GI - small bowel

Question 1

What is a hernia?

Answer 1

A protruson of part or the whole organ or tissue through the wall of the cavity that it is normally contined in

Question 2

Describe the route of a direct inguinal hernia

Answer 2

Enters the inguinal canal directly through Hasselbach’s triangle (area of weakness in posterior wall)

Runs medially to the inferior epigastric vessels

Question 3

Who are direct inguinal hernias more common in?

Answer 3

• Older patients
• Men

Question 4

Describe the route of indirect inguinal hernias

Answer 4

Protrudes through the deep inguinal ring > passes through the inguinal canal > exits via the small inguinal ring

Runs laterally to the inferior epigastric vessles

Question 5

What embryological process fails to increase the risk of indirect inguinal hernias?

Answer 5

Failure of closure of the processus vaginalis

Question 6

What group of people are indirect inguinal hernias more common in?

Answer 6

• More common in males
• Can occur in children

Question 7

Give some general risk factors for developing hernias

Answer 7

• Male
• Obesity
• Increasing age
• Raised intra-abdominal pressure
  
  • chronic cough
  • heavy lifting
  • chronic constipation

Question 8

What are the borders of the inguinal canal?

Answer 8

Question 9

How do patients with inguinal hernias usually present?

Answer 9

• Lump in the groin
  
  • if reducible will dissapear with minimal pressure or lying down
• Mild to moderate discomfort worsened by activty or standing
• If incacerated
  
  • painful
  • tender
  • erythematous
  • features of bowel obstruction

Question 10

How should you examine any groin lump?

Answer 10

• Get the patient to lie flat
• Look at the location
  
  • inguinal- superomedial to pubic tubercle
  • femoral - inferolateral to pubic tubercle
• Cough impulse (not present if irreducible)
• Is it reducible to lying down/ minimal pressure?
• If it enters the scrotum can you get above it/ separate from testes

Question 11

What are some of the differential diagnoses for a lump in the groin?

Answer 11

• Inguinal hernias
• Femoral hernias
• Saphena varix (dilation of saphenous vein at junction with femoral vein)
• Inguinal lymphadenopathy
• Lipoma
• Groin abscess
• Internal iliac aneurysm

Question 12

What investigations should you do for suspected hernias?

Answer 12

Largely a clinic diagnosis

Imaging should only be done if there is any uncertainty

1st line is USS as outpatient

If patient appears with features of obstruction/ strangulation then CT is required

Question 13

How are inguinal hernias managed?

Answer 13

• Symptomatic hernias (significant mass/discomfort) are offered surgery
• Any presentation of strangulated hernias require urgent surgical exploration
• 1/3 of patients never have symptoms and can be managed conservatively

Question 14

How are inguinal hernias surgically repaired?

Answer 14

• Open of laparascopic (preferred) reapir
• Mesh repair (synthetic or biological)

Question 15

What are the contents of inguinal canal?

Answer 15

1. Spermatic cord
2. Gentiofemoral nerve
3. Ilioinguinal nerve

Question 16

What are some of the complications of inguinal hernias and post op complications?

Answer 16

• Strangulation or obstruction
• Pain, Bruising, Haematoma
• Infection
• Urinary retention
• Recurrence (1% within 5 years)
• Chronic pain (up to 30% patients)
• Damage to vas deferens or testicular vessels
  
  • can lead to ischemic orchitis and potential sub-fertility

Question 17

Which type of hernia has the highest risk of strangulation and why?

Answer 17

Femoral hernias due to the narrow neck of the femoral canal

Question 18

What are the borders of the femoral canal?

Answer 18

Question 19

Which demographic are femoral hernias more common in?

Answer 19

• More common in women
• Pregnancy increases risk
• Increased intra-abdominal pressure
• Increasing age

Question 20

How do femoral hernias present?

Answer 20

• small lump in groin
• usually aysmptomatic but 30% present as emergency due to obstruction / strangulation

Question 21

Where are femoral hernias anaomically found?

Answer 21

Infero-lateral to the pubic tubercle

and medially to the femoral pulse

Question 22

How are femoral hernias managed?

Answer 22

All should be managed surgically due to the high risk of strangulation (ideally within 2 weeks of presentation)

Question 23

Describe the 2 different surgical approachs used in femoral hernia surgical reduction

Answer 23

1. Low approach
   
   1. incision made below inguinal ligament
   2. Advantage of not interfering with inguinal structures
2. High approach
   
   1. Incision made above inguinal ligament
   2. Preferred technique in emergency presentations fo to easy access to compromised small bowel
3. Both involve redution of hernia sac and closure of defect with prosthetic mesh

Question 24

What are some of the complications of femoral hernias?

Answer 24

• Strangulation
• Obstruction
• Risk of bowel resection in emergency presentation
• Wound infection
• Cardiorespiratory complications

Question 25

What are epigastric hernias?

Answer 25

• Hernias that occur in the upper midline through fibres of the linea alba
• caused by raised chronic intra-abdominal pressure
• typically asymptomatic

Question 26

Which age group are paraumbilical hernias seen in?

Answer 26

• Common in children (either omphalocele or gastroschisis)

Question 27

What is the most common content of a paraumbilical hernia?

Answer 27

Usually contains pre-peritoneal fat

Less commonly contrain bowel

Question 28

Where do obturator hernias occur?

Answer 28

Through the obturator foramen into to obturator canal

Question 29

Where do Spigelian hernias occur?

Answer 29

At the semilinar line around the level of the arcuate line

Question 30

Where do Richter’s herniae occur?

Answer 30

Partial herniations of bowel involving the anti-mesenteric border