How do others examine for a hernia? Do you just look at and palpate with the patient standing up? Do you also invaginate the scrotum with the little fingerinserted up through the external inguinal ring?
Since missing an incidental hernia as an intern years ago, and being told off sarcastically by someone a year ahead of me, my routine examination of the abdo includes “the belly and what hangs from it”. I check both groins by putting the right index fingertip over the left ext. inguinal ring and the thumb tip over the right ext. ring, and getting the patient to cough once. This takes four or five seconds.
At least twice a year I pick up a previously unsuspected hernia. In the case of small hernias I tell the patient – “don’t worry, but you may notice something in the next few months or years, and I don’t want you to feel you didn’t have a thorough examination.” It seems to greatly re-inforce the patient’s confidence.
Palpating the pubic tubercle by invaginating the scrotal skin has a great advantage if you are injecting the insertion (?origin) of the conjoint tendon for pain in the absence of any palpable hernia using some lignocaine, as both diagnostic and curative procedure. It helps especially in the fat patient, where you can feel the shaft of the needle. Sometimes it is difficult, just as a vasectomy is difficult, if the scrotal skin is very thick. It shouldn’t be contracted from cold antiseptic solution, because the nurse should wam this for you.
Having said all this, here is a recent blunder. Last December I saw a fat older woman with an obvious left femoral hernia giving her discomfort. At operation a few days later there was only a little redundant fat at the femoral canal, which I excised before closing the canal. At review a couple of weeks later she had lost her lump and discomfort.
Three months later she came back – so did the lump. This time it looked maybe like a saphena varix. Also, I noted a few minor scars on her thigh and calf where she had some multiple ligations she forgot to mention in her past history. Ultrasound confirmed a saphena varix, incompetent SF junction, and 4 incompetent deep perforators in the leg. The re-dissection at the groin was a nuisance because of scarring – served me right. Everything else was OK.
Ultrasound for hernias has helped me several times in the last few years, especially for occult little incisional hernias around sutures which have cut out in obese patients. These have presented with pain, relieved by repair.
What is the experience of others with ultrasound for hernias?