Abdominal Hernias Flashcards
Abdominal hernia
characterized by the presence of a reducible or nonreducible protrusion of the abdominal cavity organs under the skin, through natural or acquired defects in the musculoaponeurotic layer of the anterior abdominal wall.
At the discovery of a hernia on the anterior abdominal wall, planned surgical treatment is required.
However, when complications arise in the form of strangulation or inflammation of hernia urgent
hospitalization and emergency surgery are absolutely indicated.
Most common regions of hernia location are: inguinal, femoral, umbilical area, the linea alba and the anterior abdominal wall in the area of postoperative scarring.
Definition of hernia
Described as the exit of the abdominal organs covered with parietal layer of the peritoneum under the skin through natural or acquired defects in the musculoaponeurotic layer of abdominal wall or pelvic floor.
General theory of hernias:
A) Localization of hernias is divided into inguinal hernia, femoral, umbilical, hernia of the white line (linea alba) of the abdomen, in postop / incisional (ventral), lumbar and perineal regions.
B) A hernia is composed of hernial neck, hernial sac, hernial membrane (sheath) and contents of the hernia:
a) Hernial neck - defect in musculoaponeurotic layer of the abdominal wall through which the hernia goes;
b) The hernia sac - protrusion (single or multiple) of the parietal peritoneum sheet through a defect in the musculoaponeurotic layer of the abdominal wall. Distinguished: the mouth, neck, body and fundus of the hernia sac;
c) Hernia membrane (sheath) - the tissue surrounding the hernial sac (preperitoneal tissue, transversal fascia, in inguinal hernia in men parts of the spermatic cord)
d) The contents of the hernia - includes abdominal organs which are in the hernial sac (loops of small intestine, omentum, colon, fat appendices of colon, fallopian tubes and ovaries, bladder).
Stages of hernia:
a) initial hernia - hernial sac with contents is at the level of the inner ring in hernias that have a canal (inguinal, femoral);
b) incomplete hernia - hernial sac with contents located within the inguinal or femoral canal;
c) complete hernia - hernial sac with content goes under the skin to the outside of the inguinal or femoral canal;
d) the distinctive features of hernias:
- inguinal-scrotal hernia occurs only in men: the contents of oblique hernia lowering into the scrotum;
- sliding hernia one of the walls of the hernial sac presented by a hollow organ, partially covered by the peritoneum (urinary bladder, colon);
- postoperative ventral (incisional) hernias are distinguished by the location, size of the neck of the hernia and number of hernial chambers.
Causes of abdominal wall hernias
The main cause of hernias - a long discrepancy between intra-abdominal pressure and the resistance
of some areas of the anterior abdominal wall:
A) Factors contributing to the development of a hernia:
a) weak places of the anterior abdominal wall are located in the areas of:
- inguinal canal;
- femoral fossa ovale;
- umbilical region, supraumblical and infraumblical parts of aponeurosis of the white line (linea alba) of the abdomen;
- postoperative scars;
b) weak places of the posterior abdominal wall are located in the areas of:
- the triangle of Petit;
- the Grunfeld-Lesgaft triangle.
B) Factors contributing to the development of hernias:
a) factors contributing to the increase in intra-abdominal pressure:
- constipation, difficulty urinating;
- prolonged coughing;
- heavy child labour;
- hard physical labour;
- ascites;
b) factors contributing to the reduced resistance of the abdominal wall:
- reduction of body weight;
- abdominal trauma;
- surgeries of abdomen
The clinical course of the anterior abdominal wall hernias:
- uncomplicated;
- complicated;
- relapsing course.
Clinical signs of herniation:
A) Complaints of a patient with uncomplicated hernia of the abdominal wall:
a) protrusion in herniated place:
- increases in the standing position;
- disappears or decreases in supine position;
b) pain:
- moderate;
- without precise localization;
- Irradiation of the pain depending on the location of hernia (with umbilical hernia , white line abdominal hernia in the epigastric region; in case of an inguinal hernia testicles in men, labia or thigh in women);
c) pain intensity inversely proportional to the hernia size (in the case of initial hernia pain is more pronounced);
d) dysuric disorder in the case of inguinal hernia occurs in the presence of an urinary bladder in a hernial sac.
B) Medical history the emergence of herniation is associated with:
a) physical activity, diseases accompanied by an increase in intraabdominal pressure, or after
birth (congenital);
b) previous abdominal surgeries, abdominal injuries.
C) Objective evidence of disease:
a) visual Inspection of herniation area:
- asymmetry of the anterior abdominal wall due to herniation;
- protrusion of the anterior abdominal wall in a typical localization site of anterior abdominal wall hernia;
b) palpation on the area of hernia:
- reducible hernial contents into the abdominal cavity;
- presence of the bulge, defect reduction in musculoaponeurotic layers of the abdominal
wall (the hernial ring);
- positive “cough test”.
N.B.! Diagnosis of uncomplicated hernia of anterior abdominal wall is based on the clinical picture. Additional tests for its diagnosis are not applied.
Formation of the preliminary diagnosis is based on clinical data:
(Hernia)
Preliminary diagnosis of the disease is often final and is formed on the basis of the presence of the patient’s complaints in one of the hernia locations, increasing on exertion, presence of positive “cough test”. Additional studies to clarify the diagnosis are not provided.
Therapeutic tactics in uncomplicated hernias of the anterior abdominal wall and identifying the hernia surgical consultation indicated to decide on planned surgery:
A) Method of uncomplicated hernia treatment- planned surgery.
B) Contraindications to surgery:
a) absolute:
- acute infectious diseases;
- decompensation of the cardiovascular, respiratory and other vital systems;
- myocardial infarction, stroke in the acute phase, the presence of incurable diseases (neoplastic process);
b) relative:
- the second half of pregnancy;
- hernia in children under one year;
- exacerbation of chronic diseases to the stabilization process;
- the presence of urethral stricture or benign prostatic hyperplasia (hernia repair performed after their elimination).
C) Principles of surgery for uncomplicated anterior abdominal wall hernias include hernia repair and hernioplasty:
- anaesthetic is selected depending on the type of hernia, its size and the operated state of health of the patient;
- separate and expose hernial sac;
- the contents of the hernial sac are moved into the abdominal cavity, the excess of the hernial sac is excised and the peritoneum is sutured;
- hernioplasty (stapling homogenous tissues without tension, alloplastic methods of herniorrhaphy).
Definition: inguinal hernias
Inguinal hernias occur in inguinal gap, located within the inguinal region.
Types of hernias (inguinal)
a) initial hernia - hernia sac with contents located at the level of the inner ring in hernias that have a
canal (inguinal, femoral);
b) incomplete hernia - hernia sac with contents located within the inguinal or femoral canal.
c) complete hernia - hernia sac with content goes under the skin to the outside of the inguinal or
femoral canal;
d) inguinal-scrotal hernia - the contents of the oblique hernia goes down into the scrotum (found only in males);
e) the direct inguinal hernia - prolapse of the rear wall of the inguinal canal medial to the spermatic cord, in the projection of the medial fossa of the abdominal wall
Clinico-statistical classification of inguinal hernias:
Inguinal hernia K40
Clinical diagnosis layout: { LX } { QX } inguinal hernia, {complicated Ow }
Location:
L1 Left Side { BX}
L2 Rightsided { BX }
L3 Bilateral { BX }
Type of hernia: B1 initial B2 incomplete (canal) B3 inguinalscrotal B4 direct B5 large direct – diverticulumlike defect of posterior wall of the inguinal canal
Clinical signs:
Q1 reducible
Q2 irreducible
Q3 recurrent
Complications:
O1 strangulation { RX }
(R1) strand of omentum
(R2) small intestine
(R3) colon
O2 { RX } obstruction
(R1) small intestine
(R2) colon
O3 bowel gangrene
O4 bowel perforation
O5 peritonitis
O6 hernial sac phlegmon
Clinical signs of inguinal hernia:
A) Complaints: the presence of a bulge in the groin area, which disappears in the supine position and appears in a standing position or during exercise.
B) Inspection: there is a rounded or oval protrusion in the groin area that can descend into the scrotum at oblique hernia. The skin over it is not changed.
C) Palpation: soft mass, painless, reducible into the abdominal cavity. The outer inguinal ring is extended. Positive “cough test” symptom
Diagnosis of inguinal hernia
Conducted on the basis of the patient’s complaints and data of an objective examination.
Differential diagnosis:
inguinal hernia
a) regarding the spermatic cord (in a direct hernia hernial round form bulging is placed medial to
the spermatic cord; oblique herniaalong the spermatic cord);
b) with hydrocele:
- after pressing down of protrusion free outer inguinal ring determined;
- in hydrocele formation is not reducible into the abdominal cavity;
- due to the presence of fluid, percussion gives a dull sound;
- by transillumination hydrocele is transparent;
- fluctuation symptom can be determined in hydrocele;
c) with hydrocele of spermatic cord:
- in contrast to the inguinalscrotal hernia in hydrocele of spermatic cord the size of the protrusion does not change with an increasing of intraabdominal pressure and it does not reduce into the abdominal cavity;
d) with enlarged lymph nodes:
- lymph nodes have a solid consistency;
- lymph nodes are clearly distinguished from the external opening of the inguinal canal;
- the shape of the mass does not change in case of abdominal wall tension or coughing;
- in acute inguinal lymphadenitis, a short history, overlying skin is red, local tenderness and the presence of infected wound as a cause of lymphadenitis.
Surgical treatment of inguinal hernia:
A) Autoplasty with tensioned tissues (“simple hernioplasty”):
a) an young patients with small oblique inguinal hernias and in patients with congenital inguinal hernias, performed reconstruction of the front wall of the inguinal canal;
b) in other cases, the preference is given to the reconstruction of rear wall of the inguinal canal
(Bassini’s, Postempski’s, Shouldice’s repairs).
В) Alloplasty with synthetic materials (tensionfree):
a) lichtenstein tension free mesh repair ( inserting of synthetic mesh).
C) Laparoscopic techniques of hernioplasty:
a) to narrow dilated inguinal ring with 23 sutures (used in children);
b) preperitoneal hernioplasty (synthetic mesh is placed between peritoneum and abdominal wall muscles from the abdominal cavity).
Examination of disability and rehabilitation of patients: (inguinal hernia)
- duration of hospital stay from 3 to 7 days, the stitches are removed on the 7-8th day after the surgery;
- duration of disability - 4-6 weeks depending on the profession;
- exclusion of heavy physical labour for 10-12 months;
treatment of diseases accompanied by increased intra-abdominal pressure.
Definition: Femoral hernia
Femoral hernia is described as a condition in which the internal organs exit through the femoral canal below the inguinal ligament at the site of the femoral triangle.
Clinico-statistical classification of femoral hernia:
K41 Femoral hernia
Layout clinical diagnosis: {LX} {QX} femoral hernia, complications {OX}
Location:
L1 Left sided
L2 Right sided
L3 Bilateral
Clinical signs:
Q1 reducible
Q2 irreducible
Q3 recurrent
Complications:
O1 strangulation {RX}
(R1) strand of greater omentum
(R2) small intestine
(R3) colon
O2 {RХ} obstruction
(R1) small intestine
(R2) colon
O3 bowel gangrene
O4 bowel perforation
O5 peritonitis
O6 phlegmon
Clinical signs of femoral hernia:
a) complaints: the appearance of protrusions on the thigh below the inguinal fold;
b) visual inspection: in the vertical position, a rounded protrusion is visible under the inguinal fold on the thigh. The skin over it is not changed;
c) palpation: soft painless mass, reducible into the abdominal cavity. Hernial ring can be identified
