Gen Surg: hiatus hernia, incisional and umbilical hernias Flashcards
Define a hernia
Protrusion of a whole or part of an organ through the wall of a cavity that contains it into an abnormal position
What is a hiatus hernia?
Protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus.
Which organ usually protrudes in a hiatus hernia?
Stomach. (Small bowel, colon or mesentery rarely herniate).
What are the two sub classifications of hiatal hernias?
Sliding or rolling.
Define a sliding hiatus hernia
Sliding = cardia of stomach moves upwards or slides upwards through the diaphragmatic hiatus into the thorax.
Define a rolling hiatus hernia
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!
Name a risk factors of hiatus hernia
Age - age related loss of diaphragmatic tone, increased abdominal pressure, increased size of hiatus, pregnancy, obesity, ascites.
How does a hiatus hernia present?
Mainly asymptomatic!!!
Symptoms include GORD, vom, weight loss, bleeding, anaemia, hiccups, palpitations, swallowing difficulties.
What are differentials of hiatus hernia?
Cardiac chest pain, gastric or pancreatic cancer (if early satiety or weight loss), GORD.
What investigations might you do for suspected hiatus hernia?
Oesophagogastroduodenoscopy = gold standard. This would show upward displacement of GO junction.
Can be diagnosed incidentally - CT or MRI scan. Contrast swallow can also diagnose.
How is hiatus hernia managed conservatively?
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.
How is hiatus hernia managed surgically?
If symptomatic, if increased risk of strangulation, nutritional failure. Can do Cruroplasty and Fundoplication.
What are complications of hiatus hernia surgery?
Recurrance, abdominal bloating, dysphagia, fundal necrosis (blood supply via left gastric artery and short gastric vessels are disrupted).
What are complications of hiatus hernias?
Incarceration, strangulation, gastric volvulus.
Presents as Borchardt’s triad
What is Borchardt’s triad
Severe epigastic pain, retching without vomiting, unable to pass NG tube.
What is the pathophysiology of an incisional hernia?
Surgical incision of anterior abdominal wall means they become weakened and disrupted. Contents of abdominal herniate through this weakness.
What are RF for incisional hernia?
Emergency surgery, BMI>25, midline incision, post op wound infection, DM, steroid use, connective tissue disorders, increasing age, smoker.
How does an incisional hernia present?
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.
What investigations would you carry out for suspected incisional hernia?
Diagnosis made on clinical picture. CT imaging done to confirm.
How is incisional hernia managed?
Case-by-case different. Surgery is only usually for symptomatic hernias. Can do suture repair, open or laparoscopic repair, abdominal wall reconstruction.
What is an umbilical hernia?
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.
How does an umbilical hernia present?
Infants. Protrusion of soft swelling at the navel. Protrudes further on infant crying, straining or coughing. Painless.
What are RF for umbilical hernias?
Premature babies, low birth weight. Increased abdominal pressure (in adults).
Why is umbilical hernia at risk of incarceration?
Narrow neck of umbilicus = higher risk.
