Hernia Flashcards
Define inguinal hernia
Abnormal protrusion of an intra-abdominal structure through the inguinal canal into the inguinal region or scrotum
Causes of inguinal hernia
Pathophysiology:
- During development, the testicles develop inside the abdomen and towards the end of the pregnancy, each testicle creates a passage (process vaginalis) as it travels into the scrotum
- Failure of this passage to close → abdominal lining and bowel protrude through defect
- If bowel remains trapped → could become damaged due to increased pressure on the blood supply to the area -> bowel death -> serious infection and bowel disorders
Risk factors for inguinal hernia
The risk of incarceration is HIGHER in infants than older children
RFs
1. Preterm infants - esp those with LBW
2. Boys - as ovaries don’t leave abdominal cavity
3. Infants with chronic lung disease
4. Conditions causing ab abdo fluid or incr abdo press
5. CT disorder
Presentation
- Lump in the groin- may extend into the scrotum or labia majora
- Usually asymptomatic, intermittent, visible on straining
- Unable to palpate cord superiorly (possible with hydroceles)
- Reducible unless incarcerated (tender, red, firm)
- Non-transluminable
- Child might be in pain, irritable, vomiting
- Strangulation- causing intestinal obstruction or damage to the testes
- Expansile cough impulse
Incarceration: unsettled pain, tender, non-reducible inguinal scrotal mass, erythema, oedema, vomiting and abdominal distension (late signs)
Investigations
Examination
Basic observations
Determine type of hernia examine supine and standing, try to reduce it
* If incarcerated → tender, firm mass + vomiting, obstruction (unable to pass stool), poor feeding, erythematous/discoloured skin overlying
* More commonly on right (60%) due to delayed descent of righttesticle
Management
Surgery is mainstay (Herniotomy)
Neonates: if reducible- elective heniorrhaphy repair at next available theatre session
Infant/ child: elective case
<6w old correct within 2 days
<6m old correct within 2 weeks
<6yo correct within 2 months
Incarceration: emergency manual reduction of hernia contents under sedation (IV morphine) with repair after 48 hours to allow oedema to settle
NOTE: in girls, sometimes the ovary can get incarcerated within the hernia
Complications
Complications
Incarceration (50% with first year of life)
Herniotomy- recurrence, damage to vas deferens, testicular vessels, ascending ipsilateral testicle secondary to scarring
Prognosis
Excellent with surgical repair
Define umbilical hernia
Relatively common and may be found during newborn examination
Usually no treatment required as it typically resolves by 4-5 years of age (most by 12 months).
More common in premature infants
If a hernia persists beyond this age, should be managed with elective outpatient surgical repair due to risk of incarceration
Association of umbilican hernia
Afro-Caribbean infants
Down’s syndrome
Mucopolysaccharide storage disorders
Management of umbilical hernia
Parents should know the signs of obstruction, strangulation e.g. vomiting, pain, unable to push the hernia in
Observation until 4-5 years of age
* If small, then elective repair at 4-5 years
Elective repair at 2-3 years of age
* Large or symptomatic umbilical hernia (> 1.5cm)
* Intermittent symptoms of incarceration or recurring pain
If hernia incarcerates during observation period:
* Then should be manually reduced with pressure and surgically repaired within 24 hours.
* If it cannot be reduced, then emergency operation required
Umbilical granuloma = wet, moist and leaks fluid treat with salt
Paraumbilical hernia
These are due to defects in the linea alba that are in close proximity to the umbilicus
The edges of a paraumbilical hernia are more clearly defined than those of an umbilical hernia
They are LESS LIKELY to resolve spontaneously than an umbilical hernia
Femoral hernia
Difficult to differentiate from indirect
Located below inguinal canal (through femoral canal)
Differentiation often made during operation
S/S same as for indirect inguinal hernia
Define hydrocele
Similar underlying anatomy to a hernia but the patent processes vaginalis is NOT wide enough to form an inguinal hernia
Usually asymptomatic, sometimes appear blue
Usually possible to feel the testis despite a tense hydrocele and sometimes the hydrocele is separate from the testis in the cord.
KEY to distinguishing a hydrocele from a hernia: you can get above a hydrocele but NOT a hernia
Hydroceles also transilluminate
Although the processus vaginalis is often patent at birth, it usually closes within months
So, hydroceles usually resolve spontaneously
Surgery may be considered if symptoms persist beyond the first 2 years of life
Hydroceles are much less common in girls
Management of hydrocele
< 2 years = most resolve spontaneously before the age of 2 so observation is appropriate provided there is no evidence of underlying pathology
2-11 years
* Open repair
* Laparoscopic exploration
* Bilateral repair
* Abdominoscrotal hydroceles – require surgery through an abdominal incision
11-18 years
* Idiopathic hydrocele- observation is appropriate. Surgery may be considered if it is large and uncomfortable
* Hydrocele after varicocelectomy- conservative management is the initial approach, surgery is considered in cases that do not resolve
* Filarial-related hydrocele- complete excision of the tunica vaginalis
Varicocele
Scrotal swelling comprising of dilated (varicose) testicular veins
Occurs in up to 15% of boys, usually at puberty
Multifactorial cases, but valvular incompetence plays a role
MORE COMMON on the LEFT side because of drainage of the gonadal vein into the left renal vein, which also receives blood containing catecholamines from the left adrenal vein
May cause a dull ache, but it is usually asymptomatic
On examination- it may have a bluish colour and feel like a bag of worms
Sometimes the testis are smaller or softer than normal
MANAGEMENT
Conservative if asymptomatic
Occlusion of gonadal veins can be achieved by surgical ligation (through the groin laparoscopically or by radiological embolization)
