The key differentiator: inferior epigastric artery. Indirect hernia passes lateral to it (through deep ring); direct passes medial to it (through Hesselbach's triangle). Direct hernias bulge through a weakness in the posterior wall — they are acquired, rarely descend into the scrotum, and are at low risk of strangulation compared to indirect. The Triangle of Doom is the most important danger zone in laparoscopic (TEP/TAPP) repair.
PSA grey zone (4–10 ng/mL): cannot distinguish BPH from Ca prostate on PSA alone — use free:total PSA ratio, PSA density, PSA velocity, and MRI prostate (PI-RADS scoring). Biopsy (TRUS-guided or MRI-fusion) is definitive. TUR syndrome: hyponatraemia from absorption of hypotonic glycine irrigation fluid during TURP — presents as confusion, visual disturbance, cardiovascular instability. Treated with hypertonic saline + diuretics.
Morning Rounds · Surgery Series · Round 05
Urology & Hernias Anatomy, Timing & the Triangle of Doom