GI - Hernia

General Inspection

• Wash Hands
• Introduce Self
• Patients Name, DOB & Consent [can I call you ‘X’]
• Exposure - undressed from waist down Supine & obvious swelling = ok
• Reposition Supine & no obvious swelling = ask ptn to Stand
• +/- Chaperone

• Age
• Alert ; Well or Unwell ; Drowsy
• BMI cachexia; increased body habitus ; muscle wasting
• Breathing
• Colour Jaundice
• Devices Inhalers/ O2 delivery, IV access, aids/devices, sick
bowl, medications, NG tube

Closer Inspection

LUMP? Can you show me where it is? Ask ptn to raise head to chin = supine
Ask ptn to raise head to cough = standing
o Inspect Supine > Standing
o Inspect BOTH SIDES

• Shape o Scaphoid / Distended (fat, foetus, fluid, flatus, faeces)

• Scars / Wounds / Dressing
• Distended veins/caput medusa o Midline laparotomy
o Lapraroscopic port sites
• Striae
o Pfannensteil (C-section)
• Visible peristalsis, pulsations o Kocher (Cholecystectomy)
• Stoma (Site, spout, content ) o McBurney/Lanz (Appendix)
• Lumps (Site, size, shape, colour) o Paramedian, transverse, oblique etc

Palpation
• Explain to the patient what you are about to do.
• Ask ptn if any area is tender/abnormal = examine this area last
• Encourage the patient to relax

• Kneel & watch Ptn face for pain

• Name all 9 areas on palpation

Light palpation
• Uses 1 hand, palm flat, flexes at MCPs
• Tell me if I cause you any discomfort

Deep palpation
• Uses 2 hands, palm flat, flexes at MCPs
• Tell me if I cause you any discomfort
Palpation of Hernia

• Examine unaffected side first

• Examine Lying Down & Standing Up Tender & Warm = strangulated

Lump [TTT CAMPFIRE] Absent cough impulse = incarcerated / not a hernia at all
• Temperature - inflammation
• Tenderness - inflammation
• Transillumination - cyst
• Consistency
• Appearance
• Mobility
• Pulsatile
• Fluctuance
• Irreducible
• Regional Lymph Nodes
• Edges

• Site – near anatomical location

• Size – establish between hands • There is a mass in XXX. It is approximately (X)cm by
• Skin – intact, erythema, trauma, scars, (X)cm and bulges outwards on coughing,
• Surface • It has a regular/ irregular outline
• It is/is not situated behind any scars.
Establish • There are (no) signs of overlying
• Location to Pubic Tubercle erythema/excoriation/skin changes.
- Inguinal = Above & Medial to PT • There is a positive/negative cough reflex
- Femoral = Below & Lateral to PT • The hernia self-reduces when the patient lies down/can
be reduced.
• Reducible
• While occluding the deep ring and asking the patient
- Ask ptn to reduce it themselves ‘can you push the lump inside?’
to cough the hernia reappears/does not reappear.
- Try standing then Supine
• Relation to deep ring
- Deep ring is 2cm above mid inguinal point, midway between ASIS &
Pubic symphysis
- Occlude deep ring with 2 fingers
- Ask ptn to cough = Hernia re-appears = Direct [Hesselbach’s]
= Hernia doesn’t reappear = Indirect

Scrotal Exam

• If cannot get below lower border of hernia, assess for scrotal extension Scrotal extension common for indirect inguinal hernia
• If a mass is found in the scrotum, offer to trans-illuminate

Auscultation

Bowel Sounds
• Auscultates over the Hernia using diaphragm of stethoscope up to 1
minute for bowel sounds

Renal bruits
• 3cm superior and lateral to umbilicus using bell of stethoscope on both
sides
- Renal artery stenosis

Complete Exam
• Examine the contralateral side
• Perform a full GI examination to look for a cause of raised
intraabdominal pressure
• Perform relevant investigations = US abdomen / CTabdomen
 “This is a surgical station. You have 5 minutes to complete an abdominal examination and examine for herniae. I will then ask you to present your findings and
answer a question”.
Examination Expected/Normal Comments Potential/Abnormal Comments
Introduction
Hand hygiene Abbreviation key (NB: these abbreviations are not
• Cleans hands with alcohol gel necessarily medically acceptable abbreviations and
have been abbreviated for the purposes of this
Introduction, explanation and consent Hi my name is X. I’m a third year medical student at document only):
• Introduces self with name and level, explains RCSI. What’s your name? Nice to meet you. I’ve
what he/she will be doing and obtains been asked to examine your abdomen today. That RHC = right hypochondrium
consent for same will involve me havng a look, feel and listen to your EPG = epigastrium
abdomen. Would that be ok?
LHC = left hypochondrium
Position and exposure Mr/Mrs A is appropriately positioned and exposed RF = right flank
• Patient positioned at 180 degrees and for this examination.
LF = left flank
undressed to the waist
UMB = umbilicus
Enquires about pain Are you in any pain?
RIF = right iliac fossa
• Prior to examining
LIF = left iliac fossa
SPC = suprapubic

General Inspection
Patient
Performed from the end of the bed On general inspection Mr/Mrs A appears well, there • Appears unwell/in pain/pale/jaundice
• Inspects for are no peripheral stigmata of gastrointestinal • BMI eg cachexia, muscle wasting
o Patient disease and no equipment around the bed. • Obvious herniae, wounds, dressings, scars,
o Equipment stomas, masses, pulsations etc
• Asks patient to cough and comments on
presence or absence of swelling
Closer Inspection
• Shape
Performed from the right side of the bed o Scaphoid / Distended (fat, foetus, fluid, flatus,
faeces)
• Comments on • Scars
o Scars/wounds/dressings o Midline laparotomy
o Distention o Lapraroscopic port sites
“On closer inspection of the abdomen there are no
o Masses / Stoma o Pfannensteil (C-section)
stigmata of gastrointestinal disease.”
o Hernia (ask patient to cough) o Kocher (Cholecystectomy)
o Pulsations o McBurney/Lanz (Appendix)
o Ecchymosis o Paramedian, transverse, oblique etc
• Distended veins/caput medusa
• Striae
• Visible peristalsis, pulsations
• Lumps (Site, size, shape, colour)
• Stoma (Site, spout, content )
Equipment
• O2 delivery, IV access, aids/devices, sick bowl,
medications, NG tube
Palpation
Light palpation
• Kneels & watches face for pain • There is tenderness in the RIF/LIF/
• Names all 9 areas on palpation “On palpation the abdomen was soft and non- SPC/RF/LF/UMB/LHC/RHC/EPG with (no)
tender.” guarding/rigidity.
Light palpation • Or The abdomen is diffusely rigid with
• Uses 1 hand, palm flat, flexes at MCPs tenderness and guarding throughout.
Deep palpation
• There is palpable mass in RHC/EPG/
Deep palpation
LHC/RF/LF/UMB/RIF/SPC/LIF. It is
• Uses 2 hands, palm flat, flexes at MCPs
smooth/irregular, tender/non-tender,
fluctuant/non fluctuant, mobile/ immobile,
approx Xcm and (shape).
Hernia Inspection
Inspects for • There is a mass in the RIF/LIF/SPC/LF
o Site “On inspection I cannot see evidence of a hernia” /RF/UMB/RHC/EPI/LHC.
o Size • It is approximately (X)cm by (X)cm and bulges
o Shape outwards on coughing,
o Regularity • It has a regular/ irregular outline
o Relationship to scars • It is/is not situated behind any scars.
o Overlying skin changes • There are (no) signs of overlying
erythema/excoriation/skin changes.
Hernia Palpation
• Examine the unaffected side first, then move
onto affected side.
• Examines hernia with patient lying flat &
standing up
• Feels for cough impulse
• Assess for self-reducibility- student attempted
to reduce it manually
• If not self-reducible asks patient if they can
reduce it.
• If patient unable to reduce, comments that
ideally would reduce.
• Direct vs indirect hernia: localizes deep ring
(half an inch above midpoint of inguinal
ligament. Midpoint of inguinal ligament
identified as halfway between the pubic
tubercle and ASIS), occludes deep ring and
asks patient to cough. If hernia reappears on
coughing despite pressure on deep ring-
direct hernia.
Scrotal Exam
• If cannot get below lower border of hernia,
candidate assess for scrotal extension
• If a mass is found in the scrotum, offers to
trans-illuminate
Auscultation
Bowel Sounds
• Auscultates over the ileocecal valve using
diaphragm up to 1 minute
Renal bruits
• 3cm superior and lateral to umbilicus using
bell of stethoscope on both sides
Conclusion
• Thanks patient
• Full abdominal exam (in particular looking for a cause of raised intra-abdominal pressure).
• Digital Rectal Examination
• Urine Dipstick
“I cannot palpate evidence of a hernia”
On palpation of the scrotum there is no evidence
of scrotal extension of the hernia.
Bowel sounds are present and normal.
There are no renal bruits.
‘On palpation...
• The mass is
o Firm/soft
o Tender/ non-tender
o Approx (X)cm by (X)cm.
• There is a positive/negative cough reflex
• The hernia self-reduces when the patient lies
down/can be reduced.
• While occluding the deep ring and asking the
patient to cough the hernia reappears/does not
reappear.
• On examination of the scrotum, there is
thickening around the spermatic cord suggestive
of scrotal extension of the hernia which is most
consistent with the presence of an indirect
inguinal hernia.
• The lump is transillumnable/not.
Bowel Sounds
• On auscultation there was high pitched,
tinkering/ increased /no bowel sounds
Renal Bruits
• On auscultation there was a right/left/bilateral
renal bruit/s
Thank you Sir/Madam (to patient).
To conclude my examination ideally I would perform a
full abdominal exam, a DRE and do a urine dipstick.