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GI Unit > 2.2 Abdominal Wall Hernias > Flashcards

2.2 Abdominal Wall Hernias Flashcards

1
Q

What is a hernia?

A

A hernia is a protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall

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2
Q

What are the signs and symptoms of a non-incarcerated hernia?

A

Fullness or swelling
Gets larger when intra abdominal pressure increases (sneezing)
Aches

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3
Q

What are the signs and symptoms of an incarcerated hernia?

A

Pain
Cannot be moved
Nausea/vomiting
Systemic problems if bowel has become ischaemic

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4
Q

What are causes of abdominal hernias?

A

Weakness in containing cavity - congenitally related, post surgery where wounds have not healed adequately, normal points of weakness

Anything that increases intra-abdominal pressure - obesity, weightlifting, chronic constipation/coughing

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5
Q

What is an incisional hernia?

A

hernia that occurs through a previously made incision in the abdominal wall, ie the scar left from a previous surgical operation

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6
Q

What are the 3 parts of a hernia?

A
  1. The sac - pouch of peritoneum
  2. Contents of the sac - any structure found within the abdominal cavity that is within the sac. Commonly loops of bowel/omentum
  3. Coverings of the sac - layers of the abdominal wall that the hernia has passed through.
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7
Q

What are the 4 main types of hernias?

A
  • Inguinal canal
  • Femoral canal
  • Umbilicus
  • Previous incisions
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8
Q

What is the inguinal canal?

A

Oblique passage through lower part of the abdominal wall
• In males = Structures pass through from abdomen to testis
• In Females = Round ligament goes from Uterus to labium majus

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9
Q

When do testis descend?

A

In the 7th to 8th month

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10
Q

What is the processus vaginalis?

A

An out pouching of peritoneum

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11
Q

What is the gubernaculum?

A

Condensed band of mesenchyme that links inferior portion of testis (gonad) to labioscrotal swelling ( genital swellings)

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12
Q

What is an incarcerated hernia?

A

When the contents of the sac (usually bowel) gets stuck outside the containing cavity. Contents cannot be reduced?

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13
Q

What is meant by reducing a hernia?

A

Pushing the contents back into the containing cavity. Cannot be done in an incarcerated hernia

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14
Q

Why is an incarcerated hernia more concerning than an ordinary hernia?

A

As can disrupt venous drainage from contents. Contents swells. Arterial blood flow disrupted. Areas of the bowel can become ischaemic and then necrotic. Bowel can perforate and cause peritonitis

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15
Q

Why are males more likely to get inguinal hernias?

A

Due to the descent of the testis through the inguinal canal, if processes vaginalis does not obliterate then an open channel between the peritoneal cavity and scrotum persists. Hernias can descend into the testis.

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16
Q

What is the tunica vaginalis?

A

A remnant of the processus vaginalis that surrounds the testis in the scrotum

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17
Q

What is a hydrocele?

A

A collection of serous fluid within the tunica vaginalis. The congenital form is most commonly due to a failure of the processus vaginalis to close. Adult hydrocele is often associated with inflammation or trauma and rarely, testicular tumors.

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18
Q

What forms the inguinal ligament?

A

The thickened inferior aspect of the external oblique muscle.

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19
Q

What is the conjoint tendon?

A

The structure formed from the lower part of the common aponeurosis of the internal oblique muscle and the transversus abdominis as it inserts into the crest of the pubis and pectineal line immediately behind the superficial inguinal ring.

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20
Q

What are the boundaries of the inguinal canal?

A

Inferior/floor = inguinal ligament
Anterior = aponeurosis of external oblique
Roof = transversalis fascia ( internal oblique / transversalis abdominus)
Posterior wall = transversalis fascia

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21
Q

What is the deep inguinal ring?

A

deep inguinal ring is located just above the midpoint of the inguinal ligament and lateral to the epigastric vessels. The deep ring is formed by the transversalis fascia which provides the posterior covering of the contents of the inguinal ring.

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22
Q

What is the lacunar ligament?

A

A medial triangular extension of the inguinal ligament that inserts into the pectineal line

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23
Q

What is the pectineal line?

A

The pectineal line of the pubis is a ridge on the superior ramus of the pubic bone. It forms part of the pelvic brim

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24
Q

What is the superficial inguinal ring?

A

Formed by the aponeurosis of the external oblique on the anterior of the inguinal canal. Located medially above the pubic tubercle. Where inguinal hernias protrude.

25
Q

What are the 2 different type of inguinal hernias?

A

Direct inguinal hernia

Indirect inguinal hernia

26
Q

What is the most common type of hernia?

A

Indirect inguinal hernia (followed by direct)

27
Q

Describe the path of an indirect inguinal hernia

A
  • Passes through the deep Inguinal ring
  • The inguinal canal
  • The superficial Inguinal ring
  • Then depending on where the Processus Vaginalis was obliterated can potentially descend into the scrotum
28
Q

Describe the path of a direct inguinal hernia

A

• Bulges through Hesselbach’s triangle

◦ In the vicinity of the superficial Inguinal ring

29
Q

What is the anatomical differences between direct and indirect inguinal hernias?

A 
Direct = medial to the inferior epigastric vessels
Indirect = lateral to the inferior epigastric vessels
30
Q

What patients more commonly get femoral hernias?

A

Females - due to different pelvic anatomy meaning entrance to the femoral canal in females is wider

31
Q

What patients commonly get umbilical hernias?

A

Commonly found in infants. Most will close by age 3 (89-90%)
African descent
Low birthweight

32
Q

What is a para-umbilical hernia?

A

An umbilical hernia acquired as an adult. Goes through linea alba at the region of the umbilicus.

33
Q

Who is most at risk of getting a paraumbilical hernia?

A

Females

Obese patients

34
Q

What hernias are prone to incarceration?

A

Femoral hernias

Para-umbilical

35
Q

What is a strangulated hernia?

A

Blood supply is disrupted - can lead to tissue necrosis. Often follows incarcerated hernia

36
Q

What are the borders of hasselbach’s triangle?

A 
Medial = lateral abdominus rectus 
Inferior = inguinal ligament 
Supero-lateral = inferior epigastric vessels
37
Q

What determines the degree of herniation of an indirect inguinal hernia?

A

Level of obliteration of processus vaginalis

38
Q

How is location of herniation decribed?

A

Based on where the hernia leaves its containing cavity.

39
Q

What are the borders of the femoral canal?

A 
Superior = inguinal ligament 
Medial = adductor longus 
Lateral = medial border of sartorius
40
Q

Where is a lump felt in a femoral hernia?

A

Saphenous opening

41
Q

Describe the path of a femoral hernia

A
  • travel inferior to the inguinal ligament via the femoral ring
  • travel medially to the femoral vein and laterally to the lacunar ligament
  • descend in femoral canal
  • saphenous opening
42
Q

Why are femoral hernias more concerning than inguinal hernias?

A

More likely to become strangulated as femoral ring is narrow

43
Q

How can an incarcerated hernia become strangulated?

A
  • hernia becomes incarcerated
  • venous drainage occluded. Arterial pressure is greater than venous pressure so blood accumulates in the incarcerated hernia
  • swelling
  • blood supply compromised - pressure builds as blood accumulates, arterial pressure overcome
  • ischaemic
  • strangulated hernia
  • necrosis - break down of tissue contents of hernia
44
Q

Describe the path of an umbilical hernia

A

Hernia goes through umbilical ring

Umbilical cord passes through (should normally close at birth but may remain patent)

45
Q

What does the umbilical cord consist of?

A

Umbilical veins, umbilical arteries, Vitelline duct, Allantois duct

46
Q

How are umbilical hernias usually treated?

A

Usually left - painless, unlikely to have incarceration or strangulation and most close by 3-4 years of age
If problematic, surgery is very effective

47
Q

What are risk factors of incisional hernias?

A 
Previous surgery (x2 risk in emergency surgery)
Obesity
Midline incision 
Wound infection 
Advancing age
Pregnancy
Pre-op chemo
48
Q

What are the 5 common incisions?

A 
Midline incision
Paramedian
Gridiron
Pfannenstiel
Kocher
49
Q

What is a midline incision?

A

An incision through the linea alba that avoids the umbilicus

50
Q

What are the pros and cons of a midline incision?

A

Pros: Midline is relatively avascular which is useful during surgery, extendable so can increase operative filed if needed
Cons: Very painful post op

51
Q

What are the pros of a paramedian incision?

A

Poor cosmetics

Can damage nerve/structures (falciform ligament/nerve supply to rectus muscles)

52
Q

What is a paramedian incision?

A

An incision of the abdomen made on the lateral side of the rectus abdominus muscles, parallel to the midline

53
Q

Where is a gridiron incision done?

A

2/3 of the way laterally between the umbilicus and ASIS

54
Q

When is a gridiron incision commonly done?

A

Appendicectomy

55
Q

What is a pfannenstiel incision?

A

A horizontal incision made below to umbilicus.

56
Q

When is a pfannenstiel incision used?

A

Obstetrics and urology

- access gravid uterus

57
Q

Where is a kocher incision?

A

Parallel to subcostal margin

58
Q

When is a kocher used?

A

In an open cholecystectomy - removing the gallbladder

GI Unit (14 decks)

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