A 59 year old male weightlifter presents to ED with a painful lump in his groin. Your consultant determines that he most likely has a direct inguinal hernia. Where would you expect the hernia to emerge:
An inguinal hernia is the protrusion of a peritoneal sac through a weakened part of the abdominal wall in the groin.
Hernia | Indirect Inguinal Hernia | Direct Inguinal Hernia |
---|---|---|
Aetiology | Congenital – patent processus vaginalis | Acquired – weakened abdominal musculature |
Mechanism | Peritoneal sac herniates through deep inguinal ring | Peritoneal sac herniates directly through posterior wall of inguinal canal |
Relation to inferior epigastric vessels | Lateral to inferior epigastric vessels | Medial to inferior epigastric vessels |
In indirect inguinal hernias, the most common type, the peritoneal sac enters the inguinal canal by passing through the deep inguinal ring, due to a patent embryonic processus vaginalis. If the entire processus vaginalis remains patent, the peritoneal sac may traverse the length of the canal, exit the superficial inguinal ring and continue into the scrotum or labia majora.
In direct inguinal hernias, the peritoneal sac passes directly through the posterior wall of the inguinal canal. It usually occurs when abdominal musculature has been weakened, in older men, following surgery or due to persistent raised intra-abdominal pressure. This type of hernia does not traverse the inguinal canal, but may still exit the superficial inguinal ring to enter the scrotum.
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Biochemistry | Normal Value |
---|---|
Sodium | 135 – 145 mmol/l |
Potassium | 3.0 – 4.5 mmol/l |
Urea | 2.5 – 7.5 mmol/l |
Glucose | 3.5 – 5.0 mmol/l |
Creatinine | 35 – 135 μmol/l |
Alanine Aminotransferase (ALT) | 5 – 35 U/l |
Gamma-glutamyl Transferase (GGT) | < 65 U/l |
Alkaline Phosphatase (ALP) | 30 – 135 U/l |
Aspartate Aminotransferase (AST) | < 40 U/l |
Total Protein | 60 – 80 g/l |
Albumin | 35 – 50 g/l |
Globulin | 2.4 – 3.5 g/dl |
Amylase | < 70 U/l |
Total Bilirubin | 3 – 17 μmol/l |
Calcium | 2.1 – 2.5 mmol/l |
Chloride | 95 – 105 mmol/l |
Phosphate | 0.8 – 1.4 mmol/l |
Haematology | Normal Value |
---|---|
Haemoglobin | 11.5 – 16.6 g/dl |
White Blood Cells | 4.0 – 11.0 x 109/l |
Platelets | 150 – 450 x 109/l |
MCV | 80 – 96 fl |
MCHC | 32 – 36 g/dl |
Neutrophils | 2.0 – 7.5 x 109/l |
Lymphocytes | 1.5 – 4.0 x 109/l |
Monocytes | 0.3 – 1.0 x 109/l |
Eosinophils | 0.1 – 0.5 x 109/l |
Basophils | < 0.2 x 109/l |
Reticulocytes | < 2% |
Haematocrit | 0.35 – 0.49 |
Red Cell Distribution Width | 11 – 15% |
Blood Gases | Normal Value |
---|---|
pH | 7.35 – 7.45 |
pO2 | 11 – 14 kPa |
pCO2 | 4.5 – 6.0 kPa |
Base Excess | -2 – +2 mmol/l |
Bicarbonate | 24 – 30 mmol/l |
Lactate | < 2 mmol/l |