4. Hernias Flashcards
What is a hernia? What combination of 2 things are they caused by?
Describe the 2 different types of groin hernia.
Abnormal protrusion of a viscus (hollow organ) or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.
Caused by combination of increasing abdominal cavity pressures and decreasing abdominal wall strength e.g. obesity, heavy lifting, coughing/chronic lung disease, ascites, hereditary, old age
Inguinal hernia: above and medial to pubic tubercle, commonest type
Femoral hernia: below and lateral to pubic tubercle
List some differential diagnoses for groin lumps, and their distinguishing features.
What are some differential diagnoses for testicular swellings?
- *Femoral artery aneurysm:** expanding and pulsatile
- *Saphena varix:** compressible, palpable thrill medial to artery. Dilation at top of long saphenous vein due to valvular incompetence
- *Enlarged lymph node:** often multiple, mobile, firm, tender. Could be recent infection, malignancy e.g. from testicular cancer
- *Undescended testes:** empty scrotum
- *Psoas abscess:** fluctuant swelling lateral to artery
- *Soft tissue lumps:** lipoma, sebaceous cyst
Hydrocele, varicocele, spermatocele, tumour
What questions would you ask a patient who presents with a groin lump?
How do you focus the examination?
Label A-G of hernias of the anterior abdominal wall.
Does it come and go (if no - lymph node? Irreducible hernia)? Painful, dragging sensation? Previous surgeries (incisional hernia)? Fever (abscess), overlying skin changes (hernia stuck)? Obstructive symptoms? Medical history (asthma, COPD)? Duration of onset?
Examine hernia orifices. Lying and standing (if lump disappears = reducible hernia). Ask patient to cough. Can you reduce the hernia? (stand from lying/cough = increased intraabdominal pressureand will hopefully show hernia)
- *A: Epigastric**
- *B: Paraumbilical**
- *C: Inguinal:** hernia passing through inguinal canal (most common)
- *D: Incisional:** through an operation scar
- *E: Spigelian:** throuhg Spigelian fascia at lateral border of rectus abdominus
- *F: Umbilical**
- *G: Femoral:** hernial passing through femoral canal
What are the 5 points to remember when describing hernias?
What are the following types of hernia:
a) Obstructed
b) Incarcerated
c) Strangulated
Location. Reducible/irreducible? Incarcerated? Strangulated? Special hernias.
a) Bowel contents cannot pass through them - classic features of intestinal obstruction seen (vomiting, colicky pain, constipation, distension)
b) Contents of hernial sack stuck inside by adhesions, irreducible and obstructed but not nesessarily unhealthy in terms of tissue and sac (yet)
c) Visceral contents become trapped and twisted with a compromised blood supply - ischaemia occurs due to obstructed vasculature [pic]
* With a and b, hernia is irreducible but contents viable*
Label A-H of the inguinal canal (path for testes descent; females = round ligament).
A: Linea alba
B: ASIS
C: Deep inguial ring
D: Superficial inguinal ring
E: External oblique
F: Aponeurosis of external oblique
G: Inguial ligament
H: Spermatic cord
Define inguial hernia and differentiate between an indirect and direct inguinal hernia.
What are the 2 types of indirect inguinal hernia?
They exit through the superficial (external) ring, having passed through part of the inguinal canal. [L Pic]
Indirect hernias pass through the deep ring, traverse the canal and exit through the superfical ring (black line).
Direct hernias pass directly through the abdominal wall to bulge through the superficial ring (green line).
NB test: reduce all the way back if you can, occlude deep inguinal ring (~ 1/2 along inguinal ligament), ask pt to cough. If reappears = direct
1. Congenital: hernia passes through patent processus vaginalis (which should close before birth) following the path of the testes during pre-birth development
2. Acquired: passes through deep and superficial rings, can occur at any stage but commoner in older people, can still descend into scrotum [M and R Pic]
Describe how direct inguinal hernias occur.
What are the borders of Hesselbach’s triangle?
Protrude through abdominal wall in Hesselbach’s triangle. Transversalis fascia forms hernia sac. Abdominal wall is slightly thinner here. Usually in middle age-elderly who have weaker abdominal wall. [Pic] Less inclined to go to scrotum
Lateral border of rectus abdominus, inferior epigastric artery, inguinal ligament [Pic]
Compare direct and indirect inguinal hernias in terms of:
a) Age
b) Frequency
c) Cause
d) Bilateral
e) Course
f) Neck of sac
g) Relation to inferior epigastric vessels
[Pic]
Indirect - narrow neck of sac = more chance of strangulation
How are non-urgent/emergency cases managed/repaired?
Surgical repair recommended for symptomatic hernias, or asymptomatic hernias in <65s.
Open repair: with mesh -> Lichtenstein repair; without mesh -> Shouldice repair
Laparoscopic repair: associated with less acute and chronic pain, less nerve injuries, quicker return to normal work and significantly fewer post-op complications e.g. infection and hematoma. But hospital costs are higher and it needs GA. Insert ports into ant. abdo wall to inflate way down to inguinal region and decrease hernia without having to open up peritoneum
Conservative management: e.g. trusses, watch and wait
Describe the Lichtenstein open tension-free repair.
For inguinal hernias, can be perfomed under LA, mesh insterted and sutured to the inguinal ligament (inferiorly) and the underlying aponeurosis (superiorly). A lateral suture closes the 2 tails of the mesh around the internal ring. [Pic - spermatic cord lifted up]
What is a femoral hernia? What gender is it more common in?
What can a strangulated femoral hernia lead to?
Acquired downward protrusion of peritoneum in the potential space of the femoral canal. Protrusion through femoral canal and femoral ring. Lump often small and unimpressive [Pic]
Much more common in females due to pelvis shape - femoral canal more exposed. 6% of all groin hernias. Often symptomless until they strangulate or incarcerate (lump becomes tender and hard). More dangerous b/c femoral ring smaller so hernia more likely to strangulate. Dx mainly clinical but USS can aid
Ischaemia, perforation and sepsis.
How is a (strangulated) femoral hernia managed/repaired?
List some of the ‘special hernias’?
All hernias should be repaired as elective proceedures due to risk of strangulation (surgical emergency!).
Repair: dissection of sac with reduction of its contents, followed by ligation of sac and closure between inguinal and pectineal ligaments. Laparoscopic approaches more common. Evidence is increasingly supporting use of mesh
[Pic] From top left clockwise:
1. Sliding/rolling hernia: retroperitoneal cecum and intraperitoneal structure come out of hernia
2. Amyand’s hernia: appendix included in hernial sac and becomes incarcerated
3. Maydl’s hernia: large hernial neck with 2 loops of bowel protruding out. Obstructed loop of intestine within peritoneal cavity so hard to detect
4. Obturator hernia: bowel falls through floor of obturator canal, hard to dx
5. Littre’s hernia: contains Meckel’s diverticulum
6. Parasternal hernia: bring out stoma from ileum, hernia forms next to it. E.g. herniation of abdo contents into chest
7. Pantaloon hernia: get 2 hernias; 1 on either side of inferior epigastric vessels - medial (direct) and lateral (indirect)
