42 - 46 Hernias Flashcards
groin hernia femoral hernia umbilical hernia & Epigastric paraesophageal hernias
1
Q
Hernia DEFINITION
most common types
A
Abnormal protrusion of a organ or part of an organ or other structure through a defect in it’s surrounding wall
mc = ABDOMINAL WALL hernias at sites not covered by striated muscle e.g. @ Apeneurosis or Facia
2
Q
what are the elements of a hernia
A
- Hernial sac- lined by peritoneum
- Hernial contents inside the sack and make up the body
- Hernial neck- loc at innermost musculoapeneurotic layer
3
Q
what can hernias contain / what can be found w/in the contents of a hernia
OSLABO
A
Omentum
S.I
L.I
Appendix
Bladder
Ovaries
4
Q
what are the 3 types of complications you can get from hernias
A
Incarcerations
Strangulation
Intestinal Obstruction
5
Q
What is an Incarcerated hernia
A
clinically irreducible hernia ( req surgey) but not b/c of Obstruction or Strangulation so (b.f is intact)
the hernia is trapped b/c of Adhesions or feceas w/in the sac
rx: non emergency surgery
6
Q
what is an Intestinal obstruction 2ndary to hernia
what are the 4 cardinal sx
A
Tense irreducible hernia usually leads to Strangulation
4 cardinal sx (assume strangulation is imminent d/2 sim sx)
- ache/ pain at incarceratiom site
- distended abdomen
- VOMITTING
- Constipation
signs
- ausc: high pitched bowel sounds w/ frequent rushes
- x-ray: dilated loops w// fluid levels
rx:
- infants- taxis (manual reduction) w/in 2 hrs if low suspicion of strangulation
- hold neck and reduce hernia w/o excess pressure
7
Q
Strangunated hernias
why is the most severe complication
signs and sx
A
LIfe threatening complication where Hernial sac becomes ishcemic and non viable d/2 compromised blood supply
- sx*
- General*
- Fever
- tachycardia
- dehydration
- localized pain at and around site
clinical signs
- In: red colour
- Pa: Tense and irreducible
- Aus: absent bowel sounds
8
Q
rx of obstructed heria
A
infants- taxis (manual reduction) w/in 2 hrs if low suspicion of strangulation
hold neck and reduce hernia w/o excess pressure
9
Q
Pathogenesis of Strangulated hernia
A
-
Straining
- pushes more bowl into sac
- exerts more pressure on hernial neck
-
Venous congestion
- leads to bowel oedema
- exerts even more pressure on the arteries
-
Blocked arterial supply
- leads to ischemia and gangrene
- making it non viable
10
Q
treatment of streangulated hernia
A
emergency rx
- rapid ressuscitation
- airway NGT
- circulation: fluid replacement
- antibiotic therapy
-
surgical hernial repair
- expose hernia by opening the sac
- remove gangrenous portion
- End 2 End anastomoses of viable portions
- reduce the hernia
11
Q
specific surgical steps to strangulatio repair
hErErnia extra err cause it’s strangulated
A
- Expose hernia by opening the sac
- remove gangrenous portion
- End 2 End anastomoses of viable portions
- reduce the hernia
12
Q
What is a RIchter’s hernia
which part is affected
most serious complication
A
part of the antimesenteric wall of the small intestine
sincd only one wall is herniated the lumen is still intact
Complication = Perforation => peritonitis
13
Q
what is a Maydl’s hernia
where is the obstruction
when is there a high degree of suspicion
what is CONTRAINDICATED in this case
A
suspected in Incarcerated hernias w/ peritonitis
Taxis is CONTRAINDICATED => misses the non viable bowel
14
Q
What are the 2 types of Groin hernias
A
- Inguinal
- direct
- indirect
- Femoral
15
Q
Anatomy of the Inguinal canal
- length
- boundaries (ant, post, sup, inf)
A
4 cm long
Ant = apeneurosis of Ex Oblique, Lat reinforced by Int Obliqe
Post = 1/3 Transversalis facia 2/3 Conjoint tendon(of In/Ex O)
Sup = Conjoint tendon Only
Inf = edge of Inguinal ligament
16
Q
contents of inguinal canal in men
A
Spermatic cord
Vas deferens
Ilioingional nerve
17
Q
contents of inguinal canal in women
A
Round ligament of the Uterus
ilioinguinal nerve
18
Q
what is the most common external abdominal hernia
which side predominates
A
Inguinal hernias = 80% of all external abdominal hernias
- infants and elderly >
- men> (1/4)
- Right side>>
19
Q
hesselbach’s triangle
aka
medial inguinal fossa
aka
inguinal trianlge
A
20
Q
which inguinal hernia is Congenital
A
Indirect hernia
21
Q
indirect hernia
etio
loca m & f
A
- Due to patent processus vaginalis
loc
- Lateral to the inferior epigastric blood vessels (outside Hesselbach triangle)
- Runs from the deep inguinal ring through the inguinal canal to the superficial inguinal ring
- M: along with the spermatic cord
- F: follows round ligament
22
Q
when does processus vaginalis regress normally
A
complete Obliteration at 28wks gestation
23
Q
what the processes vaginalis
A
outpouching of the parietal peritoneum that extends through the inguinal canal.
Normally obliterates spontaneously after the fetal testes have descended into the scrotum, within a few weeks to 2 years after birth;
failure to obliterate can cause a
- communicating hydrocele and/or an
- infantile inguinal hernia.
24
Q
RF for Indirect inguinal hernia
A
Mechanical disparity bet/w
Visceral pressure and Abdom wall resistentance caused by increased Pressure
- pregnancy
- coughing obesity
25
sx of Indirect hernia
26
which hernia is acquired (adult type)
Direct hernia
27
What is a direct hernia
location
etiology
etio
* Acquired condition Caused by _weakening_ of the **transversalis fascia**
* secondary to conditions resulting in _increased intraabdominal_ pressure
* ***_COPD_*** with chronic coughing, *constipation*, ***pregnancy*** etc
* *_long-term **glucocorticoid use**_* = steroid induced skeletal muscle and connective tissue weakness.
* Increasing age over **40**years
LOCATION of direct hernia
* _Medial_ to the **inferior epigastric** blood vessels (within Hesselbach triangle)
* sac protrudes directly through the **posterior wall** of the _inguinal canal_
* **without** involvement of the _spermatic cord or round ligament_ of the uterus
* Only herniates through the **superficial (external**) ring ONLY ( unlike indirect which pases through both)
* Only surrounded by the **external spermatic fascia**
* indirect surrounded by
1) ext crenasteric fascia 2)cremasteric muscle fibers, 3) internal spermatic fascia
28
which type of hernia has NO RISK of obstruction / strangulation
Direct hernia ?
29
sx of INGUINAL hernia
abdominal distension and pain worse w/ **physical activity** (standing, coughing, walking)
_Visible bulge_ in testicle/ vaginal labia that **dissapears when laying down**
30
which hernia can be associated with a communicating hydrocele
INDIRECT INGUINAL
b/c of patent processus vaginalis
31
physical exam of Inguinal hernia
Inspection:
* bulge vanishing when supine
* dx of **hydrocele** or Testicular swelling is KEY
Palpation of the inguinal canal
* patient standing, palpate from the scrotal skin towards the **superficial** ring.
* Ask the patient to cough or strain and bear down (Valsalva maneuver).
* Bulging can be felt with a fingertip (expansile cough impulse).
Auscultation
* abscence/ presence of bowel sounds to determine if bowel is contained w/in herniation
32
diagnosis of Hernia
CLINICAL DG based on si and sx (history & phys exam)
US can be used to confirm dg
33
treatment of INGUINAL hernias
_OPEN SURGERY (mesh vs non mesh)_
**_Lichtenstein_** _repair_: reinforcement by implementation of a **synthetic mesh** between the abdominal *_internal oblique muscle_* and the *_aponeurosis of the abdominal external oblique_* muscle
**_Shouldice_** _repair_: _doubling_ of the *_transversalis fascia_* and fixation of the abdominal internal oblique muscle and transverse muscle at the inguinal ligament by suture (a **_nonmesh repair_) [https://www.youtube.com/watch?v=NIJaYVmLzO8](https://www.youtube.com/watch?v=NIJaYVmLzO8)**
LAPAROSCOPIC SURGERY (mesh only)
**Transabdominal **_pre_**peritoneal** repair (TAPP): laparoscopic, _preperitoneal_ mesh implementation between the parietal peritoneum and transverse fascia
**Total **_extra_**peritoneal repair** (TEP): laparoscopic, extraperitoneal mesh implementation between _parietal peritoneum_ and _transverse fascia_
34
DEFINITINON of Femoral hernia
_acquired_ downward protrusion of the peritoneal contents through the femoral ring into the femoral canal
35
Which gender is 4x more likely to experience a Femoral Hernia
women are 3-4x more likely
due to the increased **width** of the _female pelvis_
femoral hernia accounts for 40% of all complicated hernias
36
epidemiology and RF of FEMORAL hernia
women
increasing age 40-70 y/o - reduxed strength of Inguinal ligament w/ age
rare in children as it's almost exclusivley acquired
rf
mx pregnancies
increasing age
increased abdominal pressure
* Obesity
* Multiparity
* Chronic constipation
* Chronic cough (e.g., due to COPD)
* Straining during micturition (e.g., due to prostatic hypertrophy)
37
Anatomy of the Femoral Canal
length
NAVEL: (from lateral to medial) femoral Nerve, Artery, Vein, Empty space (femoral canal → femoral hernia), Lymphatics
3cm long
## Footnote
Anterior: inguinal ligament (Poupart's ligament)
Posterior: pubic ramus and pectineal ligament
Medial: lacunar ligament (Gimbernat ligament)
Lateral: femoral vein (hernia is medial to them)
38
Contents of femoral triangle
NAVEL
lateral to medial
femoral **N**erve, femoral **A**rtery, femoral **V**ein, **E**mpty space = _femoral canal_ where femoral hernia occurs **L**ymphatics
39
which type of hernia is susceptible to **_incarceration_**
FEMORAL HERNIA
d/2 narrow femoral ring that increases risk of incarceration
40
Clinical feature of FEMORAL hernia
symptom: Possibly, non-specific, dragging pain and swelling
signs
INSPECTION
Thin Elderly Female
swelling in the groin
* Localization: inferior to the inguinal ligament, lateral to the pubic tubercle, and medial to the femoral vein
* Swelling enlarges with coughing (palpable cough impulse) or a Valsalva maneuver
PALPATION
* bruit
41
Diff diag of FEMORAL HERNI
1. Lymph node Enlargement
2. direct/indirect inguinal hernia in obese ppl
3. Femoral psudohernia (proninant inguinal fat pad in slim ppl
42
how to dg betw/ lymph node enlargement and femoral hernia
LN enlargement is
HARD & FIXED
assoc w/ Fever
43
Treatment of Femoral Hernia
surgery to Find sac, Liberate hernia and Close Defect
OPEN
1. cooper ligament repair
2. Peritoneal approach
Laparoscopic
1. Intraabdominal cavity
2. Preperitoneal type
3. Retroperitoneal approach
44
What is an Umbilical Hernia
what usually herniate through an umbilical hernia
a Defect and Protrusion of abdominal contents or fat into the umbilical area
usually **omental fat**
45
2nd most common hernia causing strangulation
Umbilical Hernia
46
2 types of hernia
True Umbillical hernia - Congenital
Paraumbilical hernia - Acquired
47
What is a True umbilical hernia
cause
rf
Protution through the _umbilical orifice_ in children in **infants**
caused by a patent umbilical orifice
RF
* congenital anomalies e.g Down syndrome, trisomy 18
* Persistently raised intra-abdominal pressure
* Pneumonia (cough),
* ascites (due to renal/hepatic/cardiac causes),
* constipation (e.g., Hirschsprung disease) → increased intra-abdominal pressure before the complete closure of the umbilical orifice → umbilical hernia.
48
when does the umbilical orifice close
The umbilical orifice normally closes by 5 years of age.
49
What is a Paraumbilical hernia
etio
RF
Adjacent to the umbilical orifice (superior/inferior/lateral)
Acquired abdominal wall defect d/2 increased Ab P
RF for increased IntraAb P
* pregnancy 5x more common in women
* ascites,
* intra-abdominal tumors,
* chronic cough,
50
Where is the weakest point of an Umbilical scar for a Paraumbilical defect
the **superior** aspect of between the **umbilical vein**
51
cinical features betw/ paraumbilical and umbilical hernia
_true umbilical_ 1st pic
Mass protruding THROUGH the umbilicus/ @ umbilicas
Umbilicus itself is **paper thin**
Mass _increases_ on **crying**/coughing/straining; _reduced in size on lying down_
Hernia can be ***completely reduced*** (unless incarcerated)
_paraumbilical_ 2nd pic
Mass protruding ADJACENT to the umbilical orifice pushing the umbilicus into a crescent shape
Fascial defect is **small**
52
which kind of umbilical hernia has a low risk of Incarceration
True umbilical hernia in infants has a low risk of incarceration while acquired Paraumbilical hernias have high risk *d/2 small fascial defect*
53
dx dg of true umbilical hernia
**_Omphalocele_ =** Congenital visceral malformation in which _organs herniate at the midline abdominal wall **through the umbilicus** into a hernial **sac**_. Associated with extra abdominal
* *Beckwith-Wiedemann* syndrome
* trisomies
**_Gastroschisis_** = Congenital visceral malformation with **paraumbilical herniation** of the intestine _through the abdominal wall_, most commonly on the **right side**. The herniated organs are **not covered by a sac**. Seen in **premature infants** and _associated with **bowel** abnormalities_ (e.g., atresia, malrotation, or stenosis from vascular compromise). _Extra-gastrointestinal comorbidities are uncommon_ (*unlike in omphalocele*).
54
treatment of true hernias
Conservative: ∼ 90% will spontaneously close by 5 years of age
Surgery if: 1)Incarcerationlarge hernias 2)Large defects 3) closure doesn't occur by 5,
* small incision
* reinforce w/ mesh
if baby is 5/6 use **_coin tape method_** for the first 3-4 months
55
treatment of Parahernia
Surgery w/ mesh in all cases d/2 high risk of incarceration
56
What is an EPIGASTRIC hernia
herniation _through the **linea alba**_, between the _xiphoid_ process and the _umbilicus_
Although the hernial defect is usually small (\< 2 cm), incarceration/strangulation of the hernia contents (mostly omentum) is rare.
Symptomatic epigastric hernias (pain, incarceration) should be surgically repaired by **suturing of the defect** primarily. Mesh repair is rarely needed.
57
Define Incisional hernia
Hernia of abdominal contents through a defect in the abdominal wall from **previous abdominal surgery**
occurs in 15% of pts with abdom surgery
58
RF for INCISIONAL hernia
5
1. laparotomy of the upper midline
2. emergency abdominal surgeries
3. wound dehiscence
4. poor wound healing
5. post op infections
59
sx of Incisional hernia
Most (∼ 75%) incisional hernias occur **within 3 years** of surgery
Mass/protrusion at the **site of the incisional scar** which _increases with coughing/straining_
Edges of the hernial defect can be palpated when reducing the hernia
60
treamtent of incisional hernia
how does the neck determine treatment type
when is surgery indicated
when is mesh repair done fo incisional hernia
_Conservative_ management is indicated in:
* **Asymptomatic** incisional hernias, with a **wide neck;**
* Patients who are at a **high anesthetic risk** (advanced age, multiple comorbidities)
_Surgery_ is indicated in **symptomatic**/complicated hernias or those with a **narrow neck.**
1. **Small** incisional hernias (**\< 3 cm** defect): _primary repair_
2. **Larger** incisional hernias: hernioplasty (**mesh repair**)
61
HIATIAL hernia definition
mc herniated structure
**Protrusion of any abdominal** structure/organ into the **thorax** through a **lax** _diaphragmatic esophageal_ **hiatus**.
(In 95% of cases, a _portion of the stomach_ is herniated.)
62
4 types of HIATIAL hernia
which is mc
which is rarest
Type I: **Sliding** hiatal hernia. (95% of cases)
* **GEJ** and the gastric **cardia** slide up into the posterior mediastinum.
* The gastric _fundus remains below the diaphragm._
Type II: **Paraesophageal** hiatal hernia aka _ROLLING_ hernia
* Part of the **gastric fundus** herniates into the thorax.
* The _GEJ remains in its anatomical position below the diaphragm._
* __**upside down stomach** is an extreme variant
Type III: **Mixed** hiatal hernia (types I and II)
* The **GEJ**(1) and a portion of the gastric **fundus**(2) prolapse through the hiatus.
Type IV: **Complex** hiatal hernia (Rarest type)
* Herniation of _any abdominal structure other than the stomach_ (e.g., spleen, omentum, or colon)
63
What is an upside down stomach paraesophageal hernia
a rare type of paraesophageal hernia in which the **entire stomach** herniates into the thoracic cavity and **rotates** on its organoaxial axis.
It is associated with a _high mortality and morbidity_ rate due to **strangulation of the stomach.**
64
normal anatomy of the Esophageal hiatus
_Esophageal hiatus_: **_T10_**
central opening of the diaphragm, **vagus nerve** *&* the *_esophagus_ to pass through into the peritoneal cavity*;
forms the upper part of the esophageal sphincter and the reflux barrier
Formed by:
1. Left and right paravertebral tendinous crura
2. Median arcuate ligament
65
normal anatomy of the
Gastroesophageal junction (GEJ)
what maintains it's position in the abdomen
seperates the Oesopgus from the stomach via athe **_Z-line_**
Normally lies at the _level of the **esophageal hiatus**_
**Phrenoesophageal ligament** (PEL) attaches to the esophagus at the GEJ
* Peritoneal fold that encircles the distal portion of the esophagus and gastroesophageal junction and connects them to the peritoneal surface of the diaphragm
* Enables longitudinal motion of the esophagus during respiration and swallowing.
* _Closes the esophageal hiatus_ and helps maintain the in_tra-abdominal position of the GEJ_
66
RF & PP of HIATAL hernia
* ***_Relative negative intrathoracic_*** pressure compared to Abdominal pressire
* + the ***_lax hiatus_***
* → herniation of the abdominal contents into the thorax along P gradient
* → _loss of reflux barrier_ + compromised fluid emptying of distal esophagus
* → gastroesophageal reflux disease (**GERD**)
Predisposing factors lead to laxity of the esophageal hiatus, e.g.:
1. Advanced age → ***phrenoesophageal** ligament _weakens_*
2. Smoking → *loss of elastin fibres* in the **diaphragmatic crura**
3. Obesity → deposition of **fat** in and **_around the crura_** → **widened hiatus**
67
general Clinical features of HIATAL HERNIA
* intermittent dysphagia
* d/t acute obstruction caused by an angled GEJ preventing passage of food
* chest and abdominal pain
* visceral tension and ischemia
* GIT bleeding
* mucosal ucleration where the stomach folds back on itself
* dyspepsia (heartburn)
*
68
sx of type 1 hiatal hernia
GERD SX
69
SX for type 2 and above
Epigastric/substernal pain
Early satiety
Retching
SAINT'S TRIAD cholelithiasis, diverticulosis, and hiatal hernia may occur in ∼ 1.5%
70
saints triad
CHO DIVE HIs and HERs suicide marytrs
**cho**lelithiasis, **dive**rticulosis, and **hi**atal **her**nia may occur in ∼ 1.5%
71
dg of Hiatial hernia
**_Barium swallow_**: most sensitive test
* Assesses type and size of a hernia (including location of the stomach and the GEJ)
**_Endoscopy_**: used to diagnose hiatal hernia and evaluate for possible _complications_
* Types **1** and **3** *(sliding & Mixed)*: Z-line lies **above** the diaphragmatic hiatus
* Types **2** and **4** *(rolling & complex)*: Z-line **below** the diaphragmatic hiatus
**_Manometery_**: calculates the _size_ of a **sliding hiatal** hernia by accur*_ately identifying the level of the diaphragmatic hiatus_*
**_Esophageal pH monitoring:_** determining the extent of gastroesophageal reflux
EVERY HIATAL HERNIA PT SHOULD BE SCREENED FOR GERD
**_CT_**: used for diagnosing COMPLICATION in emergency sitch
72
conservative rx of hiatial hernia
Conservative:
1. _Change L/S_ : lose weight, stop smoking,
2. _antiGERD_ rx:
* **PPI**,
* **H2 blockers**
* Effective at suppressing postprandial acid secretions, but not effective at suppressing fasting acid secretions
73
Surgical rx of HIATIAL HERNIA
laparoscopic/open **fundoplication** + **hiatoplasty** + **fundopexy**
_fundoplication_
gastric fundus is wrap_ped around the lower esophagus to form a cuff,_ effectively narrowing the distal esophagus and the gastroesophageal junction to _prevent reflux of stomach contents_. Used to treat gastroesophageal reflux disease (**GERD**) and **hiatal hernia**.
_hiatoplasty_
esophageal **hiatus is narrowed** either by adding a piece of **mesh** or by br_inging part of the diaphragm together with sutures._
_fundopexy_
gastric **fundus** is **hitched** to the **diaphragm** to _minimize risk of recurrence_.
74
Complications of HIATIAL HERNIA
type 1 and 2
Complications of type I : from **long-standing gastroesophageal reflux**
* 1) **Reflux esophagitis** → 2) **Esophageal stricture** 3) **Iron deficiency** anemia: mucosal erosions and ulcerations → chronic bleeding → anemia, 4) **Barrett esophagus:** _Reflux esophagitis_ → *stomach acid damages squamous epithelium → squamous epithelium becomes replaced by columnar epithelium and goblet cells (intestinal metaplasia, Barrett's metaplasia)*
Complications of type II, III, IV: from **vascular compromise** of the herniated portion of the _stomach_, which leads to **mucosal ischemia**
1. Upper GIT bleeding (occult/massive)
2. Gastric ulcers
3. Gastric perforation
4. Gastric volvulus
5. Total gastric obstruction
