6.2- Abdominal Wall and Hernias Flashcards
1
Q
What is the importance of everything below the arcuate line?
A
there is no posterior rectus sheath below arcuate line ie less layer at the bottom
2
Q
Define hernia
A
An abnormal protrusion of a cavity’s contents through a weakness in the wall of the cavity,
3
Q
What are the 4 common abdominal hernias?
A
- Epigastric in the midline; Linea alba or Linea Semilunaris
- Umbilicus; only in babies
- Inguinal
- Femoral
4
Q
What is a hiatus hernia?
A
- hernia through diaphragm
- can be:
- Sliding; shortens
- Rolling; bit of stomach comes through
5
Q
Which hernias are found in the groin?
A
-INGUINAL
- Direct; through hasselbach’s triangle
- Indirect; through deep inguinal ring
-FEMORAL
6
Q
What are the 7 types of VENTRAL hernias? (PESIPUP)
A
- Para-umbilical
- Epigastric
- Spighelian
- Incisional
- Para-stomal
- Umbilical
- Port Site
7
Q
What is the most common type of hernia and why?
A
- Inguinal
- more common in males bc the testicular apparatus is much more fragile than the round ligament of the uterus
8
Q
What are some general causes of herniae?
A
- Basic design weakness
- Weakness due to structures leaving/ entering the abdomen
- Developmental failures
- Collagen disease; hereditary hernias
9
Q
How can hernias develop from processus vaginalis?
A
- causes congenital indirect inguinal hernias if it does not close
- outpouching of peritoneal membrane that leads descent of testes and gubernaculum into scrotal sac
10
Q
WHEN can you get direct hernias?
A
- from muscle damage
- because muscles weaken with age; degenerative weakness of muscles and fibrous tissue
- abdominal wall gives way and a bulge occurs
11
Q
How can you get a hernia from pregnancy?
A
- uterus enlarges and puts pressure on pubic veins; causing varicosities
- if pressure increases you can get an INGUINAL hernia
- if abdominal wall gets stretched you can get an UMBILICAL hernia
from pregancy hormones, you can also get a subluxation of jointsto make ligaments slack for childbirth
12
Q
What are the two main landmarks in inguinal anatomy?
A
- Mid-point of inguinal ligament: halfway between the ASIS and the pubic tubercle
opening to inguinal canal is just above this point
- Mid-inguinal point: haflway between ASIS and pubic symphysis
you can locate the femoral artery here ie the femoral pulse here
13
Q
What is the weak area? (MPO)
A
Myo-Pectineal Orifice
- down the groin
- leads to indirect and direct inguinal hernias
14
Q
How can you get hernias at hasselbach’s triangle
A
because there is a space between the rectus abdominis and the inguinal ligament and the inferior arteries
hernia enlarges untill it gives way
15
Q
Define the cause of indirect inguinal hernias
A
- occur at deep inguinal ring
- usually congenital weakness
16
Q
Define the cause of direct inguinal hernias
A
- occur within the ‘weak area’ ie Myopectineal orifice within Hesselbach’s triangle
- usually acquired muscle weakness
- happens in old people
17
Q
Where are femoral hernias commonly seen?
A
- common in females but
- not as common inguinal hernias
- more likely to strangulate because of the inflexible lacunar ligament
-
ALWAYS refer for surgery/ repair
*
18
Q
How do femoral hernias form?
A
- very rigid borders of femoral canal esp lacunar ligament
- found infero-lateral to pubic tubercle
- median to femoral pulse
19
Q
How do you distinguish between inguinal and femoral hernias?
A
- examine the landmar of each to decide because incisions are different
- if it is a femoral hernia then you HAVE to send the patient for surgery
20
Q
How do you examine a patient with a groin hernia?
A
- examine standing up
- ask them to cough and feel and look for a cough impulse
if the hernia is not visible by standing,
- do the Invagination Test; invaginate the scrotum; finger goes up the inguinal canal
- hope to feel a cough impulse at the internal inguinal ring if a small hernia
21
Q
What are the generic differential diagnoses of a groin hernia? (3) LLS
A
- lymph node
- lipoma
- sebaceous cyst
22
Q
What are the specific differentials for a groin hernia?
A
- inguinal( direct or indirect)
- femoral
- sapheno-varox; small venous aneurysm at the junction where the long saphenous vein descends through the CRIBRIFORM FASCIA
- hydrocoele of the cord; processus vaginalis obliterates slightly above and below the spermatic cord ie a little fluid
In female, hydrocoele of the Canal of Nuck
- ectopic testes
- Psoas Abscess; from TB of spine ie Pott’s disease
abscess that travels from lumbar vertebrae down psoas sheath through iliacus muscle sheath
23
Q
What are the types of hernias?
A
- Occult ; cannot see them
- Reducible; can be pushed back into the abdomen by manual pressure
- Incarcerated; when herniated tissue becomes trapped and cannot easily be pushed back into place
- Strangulated; blood supply gets compromised
- Infarcted
24
Q
What is a strangulated hernia?
A
medical emergency
pressure in IVC is low and high in arteries
- low pressure venous blood gets cut off first and arterial blood will pour into the bowel
- therefore you get a venous gangrene therefore the veins loose their arterial pressure
- ie you get a VENOUS INFARCTION
25
Which hernia can give you strangulation without obstruction?
* Richter's hernia
* ie stopped flow of contents
26
What is a Richter's hernia?
* occurs when antiesenteric wall of intestine protrudes through a defect in the abdominal wall
* can result in strangulation and necrosis **in the absence of intestinal obstruction**
27
What is a hernia en glissade?
* sliding hernia
* retroperitoneal structure slides down the abdominal wall and herniates directly or indirectly into inguinal canal, dragging overlying peritoneum with it.
Thus sliding hernias lie behind and outside the peritoneal sac
28
# Define:
a) Sigmoid sliding hernia
b) Caecum and appendix sliding hernia
a) sigmoid colon has formed part of the wall of the hernia sac
b) caecum forms part of the sac
if you push a part of the abdominal wall into ther hernia; then it takes the retroperitoneal structure with it BECAUSE the sigmoid colon and caecum are retroperitoneal structures, covered in visceral peritoneum
29
What is a pantaloon hernia?
* a combined direct and indirect herniae
* straddle the inferior epigastric vessels
* if the direct hernia comes through the MPO then it is a left-sided hernia
30
What is an umbilical hernia and where is it seen?
* in babies
* site of umbilical cord
* often closes spontaneously
* operate if in danger of stranguation or before school bc bullying
31
What is a para-umbilical hernia?
* adults
* weakening of tissues around umbilicus
* through the linea alba above or below umbilicus
* common in obesity or multiparous women
32
What are spigelian hernias?
* occurs at the junction between the linea semilunaris and the arcuate line
* therefore can classify it differently because of the different layers in the abdomen
33
Name the causes of an incisional hernia?
* infected surgery wound -----\> weak wound-------\> defective collagen
* obesity
34
What are some predisposing factors in a patient for incisional hernia ?
* obesity
* malnutrition
* immunosuppression
* steroids
* chronic cough
* cancer
35
What are the predisposing factors for an incisional hernia?
a) Wound factors
b) Surgical factors
a)
* poor tissue
* wound infection
b)
* suture material
* suture technique
36
What is diastasis?
* divarication of recti
* complete separation of rectus abdominis/ six pack
* common during pregnancy; uterus stretches muscles in the abdomen to accommodate the stomach
* *bulge over the linea alba; muscles have come apart*
* *leave alone; surgery only for cosmetic purposes*
37
What is a para-stomal hernia?
* weak area; portion of bowel gets stuck in abdominal wall
* gets obstructed and weak; then strangulates
* PROBLEM: bowel leakagae, para-stomal hernia bag has to fit over bowel wall
38
What are the risk factors of a para-stoma hernia?
* age over 60 years
* female
* BMI\> 25 KG/M2
39
What is a lumbar hernia?
* rare
* defect in postero-lateral abdominal wall
* hernia in Triangle of Petit
* bulges but does not strangulate
potential weaknesses: lat dorsi and external oblique can ger stretched; therefore hernia can enlarge and come through
40
What is an obturator hernia?
* comes through obturator canal
* weak because obturator nerve comes througgh tehre; can form a small gap but gradually enlarges; presents as hip pain
* _common in females_
* _leg pain_
* _bowel obstruction_
41
Why do we operate on hernias?
* painful or aching symptoms
* worrying bulge
* bowel obstruction
* risk of strangulation
42
What are the operative and non-operative treatments for inguinal hernia?
**_Operative:_**
* open surgery; give GA
* GA or LA
* Laparascopic (GA)
* TAPP- Transabdominal PrePeritoneal repair
* TEPP- Total Extra Pre-peritoneal repair
**_Non-operative:_**
* Truss- pushes hernia in
* no treatment
43
What are some principles of hernia repair?
* try and obtain primary closure of musle layer
* tension free
* laparoscopic reinforcement
* use of specialised meshes
44
Describe the purpose of specialised meshes in hernia repair?
* helps with healing
* mesh generates new tissue, requires adequate healing time
45
What are the 2 main causes of groin pain **without a hernia?**
* postoperative hernia repair
* sportsman's groin
because of nerve entrapment
46
What nerves in the inguinal region are at risk of damage in operation?
* Ilioinguinal N ( supplies skin in inner aspect of thigh)
* Genital branch of genito-femoral N ; supplies area on side of scrotum
* Iligastric N; supplies area above groin
47
Name the causes of nerve entrapment causing post-operative groin pain?
* stitch; can trap nerve
* mesh; can create too much scar tissue
* scar tissue; pulls and stretches; can get chronic disomfort
48
What is sportsman's groin pain?
* pain during sports movements; twisting/ turning
* pain radiates to adductor muscle region
Causes:
* torn external oblique aponeurosis
* conjoint tendon tear
* conjoint tendon torn from pubic tubercle
* tear in transversalis fascia
