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Year 3 - Met3a > A lump in the grion > Flashcards

A lump in the grion Flashcards

1
Q

What is the area of the groin

A
  • anterior superior illaic spine to the scrotum
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2
Q

where is the deep ring

A
  • midpoint at the inguinal ligament
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3
Q

what is the midpoint of the midinguinal point

A
  • femoral artery
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4
Q

What should you ask in a history for the lump in a groin

A
  • site of swelling
  • duration
  • how did it start
  • pain
  • changes in size
  • associated symptoms
  • any other lumps elsewhere
  • previous history of lumps
  • past medical history
  • family history
  • drugs
  • social history
  • review of systems
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5
Q

How do you examin the lump

A

6 Ss

  • site
  • size
  • shape
  • surface
  • conSistency
  • fieSity (fixity - attached to any other structures)
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6
Q

What questions should you ask yourself on groin examination

A
  • can i get above it
  • is it reducible
  • does it relate to anatomical landmarks
  • does it have a cough impulse
  • is it pulsatile
  • does it transilluminate
  • can i feel the testis separate from the lump
  • other lumps - such as lypmhadenoapthy
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7
Q

What are the differential diagnosis for lumps in the groin

A
  • Soft tissue lumps - lipoma, sebaceous cyst, abscess
  • hernia - femoral or inguinal
  • femoral artery aneurysm - expanding and pulsatile
  • saphena varix - comproendable, palpable thrill medial to femoral artery
  • enlarged lymph node - often multiple, mobile, firm and tender
  • undescended tested - empty scrotum
  • psoas abscess - fluctuant swelling lateral to an artery
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8
Q

what is a saphena varix

A
  • varice vein at the saphena femoral junction
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9
Q

What is a hernia

A
  • the abnormal protrusion of a viscus or part of a viscus through its normal coverings
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10
Q

what are the types of hernia

A
  • femoral
  • inguinal
  • incisional
  • umbilical
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11
Q

What are hernias caused by

A

Combination of increasing abdominal cavity pressures and decreasing abdominal wall strength

E.g.

  • heavy lifiting
  • cough/chronic lung disease
  • chronic constipation
  • urinary outflow obstruction
  • ascities
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12
Q

What do you describe when talking about a hernia

A
  • location
  • reducible or irreducible
  • incacerated
  • strangulated
  • special hernias
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13
Q

what are the two types of inguinal hernia

A
  • Direct

- Indirect

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14
Q

What is the difference between a femoral hernia and inguinal hernia in relation to the pubic tubercle

A

Femoral hernia
- lateral and below to the pubic tubercle

Inguinal
- medial and above the pubic tubercle

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15
Q

What is an incacerated irreducible hernia

A
  • intestine is trapped within the hernia sac and cannot be pushed back but the content is viable as it still recieves a blood supply
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16
Q

What is a strangulated hernia

A
  • Intestine is trapped and the vascular supply to that loop of bowel is compromised therefore ischaemia occurs
  • if the hernia is stuck in the sac the blood can enter but if the venous drainage is reduced swelling occurs and the blood supply is cut of
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17
Q

What are the complications of hernia

A
  • Small bowel obstruction
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18
Q

What should you do if hernia causes small bowel obstruction

A
  • Typical symptoms of obstruction
  • Hernia irreducible
  • resuscitate
  • emergency surgery
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19
Q

What are the typical symptoms of obstruction

A
  • vomiting
  • abdominal pain
  • abdominal distension
  • absolute consitpation
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20
Q

What happens if the straugulated hernia is not repaired

A
  • Narrow necked hernia
  • tender irreducible red
  • tachycardia and pyrexia
  • WCC raised
  • gangerous
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21
Q

Define an indirect inguinal hernia

A
  • inguinal hernias pass through the deep ring, transverse the canal and exit through the superficial ring
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22
Q

Define a direct hernia

A
  • direct hernia pass directly through the abdominal wall to bulge through the superficial ring
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23
Q

describe how an indirect inguinal hernia is caused

A

Congential

  • passes through patent processus vaginalis whcih should close before birth, following path of the testes during intra uterine development
  • hernia usually descend into the scrotum
  • males>females

Acquired

  • passes through the deep and superficial ring
  • can occur at any age but more common in older people
  • often descend into scrotum
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24
Q

What happens in a direct inguinal hernia

A
  • protrude through abdominal wall in hasselbach’s triangle
  • traversalis fascia forms a hernia sac
  • abdominal wall is slightly thinner here
  • usually occurs in middle age and eldelry who have weaker abdominal wall
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25
Q

What makes up hasselbacks triangle

A
  • inguinal ligament
  • inferior epigastric vessels
  • rectus abdominis
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26
Q

inguinal hernias are commoner than

A

inguinal hernias are commoner than femoral hernias in women

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27
Q

What is the management of inguinal hernias

A
  • Elective or emergency
  • conservatively or surgical
  • laparoscopic or open surgery
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28
Q

How does open mesh repair work for inguinal hernias

A
  • can be performed under local anaesthetic
  • hernia sac is reduced or excised
  • mesh is inserted to reinforce the posterior inguinal canal
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29
Q

What is laparoscopic repair of an inguinal hernia recommended for

A
  • recurrent and bilateral inguinal hernia
  • reduced risk of chronic pain due to nerve injuries
  • more expensive
30
Q

what happens to cause a femoral hernia

A

femoral hernia goes through the femoral canal and femoral ring

31
Q

when do you get symptoms of a femoral hernia

A
  • when they strangulate or incarcerate
32
Q

What is risk of strangulation of a femoral hernia

A
  • 22% at 3 months and 45% at 21 months
33
Q

Describe the lump in a femoral hernia

A
  • approximatley 2cm
34
Q

what can strangulation lead to

A
  • ischaemia and perforation
35
Q

What is the managemnet of femoral hernias

A
  • should be referred promptly for repair as an elective proceudre
  • femoral hernias are not suitable for truss
  • usually requires suture>mesh>laproscopic
36
Q

What is richters hernia

A
  • part of the bowel well incarcerated in hernia and can strangulate
  • strangulated but not obstructed
37
Q

what is an incarceration hernia

A
  • Contents of hernia sac are stuck inside by adhesions
38
Q

Describe the types of surgery that can be used for repair of a femoral hernia

A
  • Herniotomy - ligation and excision of the sac

- Herniorrhaphy - repair of hernia defect

39
Q

Why is a femoral hernia likely to be irreducible and strangulated

A
  • due to the rigidity of the canal’s borders
40
Q

How does the femoral hernia present

A
  • mass in the upper thigh or above the inguinal ligament where it points down the leg
41
Q

What are the differential diagnosis of a femoral hernia

A
  • inguinal hernia
  • saphena varix
  • enlarged Cloquet’s node
  • Lipoma
  • femoral aneurysm
  • Psoas abscess
42
Q

Where does a paraumbilical hernia occur

A
  • occurs just above or below the umbilicus - omentum or bowel herniates through the defect
43
Q

What are the risk factors for a paraumbilical hernia

A
  • obesity

- ascites

44
Q

How do you treat a paraumbilical hernia

A
  • repair of the rectus sheath (mayo repair)
45
Q

Where does an epigastric hernia pass

A
  • passes through the line alba above the umbilicus
46
Q

what is an incisional hernia

A
  • following breakdown of muscle closure after surgery
47
Q

How do you repair an incisional hernia

A
  • mesh repair decreases recurrence but increases risk of infection over sutures
48
Q

What is a spigelian hernia

A
  • occur through the line semilunaris at the lateral edge of there rectus sheath, below and lateral to the umbilicus
49
Q

What is a lumbar hernia

A
  • occur through the interior or superior lumbar triangles in the posterior abdominal wall
50
Q

What is Maydl’s hernia

A
  • involves a herniating double loop of bowel; the strangulated portion may reside as a single loop inside the abdominal cavity
51
Q

What is Littres hernia

A
  • hernial sacs containing strangulated Meckel’s diverticulum
52
Q

What is an obturator hernia

A
  • occur through the obturator canal; typically presents as pain along the medial side of the thigh in a thin women
53
Q

What is a sciatic hernia

A
  • pass through a lesser sciatic foramen; GI obstruction and +- gluteal mass
54
Q

What is a sliding hernia

A

Contain a partially extra-peritoneal structure (e.g. caecum on the right and sigmoid colon on the left); sac does not completely surround the contents

55
Q

What is gastroschisis

A

protrusion of abdominal contents through a defect in anterior abdominal wall to the right of the umbilicus; prompt surgical repair required

56
Q

What is exomphalos

A

Abdominal contents found outside the abdomen, covered in a three-layer membrane consisting of peritoneum, Wharton’s jelly, and amnion; surgical repair less urgent because the bowel is protected by these membranes

57
Q

Where is the deep ring

A
  • this is the mid-point of the inguinal ligament - 1.5cm above the femoral pulse
58
Q

Where is the superficial ring

A

= split in the external oblique aponeurosis just superior and medial to the pubic tubercle

59
Q

What are the predisposing conditions to inguinal hernias

A
  • males
  • chronic cough
  • constipation
  • urinary obstruction
  • heavy lifting
  • Ascites
  • past abdominal surgery (e.g. damage to the iliohypogastric nerve during appendectomy)
60
Q

How should you conduct an examination for inguinal hernias

A
  • look for previous scars
  • feel the other side (more common on the right)
  • examine the external genitialia
  • is the lump visible - if so, ask if the patient can reduce it, if he cannot make sure it is not a scrotal lump, ask the patient to cough - appears above and medial to the pubic tubercle
  • if no lump is visible feel for cough impulse
  • repeat examination with the patient standing
61
Q

How do you distinguish direct from indirect hernias

A
  • reduce the hernia and occlude the deep inguinal ring with two fingers

Ask the patient to cough or stand

  • if the hernia is restrained it is indirect
  • if the hernia is not it is direct
  • Gold standard for determining type of inguinal hernia is at surgery; direct hernias arise medial to the inferior epigastric vessels, indirect hernia are lateral
62
Q

What lifestyle advice do you give someone with a hernia

A
  • weight loss

- stop smoking

63
Q

What should patients be warned about pre op to a hernia

A
  • warn that hernias may recur

- patients should be counselled about possibility of chronic pain post-op

64
Q

When is a mesh repair of a hernia contraindicated

A
  • strangulated hernia

- contamination with pus/bowel contents

65
Q

How does a mesh repair work

A
  • Polypropylene mesh reinforces the posterior wall

- Recurrence rate is less than with other methods (eg <2% vs 10%)

66
Q

How long does it take to return to work after a hernia

A
  • rest for 4 weeks and convalescence over 8 weeks with open approaches
  • laparoscopic repairs may allow return to manual work and driving in less than 2 weeks if all is well
67
Q

What are the complications of a strangulated hernia

A
  • Ischaemia
  • perforation
  • sepsis
68
Q

What is the only treatment for strangulated hernia

A
  • Surgical emergency
69
Q

What are the complications with an open repair of a hernia

A
  • Early: Bruising and wound infections

- Late: chronic pain and recurrence

70
Q

with hernias you should treat…

A

Medically fit patients even if they are asymptomatic

Year 3 - Met3a (43 decks)

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