Abdominal wall hernias

Question 1

Define hernias of the abdominal wall

Answer 1

An abnormal protrusion of abdominal contents though the fascia of the abdominal wall

Question 2

List the contents of a hernia

Answer 2

Always contains a portion of the peritoneal sac May contain viscera, usually small bowel and omentum

Question 3

Describe the aetiology of congenital abdominal hernias

Answer 3

Associated with developmental disorders e.g. persistent processus vaginalis, failure of complete obliteration of the umbilical opening

Question 4

Describe the aetiology of acquired abdominal hernias

Answer 4

Weakness of the abdominal wall due to ageing or previous surgery. Risk increased in conditions that increase intra-abdominal pressure.

Question 5

What terms are used to describe an abdominal hernia?

Answer 5

Reducible: contents can be fully restored to the abdominal cavity, spontaneously or with manipulation. Incarcerated: part or all of the contents cannot be reduced due to narrow neck and/or adhesions. Strangulated: twisting or entrapment compromises blood supply to the hernia ➔ obstruction and infarction

Question 6

What may be seen on examination of a hernia?

Answer 6

Occur at weak spot May reduce on lying down, or with direct pressure May have expansile cough impulse

Question 7

Name 5 common types of abdominal wall hernias

Answer 7

Inguinal hernia (commonest) Femoral hernia Incisional hernia Epigastric hernia Umbilical hernia

Question 8

What is the commonest type of abdominal hernia?

Answer 8

Inguinal hernia

Question 9

What is the M:F ratio for inguinal hernias?

Answer 9

8:1

Question 10

How can inguinal hernias be classified?

Answer 10

Direct: medial to inferior epigastric artery Indirect: lateral to inferior epigastric artery

Question 11

Differentiate between an indirect and direct inguinal hernia

Answer 11

Indirect: occurs at any age (usually young), congenital, lateral to inf epigastric a, often descend to scrotum, narrow neck ➔ more likely to strangulate Direct: uncommon in children and young adults, acquired, medial to inf epigastric a, rarely descend to scrotum, wide neck ➔ rarely strangulate

Question 12

Name 2 risk factors for indirect inguinal hernias

Answer 12

Prematurity Male

Question 13

Name 3 risk factors for direct inguinal hernia

Answer 13

Male Obesity Constipation Chronic cough Heavy lifting

Question 14

Describe the presentation of inguinal hernias

Answer 14

Lump in the groin May have sudden pain Expansile cough impulse Ache or dragging sensation, especially at the end of the day

Question 15

Outline the management of inguinal hernias

Answer 15

Reassurance if small and asymptomatic Symptomatic hernias or Hx of incarceration or bowel obstruction ➔ offered hernia repair -Consider hernia truss: supports tissue and relieves pain Hernia repair: reduction or excision of sac, closure of defect with minimal tension.

Question 16

What structure do indirect inguinal hernias travel through?

Answer 16

Inguinal canal: transmits the spermatic cord/round ligament, and the ilioinguinal nerve.

Question 17

What is the content of the spermatic cord?

Answer 17

Vessels: testicular a, cremasteric a, artery of vas deferens Nerves: genital branch of genitofemoral, autonomic supple to testicles, ilioinguinal n Structures: vas deferens, pampiniform venous plexus, testicular lymphatics Coverings: external spermatic fascia, cremasteric fascia, internal spermatic fascia

Question 18

What anatomical location is most commonly associated with direct inguinal hernias?

Answer 18

Hesselbach’s triangle: -Inguinal ligament (inferiorly) -Inferior epigastric artery (laterally) -Lateral border of rectus abdominis (medially)

Question 19

Outline the anatomy of the femoral canal

Answer 19

Anterior: inguinal ligament Posterior: pectineal ligament Medial: lacunar ligament Lateral: femoral vein

Question 20

Which sex is most likely to have a femoral hernia?

Answer 20

Women

Question 21

Describe the presentation of femoral hernias

Answer 21

Lump in the groin, lateral and inferior to the pubic tubercle, medial to femoral pulse Lower abdominal pain if incarcerated *30% present as emergencies due to high risk of strangulation

Question 22

Name 3 differentials for femoral hernias

Answer 22

Low presentation of inguinal hernia Femoral canal lipoma Saphena varix (dilatation of proximal long saphenous v) Hydrocele Spermatic cord hydrocele Lymphadenopathy Psoas abscess Varicocele

Question 23

What is the most concerning complication of femoral hernia?

Answer 23

Strangulation of the femoral hernia. High risk due to the narrow opening and rigid boundaries of the femoral canal.

Question 24

Describe the presentation of a strangulated hernia

Answer 24

Red and tender Tense and irreducible Colicky abdominal pain Distension Vomiting

Question 25

Outline the treatment of femoral hernias

Answer 25

Due to high risk of strangulation, all femoral hernias should be repaired as an elective process. -Low approach (Lockwood’s) -Trans-inguinal approach (Lotheissen’s) -Thigh approach (McEvedy’s) Truss (conservative) has no place in management

Question 26

What can be done to reduce the rate of recurrence of femoral hernias?

Answer 26

Narrowing of the femoral canal after hernia repair

Question 27

State 3 differences between true umbilical hernias and paraumbilical hernias

Answer 27

True: occur through the umbilical cicatrix, almost always congenital, commoner in Afro-Caribbean races. Para: occur through the paraumbilical tissue, acquired, common in obese and parous women.

Question 28

Describe the pathophysiology of epigastric hernias

Answer 28

Defects in the line alba between the xiphisternum and umbilicus, at sites of penetration of nerves and vessels.

Question 29

Describe the presentation of umbilical hernias

Answer 29

Small, centrally places within the umbilicus Often contains pre-peritoneal fat Rarely contains bowel or omentum May be painful, but rarely strangulates

Question 30

Describe the presentation of paraumbilical hernias

Answer 30

Variable size, up to moderate Many potential locations Distorts shape of umbilicus May contain bowel or omentum Often painful and occasionally strangulates

Question 31

Describe the presentation of epigastric hernias

Answer 31

Variable size, up to large Always along midline Most frequently only contains pre-peritoneal fat Moderate risk of strangulation

Question 32

Outline the management of umbilical hernias

Answer 32

<1cm ➔ almost always spontaneously close by 5yr >1.5cm or in child >4yr ➔ repair Symptomatic hernias or high risk complications ➔ repair

Question 33

Name 3 factors that predispose to incisional herniation?

Answer 33

Wound infection Steroid use, anaemia, or malnutrition pre-op Midline laparotomy Poor surgical technique in abdominal closure

Question 34

When do incisional hernias most commonly present?

Answer 34

Up to 5yr post-op

Question 35

What significant complication can occur following large incisional herniation?

Answer 35

Viscera are often permanently herniated If this occurs for a long period of time, the abdominal wall muscles retract ➔ small abdominal cavity that may not contain all the retracted viscera.

Question 36

Outline the management of incisional hernias

Answer 36

<4cm (S) ➔ simple sutured repair >4cm (M or L) ➔ mesh repair -Above umbilicus: between post rectus sheath and rectus abdominis muscle -Below umbilicus: pre-peritoneal space *Arcuate line

Question 37

What are the signs of a strangulated hernia?

Answer 37

Irreducible Tender Overlying erythema or cellulitis

Question 38

Why is it important to identify a strangulated hernia?

Answer 38

The region becomes ischaemic and subsequently gangrenous. Gangrene can lead to perforation of the bowel with ensuing peritonitis.

Question 39

What is the management of a strangulated hernia?

Answer 39

Emergency surgery within 6hr of strangulation

Question 40

What feature increases the risk of a hernia strangulating?

Answer 40

Narrow opening in the containing wall