Chapter 35: Hernias

Question 1

What is hernia?

Answer 1

(L.rupture) Protrusion of a peritoneal sac through a musculoaponeurotic barrier(e.g., abdominal wall); a fascial defect

Question 2

What is the incidence?

Answer 2

5% to 10% lifetime

• 50% are indirect inguinal
• 25% are direct inguinal
• ≈5%are femoral

Question 3

What are the precipitating factors?

Answer 3

• Increased intra-abdominal pressure:
  
  • straining at defecation or urination
    
    • rectal cancer
    • colon cancer
    • prostatic enlargement
    • constipation
• obesity
• pregnancy
• ascites
• valsavagenic (coughing) COPD
• an abnormal congenital anatomic route(i.e., patent processus vaginalis)

Question 4

Why should hernias be repaired?

Answer 4

To avoid complications of incarceration/strangulation, bowel necrosis, SBO,pain

Question 5

What is more dangerous: a small or large hernia defect?

Answer 5

Small defect is more dangerous because a tight defect is more likely to strangulate if incarcerated

Question 6

Reducible

Answer 6

Ability to return the displaced organ or tissue/hernia contents to their usual anatomic site

Question 7

Incarcerated

Answer 7

Swollen or fixed within the hernia sac (incarcerated = imprisoned); may cause intestinal obstruction (i.e., an irreducible hernia)

Question 8

Strangulated

Answer 8

Incarcerated hernia with resulting ischemia; will result in signs and symptoms of ischemia and intestinal obstruction or bowel necrosis (Think: strangulated= choked)

Question 9

Complete

Answer 9

Hernia sac and its contents protrude all the way through the defect

Question 10

Incomplete

Answer 10

Defect present without sac or contents protruding completely through it

Question 11

What is reducing a hernia “en masse”?

Answer 11

Reducing the hernia contents and hernia sac

Question 12

Sliding hernia

Answer 12

Hernia sac partially formed by the wall of a viscus (i.e., bladder/cecum)

Question 13

Littre’s hernia

Answer 13

Hernia involving a Meckel’s diverticulum (Think alphabetically: Littre’sMeckel’s = LM)

Question 14

Spigelian hernia

Answer 14

Hernia through the linea semilunaris (or spigelian fascia); also known as spontaneous lateral ventral hernia (Think: Spigelian = Semilunaris)

Question 15

Internal hernia

Answer 15

Hernia in or involving intra-abdominal structure

Question 16

Petersen’s hernia

Answer 16

Seen after bariatric gastric bypass—internal herniation of small bowel through the mesenteric defect from the Roux limb

Question 17

Obturator hernia

Answer 17

Hernia through obturator canal (females > males)

Question 18

Pantaloon hernia

Answer 18

Hernia sac exists as both a direct and indirect hernia straddling the inferior epigastric vessels and protruding through the floor of the canal as well as the internal ring (two sacs separated by the inferior epigastric vessels [the pantcrotch] like a pair of pantaloon pants)

Question 19

Incisional hernia

Answer 19

Hernia through an incisional site; most common cause is a wound infection

Question 20

Ventral hernia

Answer 20

Incisional hernia in the ventral abdominal wall

Question 21

Parastomal hernia

Answer 21

Hernia adjacent to an ostomy (e.g., colostomy)

Question 22

Richter’s hernia

Answer 22

Incarcerated or strangulated hernia involving only one sidewall of the bowel,which can spontaneously reduce, resulting in gangrenous bowel and perforation within the abdomen without signs of obstruction

Question 23

Epigastric hernia

Answer 23

Hernia through the linea alba above the umbilicus

Question 24

Umbilical hernia

Answer 24

• Hernia through the umbilical ring
• in adults associated with:
  
  • ascites
  • pregnancy
  • obesity

Question 25

Femoral hernia

Answer 25

Hernia medial to femoral vessels (under inguinal ligament)

Question 26

Indirect inguinal

Answer 26

Inguinal hernia lateral to Hesselbach’s triangle

Question 27

Direct inguinal

Answer 27

Inguinal hernia within Hesselbach’s triangle

Question 28

Hiatal hernia

Answer 28

Hernia through esophageal hiatus

Question 29

What are the boundaries of Hesselbach’s triangle?

Answer 29

1. Inferior epigastric vessels
2. Inguinal ligament (Poupart’s)
3. Lateral border of the rectus sheath
4. Floor consists of internal oblique and the transversus abdominis muscle

Question 30

What are the layers of the abdominal wall?

Answer 30

1. Skin
2. Subcutaneous fat
3. Scarpa’s fascia
4. External oblique
5. Internal oblique
6. Transversus abdominus
7. Transversalis fascia
8. Preperitoneal fat
9. Peritoneum

Note: All three muscle layer aponeuroses form the anterior rectus sheath, with the posterior rectus sheath being deficient below the arcuate line

Question 31

What is the differential diagnosis for a mass in a healed C-section incision?

Answer 31

Hernia, ENDOMETRIOMA