Gen Surg: Hernias Flashcards
What is a hernia?
A protrusion of a viscus/part of a viscus (organ) through a defect of the wall of its containing cavity into an abnormal posiiton
What is meant if a hernia is irreducible?
Contents cannot be pushed back into place
What is meant when a hernia is described as obstructed?
Bowel contents cannot pass - features of intestinal obstruction (painful)
What is meant by a strangulated hernia?
A hernia that is cutting off the blood supply to the intestines and tissues in the abdomen.
(painful- pateint becomes toxic and requires urgent surgery)
What is meant by incarceration of a hernia?
Contents of the hernial sac are stuck inside by adhesion
What is the cause of hernias?
Abdominal wall hernias occur at sites of inherent wekaness
Operations + advancing age + obesity + malnutrition = further loss in muscle strength
Raised intra-abdominal pressure is a risk factor (chronic cough, constipation, urinary obstruction, heavy lifting)
General presentation of hernia
Lump
Normally painless (unless complicated)
Expansible cough imulse
Diagnosis of hernias
Clinical
US if unsure
Complications of hernias
Obstruction
Strangulation
Irreducable/incarcerated
What is a femoral hernia?
Bowel enters the femoral canal, presenting as a mass in the upper medial thigh or above the inguinal ligament where it points down the leg
What sex do femoral hernias occur most commonly in?
Females - especially middle aged and elderly
What is the anterior boundary of the femoral triangle?
Inguinal ligament
What is the medial boundary of the femoral canal?
The lacunar ligament and pubic bone
What is the lateral border of the femoral triangle?
Iliopsoas and femoral vein
What are the contents of the femoral canal?
- Fat
- Cloquet’s node/lacunar node
- Empty sapce
- Loose conective tissue
- Lymphatic vessles
What is the differential diangosis for someone presenting with features of a femoral hernia?
- Inguinal hernia
- Saphena varix - dilatation at top of long saphenous vein due to vascular inconpetance (soft and compressable, dissapears on lying down, +ve expansable cough impulse)
- Inguinal lymphadenopathy
- Groin abscess
- Enlarged Cloquet’s node
- Lipoma
- Femoral aneurysm
- Psoas Abscess
How would you manage a femoral hernia?
Surgical repair
- Herniotomy - excision of hernia sac
- Herniorrhaphy - repair of hernia defect
Reduction of hernia and narrowing of femoral ring.
Surger recommended as hernia is prone to strangulation and osbtruction.
What is a TRUSS?
Life a corset thing. For those excluded from surgery.
Where are paraumbilical hernias found?
Occur just above of below the umbilicus
What are risk factors for paraumbilical hernias?
- Obesity
- Ascites
How would you manage a paraumbilical hernia?
Leave it, or repair of rectus sheath (Mayo repair)
What are epigastric hernias?
Hernias which pass through the linea alba above the umbilicus
What is an incisional hernia?
Following breakdown of muscle closure after surgery, skin remains intact
Risk factors for incisional hernia
Emergency surgery
Wound type
BMI >25
Midline incision
Wound infection
Increased age
What is a Spigelian hernia?
Occurs through the linea semilunaris at the lateral edge of the rectus sheath, below and lateral to the umbilicus
What is an obturator hernia?
Occurs through the obturator canal
What’s the difference between inguinal and femoral hernia?
- Inguinal
- More common male
- Pass through inguinal canal
- Less commonly strangulate
- Can be treated without surgery
- Femoral
- More common female
- Pass through femoral canal
- More common to strangulate
- Must be treated surgically
(See picture in notes)
Where is pain typically felt with obturator hernias?
Along the medial side of the thigh
What is an indirect inguinal hernia?
(80% of hernias)
Passess through the internal inguinal ring, and, if large, out through the external inguinal ring.
Arises lateral to the inferior epigastric artery.
Arise from incomplete closture of process vaginalis.
Can strangulate.
What is a direct inguinal hernia?
(20% of hernias)
Hernias which push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal
Through a weakneing called hasselbach’s triangle.
Reduce easily and rarely strangulate
Medial to inferiaor epigastric.
Commoner in older people and often secondary to increase intra-abdominal pressure)
What is the surface anatomy of the deep inguinal ring?
The mid-point of the inguinal ligament - 11/2 cm above the femoral pulse (which crosses the mid inguinal point)
What is the surface anatomy of the superficial inguinal ring?
Just superior and medial to the pubic tubercle
What is hesselbach’s triangle?
The space bounded by the lateral border of the rectus abdominis medially, the inguinal ligament inferiorly, and the inferior epigastric vessels laterally.
The inguinal triangle contains a depression referred to as the medial inguinal fossa, through which direct inguinal hernias protrude through the abdominal wall
What factors predispose to the development of inguinal hernias?
- Male
- Chornic cough
- Contipation
- Urinary obstruction
- Heavy lifting
- Ascites
- Post-abdo surgery
How would you assess an inguinal hernia on examination?
Lying and standing
- Look for previous scars
- Feel other side
- Examine external genitalia
- Assess reducibility
-
Ask patient to cough - feel for impulse if not visible
- Pressure of the area when they do will prevent an indirect hernia from re-appearing whereas a direct one will.
How would you clinically try to determine if a hernia was direct or indirect?
Reduce the hernia to deep inguinal ring and occlude the ring. Ask the patient to cough/stand - if the hernia is restrained, it is indirect; if it is not, it is direct
In terms of the epigastric artery, where do direct hernias arise form?
Medial to inferior epigastric artery
In terms of the inferior epigastric artery, where do indirect hernias arise from?
Lateral to inferior epigastric artery
How could you initially manage an irreducible hernia?
Manually reduce - to prevent strangulation and necrosis
What would you advise someone coming in for a hernia repair to do pre-op?
- Lose weight
- Stop smoking
How would you repair an inguinal hernia?
Mesh repair - polypropylene mesh reinforces wall
When would mesh repair be contraindicated in managing an inguinal hernia?
- Strangulated hernias
- Contamination with pus/bowel contents
What other methods can be used to repair hernias besides mesh repair?
Laparoscopic repair - TAPP, TEP
Tends to be done in bilateral/recurent
Post op complicationshernia repair
Pain, bruising, haematoma, infection, urinary retention
Dmaage to vas deferens
Recurrence
Chronic pain
How long would you advise someone do rest following hernia surgery?
- Open approach - 4 weeks - 8 weeks
- Laparoscopic - 2 weeks
What are the contents of the inguinal canala in a male?
- External spermatic fascia
- Cremasteric muscle
- Internal spermatic fascia
-
Spermatic cord
- Vas deferens
- Lymphatics
- Remnant of processus vaginalis
- Arteries to the vas
- Pampiniform plexus
- Sympathetic nerves
- Ilioinguinal nerve
- Genital branch of the genitofemoral nerve
What are the contents of the inguinal canal in females?
- Round ligament of the uterus
- Ilioinguinal nerve
- Genital branch of genitofemoral nerve
- Blood vessels and lymphatics
What is the cremaster muscle an extension of?
Internal oblique and transversus abdominus muscle
What is the external spermatic fascia an extension of?
External oblique muscle
What is the internal spermatic fascia an extension of?
Transversus abdominus muscle
What makes the floor of the inguinal canal?
Inguinal and lacunar ligament
What makes the roof of the inguinal canal?
Fibres of transversalis and internal oblique
What makes the posterior wall of the inguinal canal?
Transversalis fascia and conjoint tendon
What makes the anterior wall of the inguinal canal?
External oblique aponeurosis and internal oblique for lateral 1/3rd
Common abdominal incisions
Midline
Pfannenstiel - common for caesarean section
McBurney
Lanz
Rooftop
