Abdominal Surgery- Hernias Flashcards
Location of femoral hernia?
Posterior and inferior to the inguinal ligament and medial to the femoral vein
Indirect vs. direct inguinal hernia?
- Indirect - congenital (patent processus vaginalis) outside go hasselbach’s triangle
- indirect inguinal hernias are the most common type of hernia in both men and women
- Common in infants
- Direct - acquired weakness transversalis fascia located within Hesselbach’s triangle
- usually occur in men > 40 years of age and are uncommon in women
Location of indirect inguinal hernia?
Lateral to inferior epigastric vessels, through the deep and superficial ring
Location of direct inguinal hernia?
Medial to inferior epigastric vessels, through the superficial ring only
Diagnosis for Inguinal Hernia
-Visible, palpable groin protrusion or bulge -Inguinal pain -Increase of symptoms during physical activity Palpation of the inguinal canal 1. With the patient standing, palpate from the scrotal skin towards the superficial (external) inguinal ring. 2. Ask the patient to cough or strain and bear down (Valsalva maneuver). Bulging can be felt with a fingertip. Testing: Ultrasound: Imaging test of choice Visualization of the hernial orifice and hernial contents may be possible. CT/MRT: to distinguish from differential diagnoses in ambiguous cases
Inguinal Hernia Complications
Incarcerated hernia: inability to reduce the hernia back into abdominal cavity; fixation of contents in the hernial sac (Surgical emergency in case of concurrent bowel obstruction) Strangulated hernia: tight constriction of hernial contents leading to constriction of blood vessels, bowel ischemia, and necrosis Patients must undergo surgery within 4–6 hours to avoid possible bowel loss. Symptoms of bowel obstruction
Indications for surgery for Inguinal hernia
- Complicated hernia
- Uncomplicated hernia + moderate symptoms:
- Inguinal pain associated with exertion
- Daily activities are limited due to pain
- Manual reduction is not possible
- Uncomplicated hernia + mild symptoms:
- elective hernia repair
- Observation
Laproscoptic vs Open Inguinal Hernia Repair-
- Laparoscopic surgical repair is indicated for uncomplicated hernias (without signs of bowel obstruction or strangulation), usually carried out as an elective procedure.
- Open surgical repair is indicated for all patients with acutely complicated inguinal hernia, i.e., incarcerated hernia with concurrent bowel obstruction or strangulated hernia
- In patients with complicated inguinal hernias, an open approach is preferred because it is easier to perform and associated with a decreased risk of bowel injury.
Risks of surgery for Inguinal Hernia Repair
- Vas deferens injury
- Spermatic vessels injury, dissection, or constriction, which may lead to testicular necrosis
- Injury to femoral nerve, artery, or vein
- Chronic inguinal pain
- Bladder injury
- General risks of surgery
Inguinal Hernia In Infants- Risk factors
- Incidence: ∼ 1–5% of all children (11% in premature children)
- ♂ > ♀ (∼ 4:1)
- Occurs more often on the right side
- Premature birth
- Urogenital dysplasia syndromes
- Increased intraabdominal pressure (e.g., gastroschisis, ascites, omphalocele)
- Weakness of the connective tissue (e.g., Ehlers-Danlos syndrome)
Rx umbilical hernia in children?
Repair if persistent >age 4, if defect >2 cm, if progressive enlargement after age 2
Hiatal Hernia- Epidimiology & Risk
Age: affects ∼ 70% of people > 70 years
↑ BMI
Prevalence
More prevalent in females and Western populations
Most commonly occur on the left side, as the liver protects the right diaphragm.
References:[1][2]
Epidemiological data refers to the US, unless otherwise specified.
NOTES
FEEDBACK
Etiology
The etiology is multifactorial. Lax diaphragmatic esophageal hiatus
Advanced age
Smoking
Obesity
Genetic predisposition (rare)
Prolonged periods of increased intra-abdominal pressure
Pregnancy
Ascites
Chronic cough
Chronic constipation
Defects of the pleuroperitoneal membrane
Sliding Hiatal Hernia
- Most common type (95% of cases)
- The Gastroesophageal junction and the gastric cardia slide up into the posterior mediastinum.
- The gastric fundus remains below the diaphragm (hourglass stomach)
Paraesophageal Hiatal Hernia (type2)
- Part of the gastric fundus herniates into the thorax.
- The GEJ remains in its anatomical position below the diaphragm.
- Upside-down stomach (extreme type): a rare type of paraesophageal hernia in which the entire stomachherniates into the thoracic cavity and rotates on its organoaxial axis. It is associated with a high mortality and morbidity rate due to strangulation of the stomach.
Mixed Hiatal Hernia (type 3)
