Abdominal Wall Hernias

Question 1

Definition

Answer 1

The abnormal protrusion of a viscus or part of a viscus through a weakness in its containing wall

Question 2

composition of hernia

Answer 2

• Sac - peritoneal lining of hernia; may be complete or incomplete as in sliding
• Neck- at the level of the defect in the wall where the hernia emerges
• contents- bowel or omentum

Question 3

Irreducible

Answer 3

Hernias involving the bowel that canno be pushed back into the right place

Question 4

Incarceration

Answer 4

contents of the hernial sac are stuck inside by adhesions

Question 5

Obstructed hernias

Answer 5

GI hernias in which bowel contents cannot pass through them - classical features of intestinal obstruction soon appear

Question 6

strangulated

Answer 6

If ischaemia occurs - the patient becomes toxic and requires urgent surgery

Question 7

Types

Answer 7

• inguinal
• femoral
• incisional
• umbulical
• spigelian

Question 8

Causes

Answer 8

Abdominal wall weakness

• anatomical - inguinal canal, femoral canal
• acquired - surgical wound, stoma

Increased abdominal pressure

• straining -cough, heavy lifting
• pregnancy

Congenital

• patient processus vaginalis after testicular descent

Question 9

Symptoms/ signs

Answer 9

• Lumps- appears on straining
• reducible
• discomfrot
• nausea/vomitting if obstructed
• severe pain if strangulated

Question 10

Femoral Hernia

Answer 10

Bowel enters the femoral canal, presenting as a mass in the upper medial thigh or above the inguinal ligament where it points down the leg (unlike inguinal where it points to groin)

Question 11

Inguinal canal walls

Answer 11

Question 12

The inguinal canal is made up of

Answer 12

• anterior and posterior walls
• superficial and deep rings
• roof and floor

Question 13

Deep ring position

Answer 13

Just above the midpoint of the inguinal ligament

Question 14

Superficial (external ring) position

Answer 14

Superior to the pubic tubercle

Question 15

Contents of the inguinal canal

Answer 15

• Men - spermatic cord -passes through the inguinal canal to supply and drain the testes
• Women - round ligament of uterus traverse through the canal

Question 16

Function of inguinal canal

Answer 16

acts as a pathway by which structures can pass from the abdominal wall to the external genitilia

Clinical importance- potential weakness, and a common site of herniation

Question 17

Mid- Inguinal point definition

Mipoint of the inguinal liganment defintion

Answer 17

Mid-inguinal point - halway between the pubic symphysis and the ASIS - femoral arterty cross into the lower limb at this point

Midpoint of the inguinal ligament - the inguinal ligament runs from the pubic tubercle to teh ASIS so the midpoint is halfway between these structure.

Question 18

Inguinal hernia types

Answer 18

• Direct - A direct inguinal hernia is caused by a weakness in the posterior wall of the inguinal canal. The abdominal contents (usually just fatty tissues, sometimes with bowel) are forced through this defect and enter the inguinal canal. This means that the contents emerge in the canal medial to the deep ring
• Indirect- An indirect inguinal hernia, however, does not pierce the posterior wall. The abdominal contents pass through the deep inguinal ring, passing through the inguinal canal and can exit via superficial ring

Question 19

Epidemiology of inguinal hernias

Answer 19

• commonest type of abdominal hernia
• males > females 8:1

Question 20

Diagnosis of hernia

Answer 20

• history of lump appearing on straining - often reduces at night
• lump appearing on coughing (stand patient up if not seen)
• reducible into abdomen- may be irreducivble
• herniogram (CT scan with contrast)
• Ultrasound- scrotal lump to exclude hydocoele

Question 21

Indirect vs direct hernia

Answer 21

Question 22

Femoral hernia

Answer 22

• more in females.
• irreducible and strangulate.
• These go down the femoral canal (not the inguinal canal).
• They are usually found below and lateral to the inguinal ligament – this is the opposite of inguinal hernias!
• However, can present above the inguinal ligament as well – but when they do, they will point along the femoral canal, and down the leg, as opposed to towards the groin (like inguinal ones do).
• Repair is recommended for these hernias. -

Question 23

Paraumbillical hernia

Answer 23

• These are found just above or just below the umbilicus.
• Omentum or bowel can herniated through them.
• Surgery involves repair of the rectus sheath.
• Risk factors involve obesity and ascites

Question 25

Incisional hernia

Answer 25

These appear along lines of previous incision due to surgery. They occur in up to 11-20% of cases of surgery.

Question 26

Treatment of inguinal hernias

Answer 26

• It is a common sense approach with regards to the management of inguinal hernias. If the lump is small, not increasing in size and is asymptomatic the patient may wish to leave it alone.
• If however the hernia is causing pain, or altering bowel habit then surgical management may be required.
• If the hernial contents become trapped, strangulated, infracted, or obstructed, then this represents a surgical emergency and urgent operative fixation is required.

Both direct and indirect inguinal hernias are repaired in the same way. The main decision to be made is whether to fix the hernia via an open or a laparoscopic technique.

Open inguinal hernia repair

An open technique explores the inguinal canal, identifies the important structures within it (which need to be carefully protected), reduces the hernial contents back into the abdominal cavity and places a mesh that strengthens the posterior wall to prevent further herniation. It is a simple operation with excellent results, and can be done with either general or local anaesthetic.

Laparoscopic inguinal hernia repair

Laparoscopic inguinal hernia repair is also an excellent operation in experienced hands. It has the added benefit of less post-operative pain and quicker recovery, particularly if bilateral hernia repair is performed. The basic steps of the operation involve visualising the defect from within the abdominal cavity, reducing or pulling back the contents of the hernia, and repairing the defect from within the abdomen.

Question 27

treatment of hernias

Answer 27

• elective surgical repair- hernia contents returned to abdomen and defect repaired with sutures or artifical mesh
• may be possible to perform laparoscopically
• emergency repiar if incarcerated ir strangulated
• if strangulated may need bowel resection
• external pressure (truss) only if unfit for surgery

Question 28

Complications

Answer 28

• pain
• irreducible
• incarceration- bowel obstruction
• strangulaiton- bowel ischaemia
• inflammation- red skin + pain