General surgery - Hernias

Question 1

Complications of hernias

Answer 1

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

Question 2

What is the importance of the size of the neck of the hernia clinically?

Answer 2

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

Question 3

What is a Richter’s hernia?

Answer 3

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

Question 4

What is a Maydl’s hernia?

Answer 4

A specific situation where two different loops of bowel are contained within the hernia

Question 5

What are the general management options for hernias?

Answer 5

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

Question 6

Why tension free (mesh) repair over tension repair (suturing the defect back together)?

Answer 6

Tension repair can cause pain and has a higher recurrence rate of the hernia

Question 7

Types of hernia

Answer 7

Inguinal - direct and indirect

Femoral

Incisional

Umbilical and periumbilical

Epigastric hernias

Spigelian hernias

Obturator hernias

Hiatus hernias

Question 8

Inguinal hernias broad classes?

Answer 8

Indirect - bowel herniates through inguinal canal

Direct - herniation through weakness in the abdominal wall at Hasselbach’s triangle?

Question 9

What is the purpose of the processus vaginalis?

Answer 9

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

Question 10

What is the pathophysiology of an indirect inguinal hernia

Answer 10

There is a patent Processus vaginalis

Bowel can herniate alpng this tract

Question 11

How to differentiate between a direct and indirect inguinal hernia on examination?

Answer 11

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

Question 12

How to differentiate between femoral and inguinal hernia on examination?

Answer 12

Inguinal - superior and medial to the pubic tubercle

Femoral - inferior and lateral to the pubic tubercle

Question 13

What is the pathophysiology of a direct inguinal hernia?

Answer 13

Bowel herniation through Hesselbach’s triangle

Question 14

What are the boundaries of Hasselbach’s triangle

Answer 14

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

Question 15

What are some differentials for a lump in the inguinal region?

Answer 15

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

Question 16

What is the pathophysiology of a femoral hernia?

Answer 16

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

Question 17

Management of femoral hernia

Answer 17

Urgent surgical referral due to high risk of strangulation

Question 18

What is a Spigelian hernia?

Answer 18

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

Question 19

What is an Obturator hernia?

Answer 19

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

Question 20

Presentation of obturator hernia

Answer 20

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.

Question 21

What is a hiatus hernia?

Answer 21

Herniation of the stomach through the diaphragm

Question 22

What are the types of hiatus hernia?

Answer 22

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

Question 23

Risk factors for hiatus hernia

Answer 23

Increasing age
Obesity
Pregnancy

Question 24

Presentation of hiatus hernia

Answer 24

Dyspepsia
Burping/bloating
Halitosis

Question 25

Management of hiatus hernia

Answer 25

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.

Question 26

RFs for femoral hernia

Answer 26

Female
Pregnancy (higher incidence in multiparous women)
Raised intra-abdominal pressure (e.g. heavy lifting, chronic constipation)
Increasing age

Question 27

RFs for inguinal hernia

Answer 27

Male
Increasing age
Raised intra-abdominal pressure, from chronic cough, heavy lifting, or chronic constipation
Obesity