General surgery - Hernias Flashcards
Complications of hernias
Incarceration - hernia cannot be reduced into the proper position (can lead to obstruction and strangulation)
Obstruction - blockage in passage of faeces through the bowel
Strangulation - non-reducible hernia with cut-off blood supply causing ischaemia and will eventually lead to bowel necrosis
What is the importance of the size of the neck of the hernia clinically?
Hernias that have a wide neck are at lower risk of complications.
Always comment on the size of the neck of the hernia when examining it
What is a Richter’s hernia?
This is where only part of the bowel wall and lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity.
High risk of strangulation and progress rapidly to ischaemia/necrosis
What is a Maydl’s hernia?
A specific situation where two different loops of bowel are contained within the hernia
What are the general management options for hernias?
Conservative management - leaving the hernia alone - generally only appropriate if the hernia has a wide neck and in patients who are not good surgical candidates due to comorbidities
Surgical repair:
- Usually mesh repair (tension free repair)
- This involves placing a mesh over the defect in the abdominal wall
- The mesh is sutured to the muscles and tissues on either side of the defect
Why tension free (mesh) repair over tension repair (suturing the defect back together)?
Tension repair can cause pain and has a higher recurrence rate of the hernia
Types of hernia
Inguinal - direct and indirect
Femoral
Incisional
Umbilical and periumbilical
Epigastric hernias
Spigelian hernias
Obturator hernias
Hiatus hernias
Inguinal hernias broad classes?
Indirect - bowel herniates through inguinal canal
Direct - herniation through weakness in the abdominal wall at Hasselbach’s triangle?
What is the purpose of the processus vaginalis?
Processus vaginalis allows the descent of testes from the abdominal cavity, through the inguinal canal, into the scrotum.
The deep inguinal ring normally closes and the Processus vaginalis is obliterated after the testes have descended
What is the pathophysiology of an indirect inguinal hernia
There is a patent Processus vaginalis
Bowel can herniate alpng this tract
How to differentiate between a direct and indirect inguinal hernia on examination?
Reduce the hernia and place pressure on the deep inguinal ring (midway point between ASIS and pubic tubercle)
Indirect hernias will remain reduced, direct hernias will recur
How to differentiate between femoral and inguinal hernia on examination?
Inguinal - superior and medial to the pubic tubercle
Femoral - inferior and lateral to the pubic tubercle
What is the pathophysiology of a direct inguinal hernia?
Bowel herniation through Hesselbach’s triangle
What are the boundaries of Hasselbach’s triangle
Hesselbach’s triangle boundaries (RIP mnemonic):
R – Rectus abdominis muscle – medial border
I – Inferior epigastric vessels – superior / lateral border
P – Poupart’s ligament (inguinal ligament) – inferior border
What are some differentials for a lump in the inguinal region?
Inguinal hernia Femoral hernia Lymph node Saphena varix (dilation of saphenous vein at junction with femoral vein in groin) Femoral aneurysm Abscess Undescended / ectopic testes Kidney transplant
What is the pathophysiology of a femoral hernia?
Herniation through the femoral canal (below the inguinal ligament)
The opening between the peritoneal cavity and the femoral canal is the femoral ring. The femoral ring leaves only a narrow opening for femoral hernias, putting femoral hernias at high risk of:
Incarceration
Obstruction
Strangulation
Management of femoral hernia
Urgent surgical referral due to high risk of strangulation
What is 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 in the lower abdomen and may present with non-specific abdominal wall pain.
There may not be a noticeable lump.
USS can help diagnosis
What is an Obturator hernia?
Herniation through obturator foramen in the pelvis
Due to a defect in the pelvic floor
More common in women, particularly in older age or after multiple pregnancies
Presentation of obturator hernia
Often asymptomatic
May present with irritation to obturator nerve causing pain in the groin or medial thigh.
Howship–Romberg sign refers to pain extending from the inner thigh to the knee when the hip is internally rotated and is due to compression of the obturator nerve.
What is a hiatus hernia?
Herniation of the stomach through the diaphragm
What are the types of hiatus hernia?
Type 1 - sliding - most common - GOJ, fundus move up into thorax
Type 2 - rolling - GOJ is normally positioned, fundus herniates through to sit alongside the GOJ
Type 3 - combination of rolling and sliding
Type 4 - Large opening with additional abdominal organs entering the thorax e.g. bowel, pancreas or omentum
Risk factors for hiatus hernia
Increasing age
Obesity
Pregnancy
Presentation of hiatus hernia
Dyspepsia
Burping/bloating
Halitosis
Management of hiatus hernia
Medical treatment of Gastro-oesophageal reflux
Surgical repair - laparoscopic fundoplication - involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.
RFs for femoral hernia
Female
Pregnancy (higher incidence in multiparous women)
Raised intra-abdominal pressure (e.g. heavy lifting, chronic constipation)
Increasing age
RFs for inguinal hernia
Male
Increasing age
Raised intra-abdominal pressure, from chronic cough, heavy lifting, or chronic constipation
Obesity
