubicle. Whereas the femoral hernia is below and lateral, non tender, there's no cough and bowel. And I suspect what catches people out is this no cough and pulse? And remember that if it's incarcerated you and irreducible uh which are the same thing. Um You don't necessarily get the um intravenular pressure transmitted to your hand to feel. Um Whereas in reducible ones, you almost in indefinitely do. So this one. So Uncle Surgical F one, this so a man seve at 10 L in the right one is IVD U. So immediately alarm bells should be ringing about abscesses and pseudoaneurysms which is um which can happen due to repeated injection into the femoral uh vessels, uh femoral artery, um no per tachycardic. He's got a uh systemic inflammatory response. Uh gotta assume infection. Um So initiates sepsis. Six. Absolutely. The right thing to do. Uh The lump is laterally inferior to the PT. Uh it is irreducible, fluctuant. Fluctuant is a concern and that would suggest it's got liquid in it. Uh pulsatile, very concerning, isn't it a vessel? And the overly skin is erythematous. So, you've got uh significant inflammation which of the following D management plans, initiate sepsis. Six. Absolutely. Consider imaging. Absolutely. Uh This patient would like to get a CT angio uh to look for any involvement of the vessels. It might simply be a abscess. Um uh but it, you have to be sure that it's not a pseudoaneurysm. You certainly don't admit antics and you certainly don't incise it, uh, because it'll bleed everywhere. Pseudoaneurysm and you don't organize the, for a, uh, hernia repair. Um, I think, sorry, there's one more question in there. I will share that again. Share a tab. Uh Next question was, yes. Hernia has two parts each line, each side. Yeah. So, very big scar. So pan hernia is concurrent in direct and direct hernia, which is quite right. So stop sharing that, go back to the slides find where we stopped earlier. Yes. So these are the, the same questions we answered. So hopefully you guys have picked up on all of this. So the clinically irrelevant anatomy, um important point in the history, the examination, especially in the context of the anatomy and surface anatomy differentials. We've talked about investigations pretty straightforward in an emergency setting. Um and management. So remember to resuscitate, investigate and escalate as necessary. Um Thank you very much for coming. Uh And I've got a few more questions I think in the chat. So here we go. Uh going through the abdominal muscles do direct hernia have higher rates of obstruction, strangulation is compared to indirect. Um Good question. Uh The answer tends to be no. Um, they tend to be wider necked. Um because if you think it's punched through the um through weak muscle, whereas indirect hernia tend to because they enter the deep brain, the deep brain might widen, uh, but it still follows this, the path of the inguinal canal and they tend, they do, tend to complicate, uh, a bit more commonly. Uh, and then you've got a patient that's unwell with a hernia and you have clinical suspicion that this patient would likely go under the knife later. Would you consider antibiotics, even if not subject? Uh, no. So if, if there's evidence or concern that they have the strangulation, uh, then, absolutely, yeah. Um, obstruction, not so much really. I mean, obstruct these patients tend not to when, if you get a bowel obstruction from a hernia, uh, unless you have compromised bowel within it, uh, you tend not to need antibiotics. Really? Uh Thank you. Uh Do you mind going back to explain the question that included sepsis six as an option? Sure. Um, so I will, I think it's that one. Um, what's your specific question about it? Ahmed. I'll give you a couple of minutes, I think in the context of, yeah. So multiple current counts, current answers are C and E consider imaging. Initiate se six. Obviously you would escalate definitely unwell uh, person with a, something that's gonna lead to an operation, but it's important to important to clarify the, um, what the underlying pathology is. So, don't assume it's a hernia just because it's a lump. You've gotta look at it in the context and this is this, he doesn't really for all intensive purposes. This chap is unlikely to have a hernia, he's likely to have either an abscess, um or a pseudo and, or, or a pseudoaneurysm. All right. So I think, sure. So, uh please go back to your hernia slide and explain the significance slash how you'd repair slash, manage different uh isolated. Uh Sure. I mean, you don't really manage it particularly differently. These people tend to have big old, uh I'll just get that thing that you have. So this one is the final question. Let's see. It was. Yeah. So they tend to, to be honest, a lot of these patients are um um older patients and a lot of their, sometimes the whole back wall of the inguinal canal has kind of been chewed up. Uh So and they, these two hernia become one, um one big hernia in the groin. Um And therefore it's a bit academic, but it, it's important to appreciate that this at least follows anatomical concept. So we've got a standard indirect hernia and a standard direct hernia. They just happen together at the same time. Um A mesh repair would cover both these defects. So you'd dissect out the, the sacs of each, push the hernia back in. Uh You can put a few stitches just to keep everything in while you're putting the mesh on top and the mesh should uh incorporate and fix the hernia. Um So that pretty well. But again, we have to remember to counsel people stop smoking, you know, try and reduce their straining. So you can make sure that they're, you know, taking appropriate medication for their CO PD or uh B ph uh stop smoking. Uh No heavy lifting while things are healing, but these are all just to minimize the risk of recurrence. Um If that is the goal. Great, cool. So thank you for coming. Uh And if you watch this uh back on demand, I'm sure the guys at the Southwest Foundation trainee Surgical Society will keep it up for a while. Um Any questions you can send me a uh an email or a tweet or whatever. Uh I'm sure these guys will give you my details. Um Thank you, have a lovely weekend and good luck for the exam if you're sitting too.