Inguinal Hernia (OSCE Guide)

1/03/2020

Inguinal Hernia (OSCE Guide)

Examination of an inguinal hernia is a vital part of surgical examination methods. It is one of the most basics skills that every medical student and doctor should be aware of.

More importantly, differentiating between a femoral and inguinal hernia plays a major role here.

Firstly, introduce yourself and get consent before you proceed to examine the patient.

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INGUINAL HERNIA EXAMINATION

You will be asked to examine the groin area of a patient who is lying supine, but always remember to examine the patient in the erect position as well, at some point in your examination.

1. Get the Consent, cover the area and expose adequately.
2. Look carefully for surgical scars in the groin (Recurrent hernia?).
3. See the shape of the lump in the groin. A direct inguinal hernia is usually globular in shape and an indirect one may be sausage-shaped (inguinoscrotal swellings).
4. Ask the patient to cough,
   • To elicit expansile cough impulse.
   • Inorder to visualize a hernia that cannot be seen.
   • To see the full extent of an already visible hernia.
5. ONLY IF the hernia still cannot be seen, ask the patient where the lump is (It may be a scrotal swelling!!) and ask him to stand up at this point & look for a bulge appearing on the groin area on coughing (Very rare to give invisible ones in an exam setting).
6. Once the hernia is visible, demonstrate the palpable expansile cough impulse.
7. ONLY IF there is no past surgical scar indicating a previous repair, differentiate whether it is direct or indirect hernia.
   • Ask the patient himself to reduce the hernia fully for you.
   • If the patient is unable to do so, ask the examiner whether you may try to reduce it (DO NOT try to reduce without the consent of the examiner)
   • ONLY IF the hernia is reduced,
     1. Locate the deep inguinal ring (2methods can be used).
        • 1 cm above the femoral pulse (Easy way).
        • 1 cm above the mid inguinal point (midpoint between the anterior superior iliac spine and pubic tubercle).
     2. Ask to cough while you are applying firm pressure on deep inguinal ring with your index finger.
     3. If the lump can be controlled by digital pressure over the deep ring, it is an “Indirect inguinal hernia”, if not it is a “Direct inguinal hernia”.
8. Examine the external genitalia to exclude phimosis and coexisting scrotal lump which is very common.
9. If the patient was supine throughout your examination, ask him to stand up before you finish and look for,
   • A coexisting small hernia on the other groin.
   • A coexisting varicocele.

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PRESENTATION

This patient has got a globular shaped lump in the right groin region. It has visible and expansile cough impulse. The hernia can be completely reduced and cannot be controlled by applying firm pressure over the deep inguinal ring. He has got no phimosis and there are no coexisting scrotal lumps. The contralateral groin is normal. So my probable diagnosis is uncomplicated right-sided direct inguinal hernia and I would like to offer him inguinal hernia repair under spinal anesthesia.

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FREQUENTLY ASKED QUESTIONS