How to approach an inguinal hernia case in an Objective Structured Clinical Examination (OSCE)?

Approach to Inguinal Hernia Case in an OSCE

The most effective approach to an inguinal hernia case in an OSCE is to follow a structured assessment focusing on thorough history taking, systematic physical examination, appropriate investigations, and management planning while demonstrating clear communication with the patient.

History Taking

• Begin by introducing yourself to the patient and obtaining consent for the examination 1
• Ask about the presenting complaint - typically groin pain, bulge, or discomfort 2
• Inquire about specific symptoms:
  • Burning, gurgling, or aching sensation in the groin 2
  • Heavy or dragging sensation that worsens toward the end of the day 2
  • Pain during physical activity or when straining 3
  • Associated symptoms such as genital pain, urinary symptoms, abdominal pain, or changes in bowel habits 3
• Determine if the hernia is reducible (disappears when lying down) or irreducible 2
• Ask about risk factors:
  • Previous surgeries in the abdominal or groin area 4
  • Family history of hernias 5
  • Activities that increase intra-abdominal pressure 1
  • Chronic cough, constipation, or urinary obstruction 1

Physical Examination

• Position the patient appropriately (standing and supine) 2
• Inspect the groin area for visible bulges or asymmetry 2
• Palpate for a bulge or impulse while the patient coughs or strains 2
• Examine both groins, even if symptoms are unilateral 6
• For males, perform scrotal examination and assess the testicular position 1
• Perform digital examination of the external ring (invaginate the scrotal skin with your finger) 1
• Distinguish between direct, indirect, and femoral hernias based on the location of the defect 5
• Assess for signs of complications such as incarceration or strangulation:
  • Irreducibility, tenderness, erythema, or systemic symptoms 4
  • Check for signs of bowel obstruction 4

Investigations

• Explain that diagnosis is typically clinical, but imaging may be necessary in certain cases 2
• Ultrasound is the first-line imaging modality when:
  • Physical findings are inconclusive 6
  • Female patients with suspected hernia 6
  • Complications are suspected 6
  • Pediatric patients 6
• MRI is recommended when ultrasound findings are equivocal or nondiagnostic, with higher sensitivity (94.5%) and specificity (96.3%) 6, 7
• CT scanning may be useful in emergency settings to assess for complications like bowel obstruction or strangulation 4

Management Plan

• Explain that all symptomatic inguinal hernias generally require surgical repair 1
• Discuss surgical options:
  • Open repair (tissue suture repair or mesh repair) 5
  • Laparoscopic approaches (TEP or TAPP) 4
• Explain that the choice between open and laparoscopic repair depends on:
  • Patient factors (age, comorbidities, previous surgeries) 4
  • Hernia characteristics (size, location, recurrence) 4
  • Surgeon expertise 5
• Discuss potential complications:
  • Recurrence (generally low rates with modern techniques) 2
  • Chronic pain 2
  • Infection 4
  • Testicular complications in males 4

Communication Skills

• Maintain good eye contact and demonstrate empathy 1
• Use clear, non-technical language when explaining the condition and management 1
• Address patient concerns and answer questions appropriately 1
• Summarize your findings and management plan to the patient 1
• Document your findings systematically 1

Common Pitfalls to Avoid

• Failing to examine both sides, as bilateral hernias are common 6
• Missing femoral hernias, which are less common but have higher risk of strangulation 4
• Not assessing for complications that require urgent intervention 4
• Inadequate explanation of surgical options and their risks/benefits 5
• Forgetting to use Doppler assessment during ultrasound examination to evaluate vascular complications 6