Abdominal wall

Question 1

Descriptive words for a hernia

Answer 1

Reducible: hernia contents can be replaced into the cavity
Irreducible: contents cannot be replaced into the cavity
Obstructed: bowel contents cannot pass through the herniated bowel
Strangulated: ishcaemia of the hernia contents (due to obstructed venous return), will lead to gangrene and perforation
Incarcerated: contents of the hernia sac are stuck inside by adhesions

Question 2

What is contained in the inguinal canal

Answer 2

Arteries: testicular/ovarian, artery to the vas deferens, cremasteric
Nerves: genital branch of genitofemoral, ilioinguinal, sympathetic
Vas deferens/round ligament of the uterus
Pampiniform plexus
Testicular lymphatics

Question 3

Indirect inguinal hernia aetiology & pathology

Answer 3

2/3 of inguinal hernias, ypunger patients
Hernia covered by the processus vaginalis, and all 3 fascial coverings
Exits the superficial ring inside the cord into the scrotum/labia majorus
More likely to strangulate

Question 4

Direct inguinal hernia aetiology & pathology

Answer 4

Contents pass through a weakness of the anterior abdominal wall in the inguinal triangle
Due to increased intra-abdominal pressure: cough, straining at micturition/defecation, heavy lifting, smoking
Covered by peritoneum and transversalis fascia
Exit the superficial ring lateral to the cord

Question 5

Femoral hernia aetiology & pathology

Answer 5

Bowel exits the abdominal cavity through the femoral ring
As the hernia enlarges, it can pass out the saphenous vein opening into the deep fascia
High risk of obstruction/strangulation

Question 6

Richter’s hernia definition

Answer 6

A hernia involving only one sidewall of the bowel, not the bowel lumen
Can result in bowel strangulation/perforation without obstruction or any warning signs

Question 7

True umbilical hernia aetiology & pathology

Answer 7

3% of live births, defect in the transversalis fascia at the umbilical ring (incomplete closure of the umbilical cicatrix)
More common in black, male, premature babies
Covered by skin
Generally asymptomatic

Question 8

Paraumbilical hernia aetiology & pathology

Answer 8

Acquired hernia just above/below the umbilicus
Caused by raised IAP: obese, middle aged, multiparous women
Present: localised dragging pain, tender, colicky? + increasing in size
Mainly reducible, commonly strangulate/obstruct

Question 9

Risk factors for incisional hernias

Answer 9

Pre-op (factors that decrease wound healing): old age, poor nutrition, sepsis, uraemia, jaundice, obesity & steroids
Operative: vertical incisions, too loose/tight knots, presence of drains
Post-op: post-op ileus, coughing, obesity, wound infection

Question 10

Incisional hernia symptoms

Answer 10

Scar bulge & discomfort
Subacute bowel obstruction as hernia enlarges
Usually wide neck so strangulation uncommon, however adhesions may develop so hernia becomes irreducible (increasing likelihood of obstruction/strangulation)

Question 11

Risk factors for hernia reccurence following repair

Answer 11

Repair contraindicated by factors that predispose to an incisional hernia
Weight reduction/smoking cessation/prophylactic antibiotics increase the likelihood of a successful repair
Recurrence rate: 2-20%

Question 12

Common presenting features of epigastric herniae

Answer 12

1/more small protrusions through the linea alba above the umbilicus, usually containing only extraperitoneal fat
>75% asymptomatic, if pain it worstens on exertion/after meals

Question 13

Divarification of the rectus abdominal muscle

Answer 13

When the rectus muscles do not meet in the midline at the linea alba, thus split apart when the patient flexes the abdominal muscles
Common in obese men, parous women, chronic IAP

Question 14

What are the boundaries of Hesselbach’s triangle?

Answer 14

Medial: Rectus abdominis
Lateral: Inferior epigastric vessels
Inferior: Inguinal ligament