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Semester 3 - Gastrointestinal > 4. Abdominal Wall Hernias. > Flashcards

4. Abdominal Wall Hernias. Flashcards

1
Q

What stimuli do viscera respond to?

A

Stretch, inflammation, ischaemia

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2
Q

How is visceral pain described and where is it usually felt?

A

Diffuse, Crampy pain, not localized. Often midline

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3
Q

What signs/symptoms may accompany visceral pain?

A

Nausea, vomiting, sweating

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4
Q

What are the origins of sympathetic innervation to the gut?

A

T5-L2

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5
Q

How is visceral pain transmitted?

A

Sensory afferent fibres via the sympathetics outflow to gut (go in reverse)

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6
Q

Why is visceral pain poorly localised?

A

Low density of sensory innervation. Sensory afferent fibres converge with somatic afferents at the same spinal level at the dorsal horn. Brain interprets visceral afferent to be coming from dermatomes of that level

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7
Q

Define hernia.

A

A protrusion of part of the abdominal contents beyond their normal confines of the abdominal wall/its containing cavity

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8
Q

What are the signs and symptoms of hernias that are not stuck?

A

Fullness of swelling
Gets larger when intraabdominal pressure increases
Aches

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9
Q

What are the signs and symptoms of incarcerated hernias?

A

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

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10
Q

What is a hernia that is stuck called?

A

Incarcerated hernia

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11
Q

What are the 2 major general causes of hernias?

A

Weakness in the containing cavity and anything that increases intra-abdominal pressure

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12
Q

Why might there be weakness in the containing cavity?

A
  • Congenitally related
  • Post surgery where wounds have not healed adequately (incisional hernia)
  • Normal points of weakness
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13
Q

What are incisional hernias?

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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14
Q

Give 3 examples of things that may increase intra-abdominal pressure.

A
  • Obesity
  • Weightlifting
  • Chronic constipation/coughing
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15
Q

What are the 3 parts that make up a hernia?

A
  • The sac
  • Contents of the sac
  • Coverings of the sac
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16
Q

which hernias can be reduced?

A

hernias that are not incarcerated

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17
Q

what is the sac?

A

a pouch of peritoneum

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18
Q

what are the contents of the sac?

A

• Any structure found within the abdominal cavity

o Commonly Loops of bowel/Omentum

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19
Q

what are the coverings of the sac?

A

• Consist of the layers of the abdominal wall through which the hernia has passed

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20
Q

What is the most common type of hernia? Name 3 some other types.

A

Inguinal hernias - most common
Femoral
Umbilical
Incisional

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21
Q

Define inguinal canal.

A

Oblique passage through the lower part of the abdominal wall

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22
Q

Where does the inguinal canal run to and from in males? In females?

A

Structures pass through abdomen-testis

Round ligament goes from uterus - labium majus

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23
Q

Whats forms the anterior border of the inguinal canal?

A

Aponeurosis of the external oblique muscle

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24
Q

What forms the inferior border (floor) of the inguinal canal?

A

Inguinal ligament

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25
Q

What is the inguinal ligament formed from and what are its attachments?

A

This is the inferior edge of the external oblique aponeurosis extending from the anterior iliac spine to the pubic tubercle

26
Q

What forms the superior border (roof) of the inguinal canal?

A

Arching fibres of the internal oblique and transverse abdominus muscles

27
Q

What forms the posterior border of the inguinal canal?

A

Transversals fascia

28
Q

What structures form the entrance and exit of the inguinal canal? How do you find them?

A 
Entrance = Deep inguinal ring —> above midpoint of inguinal ligament, lateral to epigastric vessels 
Exit = Superficial inguinal ring —> above pubic tubercle
29
Q

what is the proccesus vaginalis?

A

Pouch of peritoneum

30
Q

what is the gubernaculum?

A

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

31
Q

describe the action of processus vaginalis and gubernaculum

A

◦ processus vaginalis proceeds descent of testis
◦ testis are initially retroperitoneal
◦ gubernaculum guides testis down into scrotum
◦ processus vaginalis is obliterated leaving the tunica vaginalis as a remnant
◦ the scrotal ligament is a remnant of the gubernaculum that also obliterates

32
Q

what happens if the processus vaginalis doesn’t obliterate?

A

higher liklihood of hernias developing in inguinal canal

33
Q

What is the conjoint tendon and how does it contribute to the inguinal canal?

A

aponeurotic attachments of the conjoining of the internal oblique and transversus abdominis to the pubic tubercle. Forms the most medial part of the posterior border.

34
Q

what are the two types of inguinal hernias?

A

direct

indirect

35
Q

What are indirect hernias?

A
  • herniating structures leave abdominal cavity and
  • 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

mainly right sided

36
Q

What are direct hernias?

A

Bulges through the hesselbach’s triangle, generally in the vicinity of the superficial inguinal ring. (Doesn’t go through deep inguinal ring).

37
Q

What percent of abdominal hernias are inguinal?

A

75% (50% direct, 25% indirect)

38
Q

What is the ratio of indirect hernias in males and females?

39
Q

Which vessels are important land marks in inguinal hernias?

A

Inferior epigastric vessels, pass between the superficial and deep inguinal rings

40
Q

What is Hesselbach’s triangle?

A

Region of the abdominal wall through which direct hernias tend to herniate

41
Q

What are the borders of Hesselbach’s triangle?

A

Rectus abdominis medially, Inferior epigastric vessels superolaterally, Inguinal ligament as inferior

42
Q

does a direct hernia pass through the inguinal canal?

43
Q

What is the anatomical difference between direct and indirect hernias?

A

Direct are medial to the inferior epigastric vessels. Indirect are lateral to them.

44
Q

Why might an indirect hernia descend into the scrotum?

A

If there is partial or complete failure of the processes vaginalis to obliterate.

45
Q

Who are femoral hernias more common in and why?

A

females, Due to the difference in pelvic anatomy

46
Q

What is the issue with femoral hernias?

A

Can easily get stuck and become strangulated

47
Q

How do femoral hernias occur?

A

Go through the femoral ring into the femoral canal and protrude out the saphenous opening where lump is felt - beneath inguinal ligament

48
Q

Why can a femoral hernia easily become “stuck” ie incarcerated?

A

Femoral ring is very small - so while this does mean that difficult for bowel to herniate into it, when it does - hard for it to be reversed/reduced. Therefore incarcerated.

Can become strangulated.

49
Q

Define strangulated hernia

A

Blood supply is disrupted ie ischaemic hernia, leading to tissue necrosis

50
Q

What are umbilical hernias?

A

Hernia at the site of the umbilicus which occur in children

51
Q

When do umbilical hernias spontaneously close by?

A

Age 3 (90%)

52
Q

What are umbilical hernias that occur in adults called?

A

Para-umbilical hernias

53
Q

What occurs in para-umbilical hernias and what are they usually associated with?

A

hernia through the defect in linea alba(near umbilicus), commonly associated with obesity - risk of stranfulation

54
Q

Umbilical hernia - what is it, where, painful?

A 
Hernia goes through umbilical ring (defect in linea Alba). Should normally close after birth.
Not painful
Usually resolve itself after 3-4 years
Don't incarcerate or strangulate 
surgery very effective
55
Q

what are the risk factors for incisional hernia

A

Previous Surgery (esp emergency surgery rather than planned)
Obese
Midline incision
Wound breakdown/infection

56
Q

Name 5 types of common incisions used in abdo surgery.

A
  1. midline
  2. paramedian
  3. gridiron
  4. kocher
  5. pfanenstial
57
Q

Describe two advantages to using a midline abdominal incision?

A

1) extendable

2) linea alba is avascular so minimal risk of neurovascular damage.

58
Q

What abdominal incision would give you access to the

appendix?

59
Q

What incision could be used for an open cholecystectomy?

60
Q

Explain why the failure of the processus vaginalis to obliterate increases the likelihood of a direct inguinal hernia?

A

Leaves cavity for hydrocoele (fluid) or abdominal structures to herniate through it from peritoneal cavity

61
Q

What is the deep ring of the inguinal canal a defect of?

A

Transversalis fascia

62
Q

Compare direct and indirect inguinal hernias

A

Indirect – where the peritoneal sac enters the inguinal canal through the deep inguinal ring.

They are caused by the failure of the processus vaginalis to regress.

The peritoneal sac (and potentially loops of bowel) enters the inguinal canal via the deep inguinal ring. The degree to which the sac herniates depends on the amount of processus vaginalis still present.

Direct – where the peritoneal sac enters the inguinal canal though the posterior wall of the inguinal canal.

acquired, usually in adulthood, due to weakening in the abdominal musculature.

The peritoneal sac bulges into the inguinal canal via the posterior wall medial to the epigastric vessels and can enter the superficial inguinal ring. The sac is not covered with the coverings of the contents of the canal.

Both types of inguinal hernia can present as lumps in the scrotum or labia majora.

Semester 3 - Gastrointestinal (17 decks)

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