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general surgery > 42 - 46 Hernias > Flashcards

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

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2
Q

what are the elements of a hernia

A
  1. Hernial sac- lined by peritoneum
  2. Hernial contents inside the sack and make up the body
  3. Hernial neck- loc at innermost musculoapeneurotic layer
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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

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4
Q

what are the 3 types of complications you can get from hernias

A

Incarcerations

Strangulation

Intestinal Obstruction

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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

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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
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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
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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

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9
Q

Pathogenesis of Strangulated hernia

A
  1. Straining
    • pushes more bowl into sac
    • exerts more pressure on hernial neck
  2. Venous congestion
    • leads to bowel oedema
    • exerts even more pressure on the arteries
  3. Blocked arterial supply
    • leads to ischemia and gangrene
    • making it non viable
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10
Q

treatment of streangulated hernia

A

emergency rx

  1. rapid ressuscitation
    • airway NGT
    • circulation: fluid replacement
  2. antibiotic therapy
  3. surgical hernial repair
    • expose hernia by opening the sac
    • remove gangrenous portion
    • End 2 End anastomoses of viable portions
    • reduce the hernia
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11
Q

specific surgical steps to strangulatio repair

hErErnia extra err cause it’s strangulated

A
  1. Expose hernia by opening the sac
  2. remove gangrenous portion
  3. End 2 End anastomoses of viable portions
  4. reduce the hernia
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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

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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

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14
Q

What are the 2 types of Groin hernias

A
  1. Inguinal
    • direct
    • indirect
  2. Femoral
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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

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16
Q

contents of inguinal canal in men

A

Spermatic cord

Vas deferens

Ilioingional nerve

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17
Q

contents of inguinal canal in women

A

Round ligament of the Uterus

ilioinguinal nerve

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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>>
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19
Q

hesselbach’s triangle

aka

medial inguinal fossa

aka

inguinal trianlge

A
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20
Q

which inguinal hernia is Congenital

A

Indirect hernia

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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
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22
Q

when does processus vaginalis regress normally

A

complete Obliteration at 28wks gestation

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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

  1. communicating hydrocele and/or an
  2. infantile inguinal hernia.
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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
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25
Q

sx of Indirect hernia

A
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26
Q

which hernia is acquired (adult type)

A

Direct hernia

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27
Q

What is a direct hernia

location

etiology

A

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 40years

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

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28
Q

which type of hernia has NO RISK of obstruction / strangulation

A

Direct hernia ?

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29
Q

sx of INGUINAL hernia

A

abdominal distension and pain worse w/ physical activity (standing, coughing, walking)

Visible bulge in testicle/ vaginal labia that dissapears when laying down

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30
Q

which hernia can be associated with a communicating hydrocele

A

INDIRECT INGUINAL

b/c of patent processus vaginalis

31
Q

physical exam of Inguinal hernia

A

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
Q

diagnosis of Hernia

A

CLINICAL DG based on si and sx (history & phys exam)

US can be used to confirm dg

33
Q

treatment of INGUINAL hernias

A

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

LAPAROSCOPIC SURGERY (mesh only)

Transabdominal preperitoneal repair (TAPP): laparoscopic, preperitoneal mesh implementation between the parietal peritoneum and transverse fascia

Total extraperitoneal repair (TEP): laparoscopic, extraperitoneal mesh implementation between parietal peritoneum and transverse fascia

34
Q

DEFINITINON of Femoral hernia

A

acquired downward protrusion of the peritoneal contents through the femoral ring into the femoral canal

35
Q

Which gender is 4x more likely to experience a Femoral Hernia

A

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
Q

epidemiology and RF of FEMORAL hernia

A

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
Q

Anatomy of the Femoral Canal

length

NAVEL: (from lateral to medial) femoral Nerve, Artery, Vein, Empty space (femoral canal → femoral hernia), Lymphatics

A

3cm long

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
Q

Contents of femoral triangle

NAVEL

lateral to medial

A

femoral Nerve, femoral Artery, femoral Vein, Empty space = femoral canal where femoral hernia occurs Lymphatics

39
Q

which type of hernia is susceptible to incarceration

A

FEMORAL HERNIA

d/2 narrow femoral ring that increases risk of incarceration

40
Q

Clinical feature of FEMORAL hernia

A

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
Q

Diff diag of FEMORAL HERNI

A
  1. Lymph node Enlargement
  2. direct/indirect inguinal hernia in obese ppl
  3. Femoral psudohernia (proninant inguinal fat pad in slim ppl
42
Q

how to dg betw/ lymph node enlargement and femoral hernia

A

LN enlargement is

HARD & FIXED

assoc w/ Fever

43
Q

Treatment of Femoral Hernia

A

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
Q

What is an Umbilical Hernia

what usually herniate through an umbilical hernia

A

a Defect and Protrusion of abdominal contents or fat into the umbilical area

usually omental fat

45
Q

2nd most common hernia causing strangulation

A

Umbilical Hernia

46
Q

2 types of hernia

A

True Umbillical hernia - Congenital

Paraumbilical hernia - Acquired

47
Q

What is a True umbilical hernia

cause

rf

A

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
Q

when does the umbilical orifice close

A

The umbilical orifice normally closes by 5 years of age.

49
Q

What is a Paraumbilical hernia

etio

RF

A

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
Q

Where is the weakest point of an Umbilical scar for a Paraumbilical defect

A

the superior aspect of between the umbilical vein

51
Q

cinical features betw/ paraumbilical and umbilical hernia

A

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
Q

which kind of umbilical hernia has a low risk of Incarceration

A

True umbilical hernia in infants has a low risk of incarceration while acquired Paraumbilical hernias have high risk d/2 small fascial defect

53
Q

dx dg of true umbilical hernia

A

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
Q

treatment of true hernias

A

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
Q

treatment of Parahernia

A

Surgery w/ mesh in all cases d/2 high risk of incarceration

56
Q

What is an EPIGASTRIC hernia

A

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
Q

Define Incisional hernia

A

Hernia of abdominal contents through a defect in the abdominal wall from previous abdominal surgery

occurs in 15% of pts with abdom surgery

58
Q

RF for INCISIONAL hernia

5

A
  1. laparotomy of the upper midline
  2. emergency abdominal surgeries
  3. wound dehiscence
  4. poor wound healing
  5. post op infections
59
Q

sx of Incisional hernia

A

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
Q

treamtent of incisional hernia

how does the neck determine treatment type

when is surgery indicated

when is mesh repair done fo incisional hernia

A

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
Q

HIATIAL hernia definition

mc herniated structure

A

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
Q

4 types of HIATIAL hernia

which is mc

which is rarest

A

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
Q

What is an upside down stomach paraesophageal hernia

A

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
Q

normal anatomy of the Esophageal hiatus

A

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
Q

normal anatomy of the

Gastroesophageal junction (GEJ)

what maintains it’s position in the abdomen

A

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
Q

RF & PP of HIATAL hernia

A
  • 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
Q

general Clinical features of HIATAL HERNIA

A
  • 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
Q

sx of type 1 hiatal hernia

A

GERD SX

69
Q

SX for type 2 and above

A

Epigastric/substernal pain

Early satiety

Retching

SAINT’S TRIAD cholelithiasis, diverticulosis, and hiatal hernia may occur in ∼ 1.5%

70
Q

saints triad

CHO DIVE HIs and HERs suicide marytrs

A

cholelithiasis, diverticulosis, and hiatal hernia may occur in ∼ 1.5%

71
Q

dg of Hiatial hernia

A

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 accurately 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
Q

conservative rx of hiatial hernia

A

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
Q

Surgical rx of HIATIAL HERNIA

A

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
Q

Complications of HIATIAL HERNIA

type 1 and 2

A

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

general surgery (10 decks)

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