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Y3 CBLs > CBL_Hernias > Flashcards

CBL_Hernias Flashcards

1
Q
  • Types of hiatus hernia
  • structures involved
  • how common they are (%)
A

Hiatus hernia

A. Sliding - 80%: gastro-oesophageal junction, cardia of the stomach move through diaphragmatic hiatus into the thorax

B. Rolling (para-oesophageal) - 20%: fundus of the stomach moves up and the stomach protrudes next to the oesophagus -> ‘bubble’ of the stomach in the thorax (peritoneal sac)

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2
Q

Spigelian hernia

  • location
  • management
A

Spigelian hernia

  • arcuate line (lower lateral edge of rectus andominis)

Mx: urgent surgical repair due to high risk of strangulation

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4
Q

Obturator hernia

  • anatomical location and what protrudes
  • risk factors
A

Obturator hernia

Anatomical location: pelvic muscle floor protrudes via the obturator foramen

Risk factors:

  • being a woman (wider pelvis)
  • elderly
  • rapid weight loss (as fat would be lost and more potential space via obturator foramen)
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5
Q

Signs of obturator hernia

A

Obturator hernia

  • mass in the upper medial thigh
  • features of small bowel obstruction may be present
  • positive Howship - Romberg sign (due to compression of obturator nerve) *

*Howship-Romberg sign: tight extension / medial rotation and abduction -> hip and knee pain exacerbated

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6
Q

Littre’s hernia

  • what structure does herniate?
  • what’s the location?
  • prognosis
A

Littre’s hernia

Herniation of Meckel’s Diverticulum

Location: inguinal canal

Prognosis: will often become strangulated

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7
Q

Two specific areas of weakness in the posterior lumbar wall that may precipitate lumbar hernias

A
  • Superior lumbar triangle – termed Grynfeltt’s quadrangle
  • Inferior lumbar triangle – termed Petit’s triangle
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8
Q

Lumbar hernia

  • possible causes
  • location
A

Lumbar hernia

Cause: occur following surgery - either spontaneous or iatrogenic

Location: lumbar posterior wall

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10
Q

Richter’s hernia

  • what happens
  • signs
  • management
A

Richter’s hernia

what happens: part of the bowel/ anti-mesenteric border protrudes into the hernia and becomes strangulated

signs: tender irreducible mass, bowel obstruction (varying levels - depends on how much of the bowel is involved)

management: emergency surgery

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11
Q
A
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12
Q

Risk factors for hiatus hernia

A

A. Age - as the diaphragmatic muscle tone will decrease

B. Anything that will increase abdominal pressure: pregnancy, obesity, ascites, repeated coughing

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13
Q

(possible) Symptoms of hiatus hernia

A
  • most asymptomatic
  • GORD - often severe and Rx resistant
  • weight loss and vomiting
  • anaemia and bleeding - due to possible ulceration of the oesophagus
  • hiccups and palpitations - as hernia may irritate diaphragm or pericardial sac
  • swallowing difficulties - stricture formation
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14
Q

What may be heard on examination of hiatus hernia?

A

Bowel sounds in the chest (auscultation) if the hernia is big enough

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15
Q

What’s a gold standard investigation for hiatus hernia?

What are the characteristic findings?

A

Oesophagogastroduodenoscopy (OGD)

Findings:

upward displacement of gastro-oesophageal junction = ‘ Z line’

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16
Q

Conservative management for hiatus hernia

A

A. PPI e.g. Omeprazole - to reduce irritation by gastric acid and GORD - like symptoms - take in the morning before food (otherwise ineffective)

B. Lifestyle changes:

  • exercise and weight loss - to reduce intraabdominal pressure
  • smoking cessation and reduced alcohol intake (as they will decrease the tongue of the gastro-oesophageal sphincter)

C. Diet: low fat and small meals

D. Sleeping on increased number of pillows

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17
Q

Hiatal hernia - what are the indication for the surgery?

A
  • symptomatic despite maximal medical/conservative therapy
  • nutritional failure - due to gastric outlet obstruction
  • danger of strangulation, volvulus - e.g. in rolling hernia
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18
Q

Patient presenting with the hiatus hernia

What are indications for NG tube decompression of the stomach before the surgery?

A
  • strangulation
  • stomach volvulus
  • obstruction
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19
Q

Name (only name) two types of surgery used for hiatus hernia

A
  • cruroplasty
  • fundoplication
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20
Q

What does cruroplasty surgery involve?

A

Cruroplasty (hiatus hernia):

Hernia is reduced from the thorax into the abdominal cavity -> then the stomach is fixed to the appropriate size

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21
Q

What does fundoplication surgery involve?

A

Fundoplication (for hiatus hernia)

Gastric fundus is wrapped around lower oesophagus and fixed in place

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22
Q

What is incarcerated hernia?

A

Bowel cannot be reduced back into abdominal cavity

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23
Q

What’s the best diagnostic mode for an inguinal hernia?

A

Clinical suspicion and explorative surgery

Imaging should only be considered in patients with suspected inguinal hernia if there is diagnostic uncertainty or to exclude other pathology

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24
Q

What are the indications for urgent hernia surgery?

A

Incarcerated, obstructed and strangulated hernia

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25
Q

What are the two main subtypes of inguinal hernia and their prevalence? (just names and %)

A

A. Direct (20%)

B. Indirect (80%)

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26
Q

Explain direct inguinal hernia

  • what structures are involved?
  • cause
  • epidemiology (population)
A

Direct: bowel enters the inguinal canal ‘directly’ through the posterior wall of the canal (Hesselbach’s triangle)

Cause: the weakness of the abdominal wall

Population: often in the elderly due to the weakness of the abdominal wall or increased intraabdominal pressure

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27
Q
  • Which vessel is important in differentiating between types of inguinal hernias during the surgery?
  • Explain
A

Inferior epigastric vessels

Direct hernia -> medial to the vessels

Indirect hernia -> lateral to the vessels

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28
Q

Indirect inguinal hernia - explain

A

Location: bowel enters the inguinal canal via deep inguinal ring

Cause: incomplete closure of tunica vaginalis * - congenital in origin

* tunica vaginalis is an outpouching of the peritoneum allowing testicular descent

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29
Q

Risk factors for inguinal hernias

A
  • male
  • obesity
  • advanced age
  • increased intra-abdominal pressure (heavy lifting, chronic cough and constipation)
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30
Q

Clinical features of inguinal hernia (the one that does not require urgent surgery)

A
  • mass in the groin
  • mass can be easily reduced (disappear) when a patient lies down
  • possible mild-moderate discomfort when the patient is standing or while activity
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31
Q

Signs and symptoms of inguinal hernia requiring urgent surgery

A
  • erythematous and painful mass -> incarcerated
  • bowel obstructive symptoms
  • strangulation -> when there is # blood supply
  • *A herniastrangulated*hernia will present as an irreducible and tender tense lump, with thepain often being out of proportion to clinical signs;this may be accompanied withclinical features of obstruction
32
Q

Four things to consider while examining a groin lump

A
  • cough impulse -> may not be present if hernia is the irreducible
  • location (inguinal vs femoral)

* inguinal - superomedial to pubic tubercle

* femoral - inferolateral to pubic tubercle

  • reducible - on lying down; +/- on minimal pressure
  • does it enter the scrotum - can we get above it/ separate it from the testes
33
Q

Where from the anatomical point of view the deep inguinal ring lies?

A

midpoint of the inguinal ligament

34
Q

How to differentiate between direct and indirect inguinal hernia?

*this is however unreliable method - the only way to differentiate 100% is during the surgery

A
  1. Reduce the hernia
  2. Put pressure on the deep inguinal ring (midpoint of inguinal ligament
  3. Ask the patient to cough

*if hernia protrudes (despite occlusion) -> direct hernia

*if the hernia does not protrude -> inguinal hernia

35
Q

investigations/ diagnosis of hernia

A
  • It is typically a clinical diagnosis -> confirmed with the surgery
  • USS if clinical diagnosis uncertain or to exclude other pathology
36
Q

Should the surgery be offered to every patient with a hernia?

A
  • surgery offered in case of large mass or discomfort (symptomatic)
  • if strangulated (pain out of the proportion, clinical signs)- urgent surgery

If asymptomatic, a conservative management can occur but need to make a patient aware that there is a potential for surgery at some point

37
Q

Types of surgery used for hernias

A

A. Open repair - Lichtenstein technique

B. Laparoscopic repair:

  • total extraperitoneal
  • transabdominal pre-peritoneal
38
Q

What patients are preferred for ‘open mesh repair’?

A

patients with primary inguinal hernia

39
Q

laparoscopic repair of hernia - what patients are considered for that?

A

bilateral or recurrent hernias

*may also be considered in patients with primary unilateral hernia, if at higher risk of chronic pain (young and active, main symptoms is pain) or in female - as at higher risk of femoral hernia

40
Q

Advantages and disadvantages of laparoscopic hernia repair

A
  • longer operative times
  • less cost-effective

BUT

  • quicker recovery
  • fewer complications
  • less post-operative pain
41
Q

Pathway in deciding what type of surgical repair (open/laparoscopic) to make in case of hernia

A
42
Q

Main complications of inguinal hernia

A
  • strangulation -> bowel blood supply cut off
  • incarceration/ irreducible (hernia not able to return to is original cavity)
  • obstruction -> bowel lumen obstructed/clinical features of bowel obstruction
43
Q

Possible postoperative complications of hernia repair

A
  • Pain, bruising, haematoma, infection, or urinary retention
  • Recurrence (approximately 1.0% within 5 years of surgery)
  • Chronic pain (persisting 3 months after hernia repair), can occur in up to 30% patients and is disabling in ~2%
  • Damage to vas deferens or testicular vessels, leading to ischaemic orchitis (and potentially sub-fertility)
44
Q

What’s a femoral hernia?

A

Abdominal viscera/ omentum passes through femoral ring into a potential space in a femoral canal

45
Q

Why femoral hernia is more common in women (3:1) than in men?

A

This is because women have a wider bony pelvis

*rarely happens in children

46
Q

What forms the borders of a femoral triangle?

A

Femoral triangle/Scarpa’s triangle

  • inguinal ligament
  • medial border of adductor longus
  • medial border of sartorius muscle
47
Q

Why do all femoral hernia require surgical repair? Why?

A

Increased risk of strangulation

This is due to the rigidity of the borders of the femoral ring - especially lacunar ligament

48
Q

Inguinal/ Hasselbachtriangle (inguinal hernia) borders

A

Medial: lateral border of rectus muscle

lateral: inferior epigastric a.

Inferior: inguinal ligament

49
Q

The main risk factors for femoral hernia

A

Femoral hernia:

  • being female
  • pregnancy
  • increased age
  • increased intra-abdominal pressure (heavy lifting, chronic constipation)
50
Q

Clinical presentation of femoral hernia

A

A mass in the groin

* 30% present as an emergency due to its anatomical location (strangulation risk increased as rigid borders of a femoral canal)

51
Q

Is femoral hernia reductible?

A

Unlikely,the due to tightness of femoral ring

52
Q

What’s saphena varix?

A

Dilation of the saphenous vein at the junction with femoral v. in the groin

53
Q

Clinical features of saphena varix

(how to distinguish it from a femoral hernia)

A
  • lump in the groin
  • displays cough impulse
  • disappears on lying flat
  • bluish tinge
54
Q

Saphena varix

  • associations
  • diagnostic investigation
A

Saphena varix

  • associated with varicose veins
  • USS

*shows flow on duplex USS

55
Q

Investigations of femoral hernia

A
  • usually clinical diagnosis

However, as all the patients require surgery, further investigations required

  • USS
56
Q

Femoral hernia surgery - steps

A
  1. Reduction of the hernia
  2. Surgical narrowing of the femoral ring (use of interrupted sutures)
57
Q

Two different approaches used in the surgery for femoral hernia

A
  • low approach - incision made below inguinal canal

(not interfering with inguinal structures, but limits the access to the bowel - if compromised)

  • high approach - incision made above inguinal canal, via posterior wall of inguinal canal

(preferred in an emergency situation due to easier access to compromised bowel; however requires repair of the inguinal canal on closure - potential area of weakness and secondary herniation)

58
Q

What’s an epigastric hernia?

A

Epigastric hernia through the linea alba in the epigastrium midline from xiphoid process to umbilicus

59
Q

What’s an incisional hernia?

A

Incisional hernias through scar tissue including previous hernia repairs

60
Q

What’s Spigelian hernia (location, age of prevalence and prognosis)

A

Spigelian hernias

  • through the spigelian fascia inferior and lateral to the umbilicus.
  • In >40yrs and more common if obese
  • Usual strangulates and presents as a tender mass
61
Q

What forms the anterior wall of the inguinal canal?

A

Anterior wall:

  • External oblique aponeurosis (whole length)
  • Internal oblique (lateral one third)
62
Q

What forms posterior wall of the inguinal canal?

A

Posterior wall:

  • Fascia transversalis
  • Conjoint tendon (medial one third)
63
Q

What forms the superior wall of the inguinal canal?

A

Superior wall:

  • Arching fibers of internal oblique
  • Transverse abdominis
64
Q

What forms the inferior wall of the inguinal canal?

A

Inferior wall:

  • Inguinal ligament
  • Lacunar ligament (medial one third)
65
Q

What structures does the inguinal hernia contain in women?

A

Inguinal hernia in women it contains:

  • the ilioinguinal nerve
  • round ligament of uterus
  • lymphatics
66
Q

What does the spermatic cord contain (inguinal hernia in men)?

A

Contents of Spermatic cord:

–vas deferens

  • pampiniform plexus
  • testicular and cremasteric arteries/veins
  • nerves
  • lymphatic
67
Q

Final destinations of inguinal hernia in men and women

A

men -> scrotum

women -> labia majora

68
Q

Content of direct vs indirect inguinal hernia

A
  • Direct: usually Retroperitoneal fat
  • Indirect: Omentum or bowel
69
Q

What’s Pantaloon hernia?

A

•type of inguinal hernia

  • Both types direct and indirect hernia may occur at the same time and straddle the inferior epigastric artery

•Also called sliding hernia

70
Q

Umbilical hernia

  • when detected
  • prognosis
A
  • congenital so detect at birth and 8 week check
  • Mostly will close in the first year of life.
71
Q

Para-umbilical hernias

  • population age
  • location
  • prognosis
A
  • Para-umbilical hernias are in adults
  • arise above or below the umbilicus
  • usually has a small neck and so can strangulate
72
Q
A

Y3 CBLs (13 decks)

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