Gen Surg: hiatus hernia, incisional and umbilical hernias

Question 2

Define a hernia

Answer 2

Protrusion of a whole or part of an organ through the wall of a cavity that contains it into an abnormal position

Question 3

What is a hiatus hernia?

Answer 3

Protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus.

Question 4

Which organ usually protrudes in a hiatus hernia?

Answer 4

Stomach. (Small bowel, colon or mesentery rarely herniate).

Question 5

What are the two sub classifications of hiatal hernias?

Answer 5

Sliding or rolling.

Question 6

Define a sliding hiatus hernia

Answer 6

Sliding = cardia of stomach moves upwards or slides upwards through the diaphragmatic hiatus into the thorax.

Question 7

Define a rolling hiatus hernia

Answer 7

Upward movement of the fundus of the stomach, so it lies alongside the gastro-oesophageal junction. This creates a ‘bubble’ of stomach in the thorax. Has a peritoneal sac = so a true hernia!

Question 8

Name a risk factors of hiatus hernia

Answer 8

Age - age related loss of diaphragmatic tone, increased abdominal pressure, increased size of hiatus, pregnancy, obesity, ascites.

Question 9

How does a hiatus hernia present?

Answer 9

Mainly asymptomatic!!!
Symptoms include GORD, vom, weight loss, bleeding, anaemia, hiccups, palpitations, swallowing difficulties.

Question 10

What are differentials of hiatus hernia?

Answer 10

Cardiac chest pain, gastric or pancreatic cancer (if early satiety or weight loss), GORD.

Question 11

What investigations might you do for suspected hiatus hernia?

Answer 11

Oesophagogastroduodenoscopy = gold standard. This would show upward displacement of GO junction.
Can be diagnosed incidentally - CT or MRI scan. Contrast swallow can also diagnose.

Question 12

How is hiatus hernia managed conservatively?

Answer 12

Conservatively - PPI - reduces gastric acid secretion. Lifestyle modification - weight loss, low fat diet, earlier meals, smaller portions, sleep with head raised. Smoking cessation, reduce alcohol intake.

Question 13

How is hiatus hernia managed surgically?

Answer 13

If symptomatic, if increased risk of strangulation, nutritional failure. Can do Cruroplasty and Fundoplication.

Question 14

What are complications of hiatus hernia surgery?

Answer 14

Recurrance, abdominal bloating, dysphagia, fundal necrosis (blood supply via left gastric artery and short gastric vessels are disrupted).

Question 15

What are complications of hiatus hernias?

Answer 15

Incarceration, strangulation, gastric volvulus.

Presents as Borchardt’s triad

Question 16

What is Borchardt’s triad

Answer 16

Severe epigastic pain, retching without vomiting, unable to pass NG tube.

Question 17

What is the pathophysiology of an incisional hernia?

Answer 17

Surgical incision of anterior abdominal wall means they become weakened and disrupted. Contents of abdominal herniate through this weakness.

Question 18

What are RF for incisional hernia?

Answer 18

Emergency surgery, BMI>25, midline incision, post op wound infection, DM, steroid use, connective tissue disorders, increasing age, smoker.

Question 19

How does an incisional hernia present?

Answer 19

Reducible, soft, non-tender swelling near site of previous surgical wound. Can be tender, painful and erythematous if incarcerated. Mass is palpable, may be reducible into abdominal cavity.

Question 20

What investigations would you carry out for suspected incisional hernia?

Answer 20

Diagnosis made on clinical picture. CT imaging done to confirm.

Question 21

How is incisional hernia managed?

Answer 21

Case-by-case different. Surgery is only usually for symptomatic hernias. Can do suture repair, open or laparoscopic repair, abdominal wall reconstruction.

Question 22

What is an umbilical hernia?

Answer 22

Part of abdomen protrudes through opening in abdominal muscles near to the navel, causing belly button to swell.
In babies if opening that umbilical cord passes through does not close properly.

Question 23

How does an umbilical hernia present?

Answer 23

Infants. Protrusion of soft swelling at the navel. Protrudes further on infant crying, straining or coughing. Painless.

Question 24

What are RF for umbilical hernias?

Answer 24

Premature babies, low birth weight. Increased abdominal pressure (in adults).

Question 25

Why is umbilical hernia at risk of incarceration?

Answer 25

Narrow neck of umbilicus = higher risk.