6.2 Hernias

Question 1

What are the 3 lateral abdominal wall muscles?

What 2 muscles lies down the midline, and what is their relationship with the lateral wall muscles?

Answer 1

External Oblique
Internal oblique
Transversus Abdominus

2 Rectus Abdominus muscles lie down the middle of the abdomen (lifting muscles) and are enclosed by the aponeurosis of the lateral abdominal wall muscles EXCEPT in the lower portion of the abdomen where below the arcuate line there is no posterior sheath

Question 2

Define a Hernia

Answer 2

A hernia is an abnormal protrusion of a cavity’s contents through a weakness in the wall of the cavity, taking with it the linings of that cavity.

Question 3

What is the relationship between hernias and protrusions?

Answer 3

A hernia is a protusion; not all protusions are hernias

Question 4

List and briefly describe 4 common Hernias in the abdomen

Answer 4

Inguinal hernias - these are very common.
Umbilical hernia’s - these only occur ONLY in babies
Para-umbilical hernias - these occur in adults
Epigastric hernias - occur in the midline down the linea alba

Question 5

What is the line in the middle of the abdomen called?

What are the lines either side of the rectus abdominus muscles called?

Answer 5

In the middle we have the linea alba

Either side of the rectus abdominus muscles we have the linea semilunaris

Question 6

What is the difference between a direct vs indirect hernia?

Answer 6

Direct Hernias: Occur within the “weak area” within Hesselbach’s triangle (usually acquired muscle weakness)

Indirect Hernias: occur at the deep inguinal ring (usually a congenital weakness)

Question 7

Give 7 causes why someone may be at an increased risk of Hernias?

Answer 7

1) Design weakness ➞ eg. the myopectinate orifices (area of inguinal canal)
2) Entry/Exit of structures through the abdominal wall causes weakness.
3) Developmental failures ➞ failure of processes vaginalis to obliterate following decent of testis
4) Collagen disease
5) Increasing age ➞ due to weaking of the abdominal wall.
6) Pregnancy ➞ hormones make ligaments slack + enlarging uterus. These cause abdominal wall to stretch, which can lead to the umbilical or inguinal hernia.
7) Smoking ➞ destroys CT in the body

Question 8

Give 4 examples of structures entering/exiting the abdominal wall that may lead to Hernias

Answer 8

1) Spermatic cord passing through the deep inguinal ring
2) Femoral vessels passing under the inguinal ligament into the leg
3) Oesophagus passing through the oesophageal hiatus in the diaphragm
4) Obturator nerve passing through the obturator foramen

Question 9

What 2 structures does the Inguinal ligament run between?

What is the midpoint called?

What can be found at the mid-inguinal point?

Answer 9

The inguinal ligament runs from the ASIS to the pubic tubercle.

The midpoint is the “mid-point inguinal”

The femoral artery can be found at the mid-inguinal point

Question 10

What is the myo-pectineal orifice? What type of hernias can this lead to?

Answer 10

a weak area in the groin ➞ can leads to the formation of direct and indirect hernias.

Question 11

What are the boarders of Hesselbach’s Triangle?

Why is this area prone to Hernias?

Answer 11

Boarders:
Medial – lateral border of the rectus abdominis muscle
Lateral – inferior epigastric vessels
Inferior – inguinal ligament

There is no strong tissue in this area ➞ prone to Hernias

Question 12

What is the main causes of a Femoral Hernia?

Compare a femoral hernia to an inguinal hernia (how common, strangulation, treatment)

List one problem it can lead to

Answer 12

Femoral hernias are caused by the inflexibility of the lacunar ligament (F>M)

Less common than an inguinal hernia but more likely to strangulate. Inguinal Hernias can be treated laparoscopically, femoral MUST have surgery

Can cause bowel obstruction

Question 13

How do we examine a patient with a groin hernia?

Answer 13

Stand patient up, palpate groin area and ask them to cough ➞ this should reveal the hernia (can be felt)

However, if hernia still cannot be felt because it is too small, an invagination test can be performed

Invagination test: invaginate scrotum and place ring finger into the inguinal canal (can be very painful). Ask patient to cough again and If the hernia is small you should feel the cough impulse at the deep ring

Question 14

During he invagination test why should a small hernia be felt at the deep inguinal ring?

Answer 14

Because this is where the Hernia will start before it enlarges down the inguinal canal and into the scrotum

Question 15

List 3 generic causes of lumps around the groin area

Answer 15

1) Lymph node
2) Lipoma
3) Sebaceous cyst

Question 16

List 6 specific causes of lumps around the groin area

Answer 16

1) Inguinal Hernia (direct or Indirect)
2) Femoral Hernia
3) Sapheno-varix
4) Hydrocoele of the cord
5) Ectopic Testis
6) Psoas Abscess

Question 17

What is a Sapheno-varix?

What is Hydrocoele of the cord + the female equivalent

Where can Ectopic testis be found?

What is a Psoas Abscess

Answer 17

Saphennous-varix ➞ venous aneurysm at the junction where the great saphennous vein descends through the cribriform fascia and joins the deep saphenous vein

Hydrocoele of the cord ➞ If the process vaginalis partially obliterates below and above it, leaving fluid between it (in females ➞ hydrocoele of the canal of nuck)

Ectopic testis - can be found anywhere along the path of decent

Psoas Abscess - abscess from TB of the spine that drains down the illipsoas muscle and appears in the groin

Question 18

List the 5 types of hernia based on complexity and what each is

Answer 18

Occult - small hernias that cannot be seen

Reducible - a hernia with a bulge that flattens out when you lie down or push against it gently

Irreducible (incarceration)- herniated tissue becomes trapped and cannot easily be moved back into place

Strangulation - hernia that has had its venous blood supply cut off

Infarcted - can be caused strangulation and venous gangrene

Question 19

Which type of hernia can give you strangulation without bowel obstruction?

Answer 19

Richter’s Hernia

Question 20

What causes a Richter’s Hernia?

Why does this give you strangulation without obstruction?

Answer 20

Occurs when the antimesenteric wall of the intestine protrudes through a defect in the abdominal wall

Can result in strangulation and necrosis without intestinal obstruction

Question 21

What causes a sliding hernia?

What can therefore be said about its locations

Answer 21

This is a form of diaphragmatic hernia when a retroperitoneal structure “slides” down the posterior abdominal wall and herniates directly or indirectly into the inguinal canal, dragging overlying peritoneum with it.

Thus, sliding hernias lie behind and outside the peritoneal sac.

Question 22

List 2 GI tract structures that can be involved in a sliding hernia and why?

Answer 22

1) Sigmoid sliding hernia
2) Caecum and Apendix sliding hernia

because these are both retroperitoneal structures

Question 23

What is a Pantaloon hernia?

Answer 23

This is a combined Direct and Indirect Hernia with the Inferior Epigastric vessels located between it

Question 24

What is an Umbilical hernia?

Answer 24

Occurs in children and newborns at the site of the umbilical cord. They often close spontaneously but surgery may be required if there is a danger of strangulation or has not self-resolved before school

Question 25

What is a Para-umbilical hernia? Who does it commonly affect?

Answer 25

Occurs in adults due to weakening of the tissues around the umbilicus.
Occurs through the Linea alba above or below umbilicus and in common in obese and multiparous women

Question 26

Where do Spigelian Hernias occur?

Answer 26

Occurs at the junction between the linea semilunaris and the arcuate line

Question 27

What is an Incisional Herniae?

Answer 27

An Incisional Hernia occurs through a previously made incision in the abdominal wall due to the scar left from a previous surgical operation

Often because collagen fibres haven’t healed correctly

Incisional hernias are normally very large and often cause obstruction but NOT strangulation

Question 28

Give some predisposing factor to an Incisional Herniae

Answer 28

Patient factors:

• obesity
• malnutrition
• Immunosuppression
• Steroids
• chronic cough
• Cancer

Wound Factors:

• Poor tissue
• Wound infection

Surgical factors:

• Suture material
• Suturing technique

Question 29

What is Divarication of Recti? (Diastasis)

Answer 29

A bulge cause above the Linea Alba
No danger of obstruction or Strangulation ➞ it is caused when the muscles come apart (often unfit people, or in pregnancy)

Treatment Only for Cosmesis

Question 30

What is a Para-Stomal Herniae? What is a major cause?

Answer 30

Commonly caused by Colostomy’s because the sides of the incision are very weak meaning parts of the bowl can get stuck.

It can obstruct and strangulate

A Para-stomach hernia can cause the stoma bag to not fit correctly which can result in major leakage

Question 31

What is a Lumbar Hernia?

Answer 31

It is a very rare external herniae ➞ defect in the postero-lateral abdominal wall (defect in the triangle of petit)

Question 32

What is a Obturator Hernia?

Answer 32

Obturator hernia comes through the obturator canal.
Can cause pain as the obturator nerve comes through this area also

Commonly presents with leg pain and bowel obstruction

Question 33

What are 2 main treatments for hernias

Answer 33

1) operative: open (general or local anaesthetic) laparoscopic (TAPP or TEPP)
2) non-operative: Truss, no Treatment

Question 34

What are the 2 types of laparoscopic repair?

Answer 34

TAPP - transabdominal preperitoneal

TEPP - totally extraperitoneal repair

Question 35

What are the 4 main principals of hernia repair?

Answer 35

1) Try and obtain primary closure of muscle layer
2) Tension free
3) Laparoscopic reinforcement
4) Use of specialised meshes

Question 36

Give 2 causes of groin pain without a hernia?

Answer 36

1) Post-operative hernia repair

2) Sportsman’s groin

Question 37

What causes post-operative groin pain?

Answer 37

Nerve entrapment (main cause)
Stitch Mesh 
Scar tissue (can shrink and cause nerve to be pulled against)

Question 38

What are the 3 nerves found in the groin area that are at risk of damage in surgery?

Answer 38

1) Illioinguinal nerve - supplies a area of skin in the inner aspect of the thigh
2) Genitofemoral nerve
3) Illiohypogastric

Question 39

What causes Sportsman’s Groin?

Give 4 specific examples

Answer 39

Caused by tears in the muscles or joints

examples:

1) Torn external oblique aponeurosis
2) Conjoint tendon tear
3) Tear in the transversalis fascia
4) Entrapment of the ilioinguinal or genitofemoral nerve