GI: Hernias

Question 1

which type of hernia is more common in males? in females? which are more at risk of strangulation?

Answer 1

Males: inguinal hernia - low risk
Females: femoral hernia (less common) - high risk

Question 2

describe the course of a femoral hernia

Answer 2

Protrudes through femoral ring into femoral canal (due to weakness in abdo. wall).

Can enlarge by passing through saphenous opening into subcutaneous tissue of thigh.

Question 3

describe the course of a direct inguinal hernia

Answer 3

Protrudes through weakness in transversalis fascia of Hesselbach’s triangle… traverses medial 1/3 of inguinal canal… exits via superficial inguinal ring (lateral to spermatic cord).

Rarely enters scrotum.

Question 4

describe the course of an indirect inguinal hernia.

Answer 4

Protrudes through patent processus vaginalis… through deep inguinal ring, traverses entire canal (within processus vaginalis) and exits via superficial inguinal ring… remains within spermatic cord and commonly passes into scrotum/labium majus.

Question 5

do direct/indirect inguinal hernias pass medial or lateral to inferior epigastric vessels?

Answer 5

indirect: passes lateral
direct: passes medial

Question 6

name the boundaries of Hesselbach’s trinagle

Answer 6

Medial: rectus abdominis
Lateral: inferior epigastric vessels
Inferior: inguinal ligament

Question 7

how would you differentiate between inguinal and femoral hernia based on location? and between direct and indirect inguinal?

Answer 7

Inguinal: usually superomedial to pubic tubercle.
Reduce hernia, apply pressure over deep inguinal ring and ask pt to cough. If hernia reappears, likely a direct inguinal hernia.

Femoral: usually inferolateral to pubic tubercle (and medial to femoral pulse)

Question 8

how would you manage a pt with a hernia?

Answer 8

If small and asymptomatic: watch and wait.

If expanding, large or symptomatic:

• 1st hernia: open inguinal hernia repair - open inguinal canal, reduce hernia, repair defect and place prosthetic mesh posterior to cord structures.
• recurrent or bilateral hernia laparoscopic inguinal repair - may also have mesh but typically lies posterior to deep ring.

Question 9

what are the possible compications of hernias?

Answer 9

1. become irreducible/incarcerated - due to formation of fibrous adhesions.
2. strangulation (3% risk/yr) - compression of hernia compromises blood supply causing ischaemic bowel
3. bowel obstruction - can be result of strangulation

Question 10

name the boundaries of the inguinal canal

Answer 10

Floor = inguinal ligament
Anterior wall = external oblique aponeurosis
Posterior wall = transversalis fascia
Roof = internal oblique and transversus abdominis