Clin Med - Hernias Flashcards
1
Q
what is a hernia?
A
protrusion of intra-abdominal tissue through a fascial defect in the abdominal wall
2
Q
risk factors for hernias
A
- hx of hernia or prior hernia repair
- older age
- male
- caucasian
- chronic cough
- chronic constipation
- abdominal wall injury
- smoking
- fam hx
3
Q
what is a hernia composed of?
A
- covering tissues (skin, subcutaneous tissues, etc)
- a peritoneal sac and any contained viscera
4
Q
“neck” of the hernia
A
- if the neck is narrow where it emerges from the abdomen, the bowel may be obstructed or strangulated or incarcerated
- better to have wider neck
5
Q
what happens if a hernia is not repaired early?
A
the defect may enlarge and repair becomes more complicated
6
Q
reducible hernia
A
contents of the sac return to the abdomen spontaneously or w/ manual pressure
7
Q
irreducible (incarcerated) hernia
A
- contents cannot be returned to abdomen - trapped by narrow neck
- incarceration does not mean obstruction but is necessary for obstruction to occur
8
Q
strangulated hernia
A
- compromise of blood supply
- gangrene of contents can occur
9
Q
what type of hernia has has a higher incidence of strangulation?
A
femoral hernia
10
Q
Richter hernia
A
- uncommon but dangerous
- only part of the circumference of the bowel is incarcerated/strangulated in the facial defect
11
Q
what is the risk of a Richter hernia in surgery?
A
- it may spontaneously reduce and the gangrenous piece could be overlooked
- bowel may subsequently perforate resulting in peritonitis
12
Q
where is the Richter hernia most common?
A
femoral canal
13
Q
What are the abdominal wall hernias?
A
- epigastric
- spigelian
- incisional
- umbilical
14
Q
epigastric hernia
A
- protrudes through the linea alba above the umbilicus
- often < 1cm in diameter
- M>F
- bowel incarceration/strangulation is RARE
- only repair symptomatic pts
15
Q
diastasis recti
A
- NOT a true hernia
- failure of the linea alba to approximate
- doesn’t need tx
- no increased morbidity/mortality
16
Q
spigelian hernia
A
- occur along the semilunar line (outside of posterior rectus sheath)
- relatively rare
- HIGH incidence of incarceration (up tp 20% already incarcerated on presentation)
17
Q
spigelian hernia symptom
A
- pain localized to the hernia
- aggravated by increased intra-abdominal pressure
- over time pain may become more diffuse
18
Q
diagnosis of spigelian hernia
A
- easy if there is a mass (disappears w/ pressure)
- but may not be palpable (no mass)
- should be tender over hernia orifice
- US or CT to confirm
- repair can be open or laparoscopic
19
Q
incisional hernia
A
- 10% of abdominal incisions (23% if post-op wound infection)
- upper abdominal incisions > lower
- often multiple hernias present at incision (swiss cheese)
20
Q
tx for incisional hernia
A
almost always surgery w/ mesh
21
Q
etiology of incisional hernias
A
- poor surgical technique
- failure to close laparoscopic trocar sites (>10mm in size)
22
Q
risk factors for incisional hernias
A
- older age
- debility, chronic dz, compromised nutrition
- obesity
- increased intra-abdominal pressure
- pulm. compilcations (coughing)
- drains or stomas
- blood loss during operation
- collagen defects
23
Q
umbilical hernias in children
A
- often noted at birth
- will usually close by age 2 if <1/2 inch
- need surg if doesn’t close by 2-4 yrs
- not painful
24
Q
umbilical hernias in adults
A
- most often acquired
- associated w/ intra-abdominal pressure: multiple pregnancies w/ prolonged labor, ascites, obesity, lg tumors, distention
25
females vs males umbilical hernias
- 3:1 W:M
| - men tend to present incarcerated
26
s/s of umbilical hernias in adults
- omental strangulation can cause chronic abdominal wall pain
- usually not tender unless palpated
- surgery if symptomatic
27
more on umbilical hernias in adults
- does not usually obliterate spontaneously
- increase steadily in size
- usually contain omentum
- often require emergency repair (neck is usually narrow)
28
What are the hernias of the groin?
- inguinal
- femoral
- obturator
29
how do all groin hernias occur?
-by protruding through a weakness/defect in the transversalis fascia
30
indirect inguinal hernias pass through . . .
-the internal inguinal ring into the inguinal canal
31
direct inguinal hernias extend . . .
-directly forward and DO NOT pass through the inguinal canal
32
indirect hernias
- congenital
- any age
- through inguinal ring (where spermatic cord in males exits abdomen or where round ligament exits abdomen in females)
33
what side are indirect hernias more frequent?
right side
34
direct hernias
- acquired
- more medial than indirect hernias
- "bulge" in groin
- d/t weakness in the floor of the inguinal canal
- rarely protrude into scrotum
- middle aged and elderly
- difficult to distinguish from testicle pain
35
sx of inguinal hernias
- lumps/swelling in groin
- "dragging" sensation
- sudden pain and bulge that occurred while lifting/straining
36
where does indirect hernia pain radiate to?
scrotum
37
which hernia, direct or indirect, produce fewer sx?
- direct
| - they are less likely to become incarcerated
38
PE of inguinal hernias
- mass that may or may not be reducible
- examine supine and standing - have them cough/strain
- invaginate the scrotum and palpate w/ index finger
- tissue must protrude into the inguinal canal during coughing to diagnose hernia
39
obturator hernia
- rare
- elderly women
- abdominal contents protrude through obterator foramen
40
common pts that could have obturator hernia
- chronically increased intrabdominal pressure
- COPD
- acites
- cough
- suspect in any elderly debilitate woman w/o previous abdominal operation who presents w/ small bowel obstruction
41
presentation of obturator hernia
- small bowel obstruction
- palpable proximal thigh mass (rare)
- groin pain radiating medially to knee (nerve compression)
- ecchymoses of the thigh (if necrosis has occurred)
42
What is the most lethal of all abdominal hernias?
obturator
43
femoral hernia
- descends through the femoral canal beneath the inguinal ligament
- narrow neck - prone to incarceration
- bulge just below the inguinal crease
- W>M (usually slender women)
44
symptoms of femoral hernia
- colicky abdominal pain and signs of intestinal obstruction
- NO discomfort/pain/tenderness in the femoral region
- often hx of previous inguinal hernia repair
45
signs of femoral hernia
- if small and uncomplicated: appears as small bulge in upper medial thigh just below level of inguinal ligament
- can be confused w/ inguinal hernia
46
What are the 2 kinds of diaphragmatic hernias?
- congenital: embryological defect in the diaphragm
| - acquired: usually by trauma
47
common location of diaphragmatic hernias
left side > right side
| hepatic protection
48
PE of diaphragmatic hernias
- market respiratory distress
- decreased breath sounds on effected side
- bowel sounds in chest (eek)
- movement of abdomen w/ breathing
- diffuse abdominal pain
49
diaphragmatic hernias
- surgery
- tx associated issues
- laparotomy for acquired
50
What are the 2 kinds of hiatal hernias?
- sliding
| - paraesophageal
51
sliding hiatal hernias
- GE junction above diaphragm
- 95% of hiatal hernias
- most are asymptomatic
- tx: refulx med if symptomatic
52
paraesophageal hiatal hernias
- upward dislocation of gastric fundus
- usually asymptomatic or vague symptoms
- MC sx: epigastric or substernal pain
- surgery is not frequently needed
53
tx of hiatal hernias
- trusses
- abdominal binders
- herniorrhaphy
54
when to consider surgery for hiatal hernias
- sx are present
- potential for bowel incarceration
- if hernia is between 1-8cm (8 is too big)
- sufficient size to complicate dressing or activities of daily living
