Hernias — MRCS Revision

🟤 Hernias

Inguinal · Femoral · Femoral Triangle & Canal · Rare Hernias · Complications · Repair — MRCS Part A & B

Hernia Basics — Definitions & Complications

A hernia is a protrusion of an organ or tissue through a defect or weakness in the containing wall. The hernial sac is an outpouching of peritoneum, covering the hernia contents.

Hernia Complications — Severity Spectrum

Reducible

Contents return to abdomen spontaneously or with manual pressure. No vascular compromise. Elective repair.

Irreducible / Incarcerated

Cannot be reduced. Not necessarily ischaemic. Adhesions or size may prevent reduction. Urgent assessment needed.

Obstructed

Bowel lumen occluded → bowel obstruction symptoms (vomiting, distension, pain). No vascular compromise yet. Surgical emergency.

Strangulated

Vascular supply compromised → ischaemia → gangrene → perforation. Surgical emergency. Requires resection of non-viable bowel.

Strangulation Risk — Femoral > Indirect Inguinal > Direct Inguinal

The narrower and more rigid the hernia neck, the higher the strangulation risk:

Femoral
Up to ~40%

Indirect Inguinal
Moderate risk

Direct Inguinal
Low risk (wide neck)

Special Hernia Types — Eponymous and Unusual

Type	Definition	Clinical Significance
Richter’s Hernia	Only part of the bowel circumference (the antimesenteric wall) is caught in the hernial ring — not the full lumen	Bowel can strangulate WITHOUT causing bowel obstruction (lumen not completely occluded). Classic in femoral hernias. Presents as strangulation WITHOUT obstruction symptoms — easily missed.
Maydl’s Hernia	A “W” loop of bowel is in the sac — two loops with the loop BETWEEN them in the abdomen. The intraabdominal segment strangulates first, but it is not in the sac.	The strangulated segment is within the abdomen, NOT in the sac. At operation: simply reducing the sac contents without checking the intraabdominal segment leads to missed intraabdominal strangulation.
Littre’s Hernia	Meckel’s diverticulum is the hernia content	Meckel’s diverticulum is the most common congenital anomaly of the GI tract. If it is the content of a hernia sac, it can strangulate or perforate. May occur in inguinal, femoral, or umbilical hernia.
Sliding Hernia	Part of the wall of the hernial sac is formed by a viscus (not just peritoneum covering it) — e.g., the caecum, sigmoid colon, or bladder forms part of the sac wall	Critical during repair: if the surgeon opens what they think is the sac, they may enter the bladder or bowel. The viscus is identified — the sac is reduced without opening.
Pantaloon Hernia	Both a direct AND indirect inguinal hernia are present simultaneously, straddling the inferior epigastric artery — resembling a pair of trousers	Both components must be repaired. In laparoscopic repair (TEP/TAPP), both defects are visible and the mesh covers both.

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