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Surgery > Abdominal Wall Surgery > Flashcards

Abdominal Wall Surgery Flashcards

1
Q

What is a hernia?

A

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

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2
Q

Describe the aetiology of a hernia.

A

Congenital or acquired

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3
Q

Why do people acquire hernias?

A

Ageing or previous surgery causing wall weakness, combined with increased intra-abdominal pressure.

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4
Q

What are the common causes of increased intra-abdominal pressure that increase a persons risk of developing a hernia?

A 
Chronic cough
Heavy lifting
Constipation
Urinary retention/BPH
Pregnancy
Abdominal distension or ascites
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5
Q

What are the 4 patterns of behaviour of a hernia?

A

Reducible
Incarcerated
Obstructed
Strangulated

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6
Q

What is a reducible hernia?

A

A hernia that can be put back through the wall defect, whether spontaneously or under manipulation.

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7
Q

What is an incarcerated hernia?

A

A hernia where part or all of the contents cannot be reduced dueto a narrow neck +/or adhesions.

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8
Q

What is an obstructed hernia?

A

Hernia that contains an obstructed bowel loop, usually due to kinking.

These are prone to strangulation.

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9
Q

What is a strangulated hernia?

A

Hernia where the blood supply to the contents is cut off

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10
Q

Where do groin hernias rank in the West as a cause of bowel obstruction?

A

3rd most common cause, after adhesions and cancer.

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11
Q

What is the pathological sequence that leads to strangulation of a hernia?

A

Venous and lymphatic drainage is obstructed, causing oedema and increased venous pressure.

This impedes arterial flow, which in turn causes necrosis and perforation.

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12
Q

Which is the most common type of abdominal hernia?

A

Inguinal

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13
Q

Who are inguinal hernias more common in - men or women?

A

Men by ~8 times

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14
Q

Where do the contents of the hernia protrude through in an inguinal hernia?

A

Through the inguinal canal

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15
Q

How are inguinal hernias classified as direct or indirect?

A

According to their relationship to the inferior epigastric artery

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16
Q

How do most inguinal hernias present?

A

Painless groin lump noticed

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17
Q

Other than a groin lump, how can inguinal hernias present?

A
  • Pain and lump started following a particular activity
  • Ache or dragging sensation
  • Impulse palpable on coughing
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18
Q

Is imaging used routinely for diagnosis of a hernia?

A

No, but if the diagnosis is uncertain, imaging can be helpful.

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19
Q

Which imaging modalities are used to help diagnose a hernia when the diagnosis is uncertain?

A
  • USS (cheap and no radiation but unreliable)
  • CT (accurate but radiation exposure)
  • Herniography
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20
Q

What elements of the history are incorporated into the decision to treat a hernia?

A
  • Symptoms
  • Reducibility
  • Co-morbidities/frailty
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21
Q

Describe the difference between a direct and indirect inguinal hernia.

A

Indirect is lateral to inferior epigastric artery, direct is medial.

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22
Q

What is the most common way in which indirect inguinal hernias occur?

A

Congenitally due to patent processus vaginalis

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23
Q

What is the most common way in which direct inguinal hernias occur?

A

Acquired abdominal wall weakness

24
Q

If an inguinal hernia descends into the scrotum, is it more likely to be direct or indirect?

A

Indirect

25
Q

How are inguinal hernias in infants usually managed?

A

Surgery - herniotomy (ligate and excise patent processus vaginalis)

26
Q

How are inguinal hernias in adults managed?

A

Surgery:

  1. Open mesh repair
  2. Laparoscopic repair
27
Q

What advice is given to patients following hernia repair operations?

A

Avoid heavy lifting for 2 weeks post op

28
Q

What are the risk factors for congenital inguinal hernias?

A

Prematurity

Male sex

29
Q

If an infant presents to the GP with a suspected hernia, how should they be referred to secondary care?

A

Urgently for surgical repair

30
Q

How should a hernia be assessed clinically?

A

Examine pt standing and lying down.

Ask them to cough or strain in both positions.

31
Q

Form a list of differentials for an inguinal hernia.

A 
Femoral hernia
Hydrocele
Lymph node swelling
Abscess
Varicocele
Bleeding/haematoma
Undescended testis
32
Q

What is the best method to repair bilateral inguinal hernias?

A

Laparoscopically

33
Q

How common is recurrence of an inguinal hernia following repair?

A

1% within 5 years

34
Q

Other than recurrence, what are the complications associated with inguinal hernia repairs?

A

Infarcted ovaries or testis
Wound infection
Bladder or intestinal injury
Hydrocele

35
Q

Which kind of hernia is more common in women than men?

A

Femoral

36
Q

Why do femoral hernias have a high risk of strangulation?

A

The neck of the sac has bony structures and ligaments surrounding it on 3 sides

37
Q

Where are femoral hernias found?

A

Below and lateral to pubic tubercle

Medial to femoral pulse

38
Q

Form a list of differentials for a femoral hernia.

A 
Low presenting inguinal hernia
Femoral canal pathology (lipoma, haematoma)
Femoral lymph node
Saphena varix
Femoral artery aneurysm
Psoas abscess
39
Q

Why should all femoral hernias be repaired?

A

Great risk of strangulation if not repaired

40
Q

Why are femoral hernias more common in women?

A

Due to the shape of the pelvis - wider angle of pelvis means femoral ring is proportionally wider in women.

41
Q

What are the borders of the femoral canal?

A

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

42
Q

How can umbilical hernias be further classified?

A

As true umbilical and para-umbilical hernias.

43
Q

What is a true umbilical hernia?

A

A hernia that occurs through the umbilical cicatrix - nearly always congenital

44
Q

What is a paraumbilical hernia?

A

A hernia that occurs through the periumbilical tissues - always acquired

45
Q

What is an epigastric hernia?

A

A hernia that occurs due to a defect in the linea alba (between the xiphisternum and umbilicus) at sites where vessels/nerves penetrate it.

46
Q

How do true umbilical hernias present?

A

-Small central umbilical swelling

47
Q

How do paraumbilical hernias present?

A

Eccentrically placed swelling causing umbilicus shape to become distorted

48
Q

How are umbilical hernias managed?

A

If congenital, no need to treat unless they persist past age 2/3.
Surgery

49
Q

How common is an incisional hernia following a midline laparotomy?

A

Around 10% of patients experience an incisional hernia at some point.

50
Q

What are the risk factors for an incisional hernia?

A

Anything that impairs healing:

  • Wound infection
  • Steroid use, anaemia, or malnutrition at time of surgery
  • Poor closure following surgery
51
Q

What is a rectus sheath haematoma?

A

Haemorrhage from rectus sheath vasculature.

52
Q

How does a pt with a rectus sheath haematoma present?

A

Sudden localised pain +/- tender mass
May have blunt trauma in hx
Pain increases when rectus muscles contracted

53
Q

How are rectus sheath haematomas diagnosed?

A

Hx and Ex with CT as gold standard for diagnosis

54
Q

How should rectus sheath haematomas be managed?

A
  • Conservatively if small and stable

- Larger/bilateral - hospitalisation, blood transfusion, surgical ligation or embolisation if pt deteriorates.

55
Q

What is groin disruption?

A

Overuse syndrome causing muscular imbalances of the pelvis and abdominal wall muscles

56
Q

A patient comes into A and E with an acute groin swelling. Form a list of differentials.

A 
Groin hernia
Epididymo-orchitis
Testicular torsion
Iliopsoas abscess
Acute lymphadenopathy
Saphena varix
Femoral artery aneurysm

Surgery (11 decks)

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