Abdominal Wall Surgery

Question 1

What is a hernia?

Answer 1

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

Question 2

Describe the aetiology of a hernia.

Answer 2

Congenital or acquired

Question 3

Why do people acquire hernias?

Answer 3

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

Question 4

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

Answer 4

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

Question 5

What are the 4 patterns of behaviour of a hernia?

Answer 5

Reducible
Incarcerated
Obstructed
Strangulated

Question 6

What is a reducible hernia?

Answer 6

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

Question 7

What is an incarcerated hernia?

Answer 7

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

Question 8

What is an obstructed hernia?

Answer 8

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

These are prone to strangulation.

Question 9

What is a strangulated hernia?

Answer 9

Hernia where the blood supply to the contents is cut off

Question 10

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

Answer 10

3rd most common cause, after adhesions and cancer.

Question 11

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

Answer 11

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

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

Question 12

Which is the most common type of abdominal hernia?

Answer 12

Inguinal

Question 13

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

Answer 13

Men by ~8 times

Question 14

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

Answer 14

Through the inguinal canal

Question 15

How are inguinal hernias classified as direct or indirect?

Answer 15

According to their relationship to the inferior epigastric artery

Question 16

How do most inguinal hernias present?

Answer 16

Painless groin lump noticed

Question 17

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

Answer 17

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

Question 18

Is imaging used routinely for diagnosis of a hernia?

Answer 18

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

Question 19

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

Answer 19

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

Question 20

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

Answer 20

• Symptoms
• Reducibility
• Co-morbidities/frailty

Question 21

Describe the difference between a direct and indirect inguinal hernia.

Answer 21

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

Question 22

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

Answer 22

Congenitally due to patent processus vaginalis

Question 23

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

Answer 23

Acquired abdominal wall weakness

Question 24

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

Answer 24

Indirect

Question 25

How are inguinal hernias in infants usually managed?

Answer 25

Surgery - herniotomy (ligate and excise patent processus vaginalis)

Question 26

How are inguinal hernias in adults managed?

Answer 26

Surgery: 1. Open mesh repair 2. Laparoscopic repair

Question 27

What advice is given to patients following hernia repair operations?

Answer 27

Avoid heavy lifting for 2 weeks post op

Question 28

What are the risk factors for congenital inguinal hernias?

Answer 28

Prematurity | Male sex

Question 29

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

Answer 29

Urgently for surgical repair

Question 30

How should a hernia be assessed clinically?

Answer 30

Examine pt standing and lying down. | Ask them to cough or strain in both positions.

Question 31

Form a list of differentials for an inguinal hernia.

Answer 31

``` Femoral hernia Hydrocele Lymph node swelling Abscess Varicocele Bleeding/haematoma Undescended testis ```

Question 32

What is the best method to repair bilateral inguinal hernias?

Answer 32

Laparoscopically

Question 33

How common is recurrence of an inguinal hernia following repair?

Answer 33

1% within 5 years

Question 34

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

Answer 34

Infarcted ovaries or testis Wound infection Bladder or intestinal injury Hydrocele

Question 35

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

Answer 35

Femoral

Question 36

Why do femoral hernias have a high risk of strangulation?

Answer 36

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

Question 37

Where are femoral hernias found?

Answer 37

Below and lateral to pubic tubercle Medial to femoral pulse

Question 38

Form a list of differentials for a femoral hernia.

Answer 38

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

Question 39

Why should all femoral hernias be repaired?

Answer 39

Great risk of strangulation if not repaired

Question 40

Why are femoral hernias more common in women?

Answer 40

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

Question 41

What are the borders of the femoral canal?

Answer 41

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

Question 42

How can umbilical hernias be further classified?

Answer 42

As true umbilical and para-umbilical hernias.

Question 43

What is a true umbilical hernia?

Answer 43

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

Question 44

What is a paraumbilical hernia?

Answer 44

A hernia that occurs through the periumbilical tissues - always acquired

Question 45

What is an epigastric hernia?

Answer 45

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

Question 46

How do true umbilical hernias present?

Answer 46

-Small central umbilical swelling

Question 47

How do paraumbilical hernias present?

Answer 47

Eccentrically placed swelling causing umbilicus shape to become distorted

Question 48

How are umbilical hernias managed?

Answer 48

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

Question 49

How common is an incisional hernia following a midline laparotomy?

Answer 49

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

Question 50

What are the risk factors for an incisional hernia?

Answer 50

Anything that impairs healing: - Wound infection - Steroid use, anaemia, or malnutrition at time of surgery - Poor closure following surgery

Question 51

What is a rectus sheath haematoma?

Answer 51

Haemorrhage from rectus sheath vasculature.

Question 52

How does a pt with a rectus sheath haematoma present?

Answer 52

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

Question 53

How are rectus sheath haematomas diagnosed?

Answer 53

Hx and Ex with CT as gold standard for diagnosis

Question 54

How should rectus sheath haematomas be managed?

Answer 54

- Conservatively if small and stable | - Larger/bilateral - hospitalisation, blood transfusion, surgical ligation or embolisation if pt deteriorates.

Question 55

What is groin disruption?

Answer 55

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

Question 56

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

Answer 56

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