7 - Hernias Flashcards
Hernia
Protrusion of tissue through the fascial, muscle layer or other barrier designed to contain them
Inguinal hernia
Originates above the inguinal ligament (MC type)
Femoral hernia
Originates below the inguinal ligament
Incarcerated
Not reducible
Strangulated
Incarcerated AND ischemic
Indirect inguinal hernia
Congenital hernia from patent processes vaginalis
Same congenital defect that causes hydroceles
Contents travel down spermatic cord
Most common hernia in both sexes
Presentation of indirect inguinal hernia
Bulge in groin
Can be acute or chronic
May be associated c N/V and ABD distention
Workup of indirect inguinal hernia
H and P
Quickly determine if incarcerated or strangulated
KUB may show ileus or free air
What test confirms hernia?
CT
Disposition for hernia
Routine if reducible
Urgent if incarcerated or strangulated
Surgical repair of hernia
Reduce it
High ligation of the hernia sac
Reconstruct and tighten the inguinal ring with mesh
Initial - open
Direct inguinal hernia
Acquired 2/2 weakened floor of the inguinal canal
Defect medial to the epigastric vessels
Does not pass through deep inguinal ring
Risk factors for direct inguinal hernia
Obesity • Pregnancy • Heavy lifting • Chronic cough • Straining to void (BPH/prostate ca) • Constipation • Cirrhosis with ascites • Pregnancy
Presentation of direct inguinal hernia
Bulging in the groin
May be acute or chronic
Normally doesn’t extend to the scrotum
May be associated with ABD distention, N/V
How to differentiate indirect from direct on PE
Deep palpation along spermatic cord
Pt valsalva - feel it on top of finger, indirect
Feel it medially - direct
Boundaries of Hasselbach’s triangle
Medially - lateral border of abd rectus muscle
Laterally - inferior epigastric artery
Inferiorly - inguinal ligament
Risks of inguinal hernia repair
Bleeding
Injury to surrounding structures (spermatic cord)
Recurrence
Infection
Femoral hernia
Passes below the inguinal ligament, medial to the femoral vein
More common in women
Incarcerated hernias
Can be well-perfused or ischemic
Camping pain, distention
Must operate prior to strangulation
Bowel ischemia -> necrosis -> perforation
Differentials for groin pain
Sports hernia • Lymphadenopathy • Undescended testis • Hydrocele • Epididymitis • Spermatocoele • Testicular torsion • Femoral artery aneurysm • Vericocele
Sports hernia
Not actually a hernia
Micro-tearing of fascia
Conservative txt
Hydrocele
Peritoneal fluid leaking into the sac
Congenital
Fluid filled sac
Usually non-tender
Transilluminates
DON’T ATTEMPT TO ASPIRATE - REFER
Epididymitis
Testicular pain
Associated with prostatitis or vasectomy
May see pyuria
Young dudes - STD panel, NSAIDs, scrotal support, ABX for STI’s
Old dudes - same txt - cover gram neg rods
Spermatocele
Fluid filled mass attached to epididymis
Normally nontender
Can become large
Benign finding
Confirm with US
Surgery
Varicocele
Bag o’ worms
Normally on the left
Surgery in spermatic vein occluded
Testicular CA
Masses are CA until proven otherwise
Urgent referral
Testicular torsion
Extreme pain N/V Sweating Normally after strenuous activity Tenderness in inguinal canal
Workup - urgent US with Doppler and surgical evaluation
If testes viable - re-profuse and perform orchiopexy
If ischemic-necrotic - cut it out
Epigastric hernia
Linea alba
Usually fat not bowel
No big deal
Umbilical hernia
Newborns - kids - close on their own
If still there by age 5, fix it
Rarely incarcerates
In adult? Slowly enlarge, may incarcerate - elective surgery (mesh over defect)
Incisional hernia
Previous op site
Weakening of surgical incision (inside only, outside still intact)
Wound dehiscence
Yellow-pink (salmon) colored fluid
Peritoneal fluid
Must return to OR to close it ASAP
Acute can lead to evisceration - urgent consult
Delayed (incisional hernia) - routine
Diastasis recti
Widening of the linea alba
Pregnancy
Obesity
Ascites
Large tumors
Not a hernia
Prominent midline bulge when patient raises head
Pain is weakness leaving the body
A hernia is intestines leaving the body
