Hernia Examination (OSCE)

Introduction 

Greet the patient and introduce yourself 

Confirm patient details 

Briefly explain the examination in a patient friendly manner 

Get patient consent 

Set the head of the bed to a 45° angle 

Wash hands ✋

Expose patient’s abdomen and inguinal region

Check the patient is not in any pain

General Inspection

Identify any clinically relevant signs:

Hernias: can be visualised by asking patient to cough

Scars: indicate previous abdominal surgery

Pallor: anaemia

Pain: identify position for examination

Abdominal distension: can indicate bowel obstruction caused by a hernia

Cachexia: muscle loss associated with malignancy or advanced liver failure

Identify any objects or equipment that may be clinically relevant:

Mobility aids ♿

Stoma bag: parastomal hernias can be caused by stoma formation

Surgical drains: location and contents are important

Accurately identifying a hernia

Assess both sides of a groin lump to identify clinical features:

Single lump in inguinal region

Soft when palpated

Painless (not if incarcerated)

Expands upon coughing (not if incarcerated)

Cannot get above the lump when palpated

Reducible (not necessarily if incarcerated)

When auscultated, bowel sounds 👂 present (not necessarily if incarcerated)

Features not associated with hernia:

Bruit identified when auscultated 

>1 lump

Transillumination

Hard/nodular

Can get above the lump when palpated ✋

How to identify the hernia subtype

Position in relation to the pubic tubercle:

Inguinal: above and medial

Femoral: below and lateral

Reducibility (can it be flattened):

1. Ask the patient to lay on their back and observe if the hernia spontaneously reduces
2. In the absence of spontaneous reduction, try to flatten it with pressure

A non-reducible, tender hernia needs urgent surgery as it can stop the intestines/ abdominal tissue being supplied with blood

Distinguishing between direct and indirect inguinal hernias:

1. Compress the hernia towards the deep inguinal ring, starting at the lowest point of the hernia, to reduce it
2. When you have reduced the hernia, ask the patient to cough as you apply pressure over the deep inguinal ring

How to interpret your findings:

• Direct: the hernia reappears
• Indirect: the hernia does not reappear

Further tests are required for clinical diagnosis 

Hernia Subtypes

Inguinal hernias:

When the abdominal contents move or protrude at the superficial inguinal ring

Located superomedial to the pubic tubercle

Femoral hernias:

When the abdominal contents pass through the femoral canal (this is narrow, increasing risk of strangulation and obstruction)

Located medial to the femoral pulse

Umbilical hernia:

Large hernias with low strangulation risk

Located at the umbilicus site

Incisional hernia:

Tissue integrity compromised by previous surgery

Located at the site of previous surgery

Examination of the scrotum

You should palpate the scrotum is there is testicular swelling or suspected inguinal hernia

You must get consent! ❌

If the lump is an inguinal hernia, you will not be able to get above the lump  ✋

Completion 

Tell the patient you have finished the examination

Thank the patient 

Wash hands  ✋

Summarise what the examination has revealed 

Summary:

1. Greet the patient and briefly explain the procedure
2. Inspect the patient to identify anything clinically relevant
3. Assess both sides of the groin lump to identify clinical features
4. Identify the hernia subtype by: assessing position, assessing reducibility, and distinguishing between direct and indirect inguinal hernias
5. Examine the scrotum
6. Complete the examination by thanking the patient