42 - 46 Hernias Flashcards
groin hernia femoral hernia umbilical hernia & Epigastric paraesophageal hernias
Hernia DEFINITION
most common types
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
what are the elements of a hernia
- Hernial sac- lined by peritoneum
- Hernial contents inside the sack and make up the body
- Hernial neck- loc at innermost musculoapeneurotic layer
what can hernias contain / what can be found w/in the contents of a hernia
OSLABO
Omentum
S.I
L.I
Appendix
Bladder
Ovaries
what are the 3 types of complications you can get from hernias
Incarcerations
Strangulation
Intestinal Obstruction
What is an Incarcerated hernia
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
what is an Intestinal obstruction 2ndary to hernia
what are the 4 cardinal sx
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
Strangunated hernias
why is the most severe complication
signs and sx
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
rx of obstructed heria
infants- taxis (manual reduction) w/in 2 hrs if low suspicion of strangulation
hold neck and reduce hernia w/o excess pressure
Pathogenesis of Strangulated hernia
-
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
treatment of streangulated hernia
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
specific surgical steps to strangulatio repair
hErErnia extra err cause it’s strangulated
- Expose hernia by opening the sac
- remove gangrenous portion
- End 2 End anastomoses of viable portions
- reduce the hernia
What is a RIchter’s hernia
which part is affected
most serious complication
part of the antimesenteric wall of the small intestine
sincd only one wall is herniated the lumen is still intact
Complication = Perforation => peritonitis
what is a Maydl’s hernia
where is the obstruction
when is there a high degree of suspicion
what is CONTRAINDICATED in this case
suspected in Incarcerated hernias w/ peritonitis
Taxis is CONTRAINDICATED => misses the non viable bowel
What are the 2 types of Groin hernias
- Inguinal
- direct
- indirect
- Femoral
Anatomy of the Inguinal canal
- length
- boundaries (ant, post, sup, inf)
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
contents of inguinal canal in men
Spermatic cord
Vas deferens
Ilioingional nerve
contents of inguinal canal in women
Round ligament of the Uterus
ilioinguinal nerve
what is the most common external abdominal hernia
which side predominates
Inguinal hernias = 80% of all external abdominal hernias
- infants and elderly >
- men> (1/4)
- Right side>>
hesselbach’s triangle
aka
medial inguinal fossa
aka
inguinal trianlge
which inguinal hernia is Congenital
Indirect hernia
indirect hernia
etio
loca m & f
- 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
when does processus vaginalis regress normally
complete Obliteration at 28wks gestation
what the processes vaginalis
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.
RF for Indirect inguinal hernia
Mechanical disparity bet/w
Visceral pressure and Abdom wall resistentance caused by increased Pressure
- pregnancy
- coughing obesity
sx of Indirect hernia
which hernia is acquired (adult type)
Direct hernia
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 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
which type of hernia has NO RISK of obstruction / strangulation
Direct hernia ?
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
which hernia can be associated with a communicating hydrocele
INDIRECT INGUINAL
b/c of patent processus vaginalis
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
diagnosis of Hernia
CLINICAL DG based on si and sx (history & phys exam)
US can be used to confirm dg
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
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
DEFINITINON of Femoral hernia
acquired downward protrusion of the peritoneal contents through the femoral ring into the femoral canal
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
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)
Anatomy of the Femoral Canal
length
NAVEL: (from lateral to medial) femoral Nerve, Artery, Vein, Empty space (femoral canal → femoral hernia), Lymphatics
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)
Contents of femoral triangle
NAVEL
lateral to medial
femoral Nerve, femoral Artery, femoral Vein, Empty space = femoral canal where femoral hernia occurs Lymphatics
which type of hernia is susceptible to incarceration
FEMORAL HERNIA
d/2 narrow femoral ring that increases risk of incarceration
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
Diff diag of FEMORAL HERNI
- Lymph node Enlargement
- direct/indirect inguinal hernia in obese ppl
- Femoral psudohernia (proninant inguinal fat pad in slim ppl
how to dg betw/ lymph node enlargement and femoral hernia
LN enlargement is
HARD & FIXED
assoc w/ Fever
Treatment of Femoral Hernia
surgery to Find sac, Liberate hernia and Close Defect
OPEN
- cooper ligament repair
- Peritoneal approach
Laparoscopic
- Intraabdominal cavity
- Preperitoneal type
- Retroperitoneal approach
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
2nd most common hernia causing strangulation
Umbilical Hernia
2 types of hernia
True Umbillical hernia - Congenital
Paraumbilical hernia - Acquired
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.
when does the umbilical orifice close
The umbilical orifice normally closes by 5 years of age.
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,
Where is the weakest point of an Umbilical scar for a Paraumbilical defect
the superior aspect of between the umbilical vein
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
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
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).
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
treatment of Parahernia
Surgery w/ mesh in all cases d/2 high risk of incarceration
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.
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
RF for INCISIONAL hernia
5
- laparotomy of the upper midline
- emergency abdominal surgeries
- wound dehiscence
- poor wound healing
- post op infections
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
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.
- Small incisional hernias (< 3 cm defect): primary repair
- Larger incisional hernias: hernioplasty (mesh repair)
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.)
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)
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.
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:
- Left and right paravertebral tendinous crura
- Median arcuate ligament
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_
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)
- → loss of reflux barrier + compromised fluid emptying of distal esophagus
- → herniation of the abdominal contents into the thorax along P gradient
- the lax hiatus
Predisposing factors lead to laxity of the esophageal hiatus, e.g.:
- Advanced age → phrenoesophageal ligament weakens
- Smoking → loss of elastin fibres in the diaphragmatic crura
- Obesity → deposition of fat in and around the crura → widened hiatus
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)
*
sx of type 1 hiatal hernia
GERD SX
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%
saints triad
CHO DIVE HIs and HERs suicide marytrs
cholelithiasis, diverticulosis, and hiatal hernia may occur in ∼ 1.5%
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 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
conservative rx of hiatial hernia
Conservative:
- Change L/S : lose weight, stop smoking,
-
antiGERD rx:
- PPI,
-
H2 blockers
- Effective at suppressing postprandial acid secretions, but not effective at suppressing fasting acid secretions
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.
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
- Upper GIT bleeding (occult/massive)
- Gastric ulcers
- Gastric perforation
- Gastric volvulus
- Total gastric obstruction
