Colorectal surgery: Hernias Flashcards
Define the term ‘hernia’ [1]
{{c1::Protrusion of a viscus or part of a viscus through a defect in the wall of its containing cavity}}
Define the following terms:
- Strangulated hernia [1]
- Sliding hernia [1]
Strangulated hernia:
- Intestine present in a hernia may become strangulated as the vascular supply to this loop of bowel becomes compromised.
- Blood may still enter, yet if venous drainage is reduced then swelling can occur, causing ischemia and the hernia to become gangrenous
- Risk of sepsis
Sliding hernia:
- Type of hiatus hernia
- stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax.
Where are the following types of hernia found? [3]
Richter hernia
Littre hernia
Amyand hernia
Richter hernia
herniation of only a portion of the circumference of the bowel wall
Littre hernia
Protrusion of a Meckel diverticulum through a potential abdominal openin
Amyand hernia
Appendix is trapped within an inguinal hernia.
Describe the diferent types of hernia [3]
Inguinal hernia
Femoral hernia
Umbilical hernia / paraumbilical
Inguinal hernia:
- A protrusion of abdominal cavity contents through the inguinal canal: direct or indirect
- Indirect inguinal hernias: pass through the internal inguinal ring and if large, out through the external inguinal ring.
- Direct inguinal hernias: push directly forward through the posterior wall of the inguinal canal, in a defect in the abdominal wall.
Femoral hernia:
- this is a hernia of contents, usually bowel, through the femoral canal.
Umbilical/ Paraumbilical:
- Hernia that occurs just above or below the umbilicus (paraumbilical) or through the umbilicus (umbilical).
Define epigastric -, incisional & parastomal hernias [3]
Epigastric hernia:
Hernia that passes through the linea alba, above the umbilicus
Incisional hernia:
Hernias that occur following breakdown of muscle closure after surgery. Mesh repairs have less likely recurrence of incisional hernias but increased risk of infection. Being obese makes repair harder
Parastomal hernia
Hernia that occurs through possible wall defects created during stoma formation
Fermoral hernias are more likely to develop in which population? [1]
Women
Describe how an indirect hernia occurs [3]
As the testes descend into the scrotum: they bring with them a covering of peritoneum, the processus vaginalis, which is usually pinched off automatically.
However if it doesn’t close off and there is a patent processus vaginalis, this can cause congenital indirect inguinal hernias, and also hydroceles. The hernia will usually descend into the scrotum
Pass through both deep and superificial inguinal ring
What are the borders of Hesselbach’s triangle? [3]
R – Rectus abdominis muscle – medial border
I – Inferior epigastric vessels – superior / lateral border
P – Poupart’s ligament (inguinal ligament) – inferior border
Define what is meant by a Pantaloon hernia [1]
Combination of two adjacent hernia sacs of the femoral or inguinal region (direct or indirect) on the same side.
The sacs are thus present on both sides of the inferior epigastric vessels
Thus, examples include: femoral with direct hernias, femoral with indirect hernias, indirect with direct hernias.
Describe what is meant by the palpable cough impulse? [1]
If the swelling expands upon coughing, it is said to have a ‘cough’ impulse.
Difference in anatomy of femoral and inguinal hernia? [2]
Inguinal:
superomedial to the pubic tubercle
Femoral:
inferolateral to the pubic tubercle
Describe the management of uncomplicated hernia [4]
Surgery:
Open mesh repair:
- Direct hernia: plication
- Indirect: sac excision
- Both: add mesh which produces fibrosis
Laporoscopic mesh repair:
- As above, but reduced injury of nerves & post-op chronic pain
- Reinforces wall to elimiante reoccurence
Laporoscopic pre-peritoneal mesh repair
Suture repair (high chance of reoccurance
Which nerves are present in area that open and laparoscopic mesh repair occur in? [3]
The iliohypogastric nerve, ilioinguinal nerve and genital branch of the genitofemoral nerve
Laparoscopic mesh repair is particularly good for repairing what type of hernias? [1]
Bilateral hernias
Why is surgical repair of femoral hernia a necessity? [1]
Risk of strangulation
What is a spigelian hernia? [2]
A Spigelian hernia occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris.
This is the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall. Usually, this occurs in the lower abdomen and may present with non-specific abdominal wall pain.
What’s important to note about umbilical hernias? [2]
Omentum & bowel can be inside
Inguinal hernias are more commonly found on which side? [1]
Why? [2]
Right sided
Due to descend of the testis or previous appendectomy
Which medical conditions might predispose a patient to an inguinal hernia? [2]
collagen defect medical conditions such as Ehlers-Danlos syndrome, Marfan’s syndrome.
Which type of inguinal hernia is more likely to become strangulated? [1]
Explain your answer [1]
Indirect hernias
This is because the structural defect in a direct hernia is usually a widespread weakness of the inguinal floor tissues, rather than a discrete, defined ring-like defect.
Describe the method used to test for indirect inguinal hernia c.f. direct [2]
To test for indirect inguinal hernias:
- finger pressure should be applied over the deep inguinal ring. The finger pressure will control the hernia when the patient coughs.
To test for direct hernias:
- instruct the patient to cough, and a bulge should appear medial to point of finger pressure.
What is the treatment plan for mild/asymptomatic hernias? [2]
For mild/asymptomatic hernias, the treatment management plan would be conservative watchful waiting.
Ask for a 6-month follow up
What is treatment plan for an acute hernia (strangulation/ incarceration)? [1]
Refer to general surgery ASAP
What is the surgical procedure for recurrent inguinal hernia:
- If previous anterior hernia repair? [1]
- If previous posterior hernia repair? [1]
If previous anterior hernia repair:
- open preperitoneal mesh or endoscopic approach
If previous posterior hernia repair:
- Lichtenstein’s totally extraperitoneal (TEP). A minimally invasive procedure where the mesh is used to seal the hernia from outside the peritoneum.
What management should be avoided in femoral hernias? [1]
Hernia support belts/trusses should NOT be used for femoral hernias, again due to the risk of strangulation;
If a hernia cannot be reduced it is referred to as an [] hernia - these are typically [painful / painless]
If a hernia cannot be reduced it is referred to as an incarcerated hernia - these are typically painless
What is the most sensitive investigation for hiatus hernia? [1]
Barium swallow
Describe the medical and surgical management for hiatus hernias [2]
medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias
What is the clinical consensus about treating inguinal hernias? [1]
the clinical consensus is currently to treat medically fit patients even if they are asymptomatic with surgery
Which type of repair is best suited for unilateral [1] and bilateral or recurrent inguinal hernias [1]?
unilateral inguinal hernias are generally repaired with an open approach
bilateral and recurrent inguinal hernias are generally repaired laparoscopically
What is the most likely diagnosis?
Hiatus hernia
