Hernia Flashcards
What is reducibility?
Can be pushed back, and it comes out only when counter force is applied on cough/strain (seen in uncomplicated hernia)
What is compressibility?
When the swelling return spontaneously once the pressure to reduce it is removed . seen in vascular surgery like hemangioma or lymphangioma
What is obstructed hernia/incarcerated hernia
Occurs when the contents show obstruction but the blood supply is NormaL
Obstructed hernia is
Irreducible that means there is no cough impulse
What is strangulated hernia?
Obstructed + compromised blood supply . skin changes are seen
In uncomplicated hernia process of reduction/taxis is best
Left to the patient
Based on the content in the sac, what are the two types
Omentocele and enterocele
What would you feel on palpation of omentocele?
Doughy consistency ; easy to reduce first part ; difficult to reduce second part.
What would you feel on palpation of enterocele?
Difficult to reduce first part easy to reduce second part
In the Omentocele if the content is Meckel’s diverticulum, it is called as
Litter’s hernia
In the Omentocele if the content is Appendix, it is called as
Amyand hernia
What are the steps of herniotomy ?
- Identify the sac
- Open the sac.
- Push the contents.
- Cut the excess sac.
- Close the sac.
(Highest recurrence rate)
Herniotomy is treatment of choice is
Congenital inguinal, hernia and congenital hydrocele
What is herniorrhaphy?
Step 12345+ suture the two adges of the defect together
What is the most common cause of failure of herniorrhaphy
Increase tension in the repair
What are the techniques of herniorrhaphy?
Bassini’s ;
Shouldice ;
Mayo / kell
What is the indication of herniorrhaphy
Infected/strangulated hernia’s
What is hernioplasty?
Step 12345+ put a mesh over the defect to repair it. It has leased the current state.
Which technique is used in hernioplasty?
Lichenstein’s tension free mesh hernioplasty
Which mesh is avoided when there is an infection
Synthetic
Example of synthetic mesh
Vipro : vicryl + Prolene &
PTFE
Example of Biological mesh
Alloderm ; Acellular procine dermis
Ideal mesh is
Low weight mesh ;
Thin fibers ;
Large pores
What is meshoma
Excessive collagen deposition in plug mesh ; nerves get entrapped leading to pain
What is the most common hernia in both male and female?
Inguinal
What are the boundaries of Hasselbach’s triangle
• medial: Outer border of rectus.
• inferior: Inguinal ligament.
• Superior: Inferior epigastric vessels.
How to decide if hernia is direct, or indirect
• Any hernia that comes lateral to the triangle - Indirect
• Through the triangle: Direct.
What is myopectineal orifice of fruchaud
Superior : Arching fibers of internal oblique.
Medial: Outer border of rectus.
Lateral: Tendon of ilio-psoas.
inferior: Pectineal / cooper’s ligament.
Standing position of examination, help us to differentiate between
Inguinal versus femoral hernia
inguinal hernia are
Above and medial to pubic tubercle
Femoral hernia are
Below and lateral to pubic tubercle
Complete hernia means
Reaches till the base of scrotum
What is a single best test for inguinal hernias
Deep ring occlusion test
Steps of Deep ring occlusion test
Reduce the hernia (taxis).
Localise the deep ring & put pressure by thumb of same side over it.
In standing position, ask the patient to cough.
Look for bulge. If bulge is seen : Direct hernia.
If no bulge: release thumb and ask the patient to cough
If bulge is seen : indirect inguinal hernia
What is the IOC in non palpable hernia
USG
What are the other test for hernia
Ring invagination Test ;;
Zieman 3 fingers test
What are the three type of herniorraphy are there in open surgery of inguinal hernia
Bassini ;
Shouldice repair ;
Lichenstein’s tension free mesh hernioplasty .
What is the sx of choice in herniorraphy
Lichenstein’s tension free mesh hernioplasty
What is the most common nerve injured in open inguinal hernia sx
ilio inguinal nerve
What is the most common nerve entrapped in open inguinal hernia sx
ilio hypogastric nerve
What is stoppa’s repair
mesh is placed between peritoneum & posterior rectus sheath.
works on Pascal’s law . (mesh remains in place due to abdominal pressure. There is no need of Suturing/Staples ).
Lap inguinal hernia is useful for
BL inguinal hernia and recurrent IH
Laparoscopic repair includes
TEP and TAPP
During Lap repair two places where staplers should not be applied are
Triangle of DOOM and
Triangle of Pain
What are the boundaries of triangle of doom?
Vas deferens medially.
Testicular vessels laterally.
Peritoneal reflection inferiorly.
Contents of triangle of doom
External iliac artery and vein ;
Genital branch of genito femoral nerve(GFN)
What are the boundaries of triangle of pain?
Superiorly : Iliopubic tract /inguinal ligament.
medially: Testicular vessels.
Laterally: Peritoneal reflection.
What are the contents of triangle of pain?
Lateral cutaneous Nerve of Thigh.
Femoral nerve.
Femoral branch of Genito femoral nerve.
Most common, nerve entrapped in triangle of pain
Lateral cutaneous, nerve of thigh this leads to symptom complex called Meralgia parasthetica.
Triangle of pain is also known as
Electrical hazard zone as cautery is avoided in this area
What is trapezoid of disaster
Triangle of Doom (medial) + Triangle of pain (lateral)
What is corona mortis / circle of death
Abnormal communication b/w external and internal Iliac systems.
Aberrant obturator artery is situated behind the pubic tubercle and is injured during laproscopic surgery and leads to torrential haemorrhage and bleeding.
European hernia society classification
EHS GROIN HERNIA CLASSIFICATION;
P: primary Hernia
L: Lateral / Indirect
R: Recurrent
M: medial / direct
F: Femoral Hernia
1 finger breath = how much defect
1.5 cm
What is another classification of hernia
Nyhus classification
What is gibbon hernia
Inguinal hernia + hydrocele
What is pantaloon hernia
Direct + Indirect hernia (3b as per ESH)
What is sliding hernia
Hernia en Glissade
Commonly seen in elderly males.
The posterior boundary of the sac is formed by a visceral structure.
mc on left side > Right side.
mc structure implicated: Sigmoid colon > Bladder.
What is sportsman hernia
AKA glimore hernia
seen in Athletes.
severe inguinal / groin pain.
occurs o/+ tear in the posterior wall muscle.
Sometimes a very small Hernial sac can be there. usually non palpable.
IOC: MRI
Management of sportsman hernia
MX: Rule out other causes of inguinal pain
Laparoscopic inguinal hernia surgery is done.
Pain may not resolve even after the surgery.
What is bulbonocele
Hernial sac crosses deep ring, but does not reach up to the superficial thing. It remains in inguinal canal
What is funicular
Hernial sac cross is the superficial ring, but doesn’t reach the base of the scrotum
What is complete hernia/ inguinoscrotal
Reaches till the base of scrotum
Boundaries of femoral ring
medially: Lacunar ligament.
Superiorly : Inguinal ligament.
Laterally: Septum which separates it from the veins (iliac or the femoral veins) Inferiorly : Pectineal/ Cooper’s ligament.
Femoral hernias are often associated with
Richert’s hernia
Location of Femoral hernia
Below and lateral to pubic tubercle .
F > M
C/F of femoral hernia
Swelling / bulge below inguinal ligament / pubic tubercle.
Location of inguinal hernia
Above the pubic tubercle
DD Of femoral hernia are
Inguinal hernia
Psoas abscess
Inguinal LN
Saphenavarix
Lipoma in thigh
What is Laugier’s hernia:
Femoral hernia through the lacunar ligament. Very high rate of strangulation.
What is Narath’s hernia
Femoral hernia in patients with congenital dislocation of the hip. Prone to obstruction and strangulation.
What is Serafini hernia ?
Retro-vascular hernia, sac lies beyond the femoral vessels.
What is velpeau hernia
Pre-vascular hernia, sac lies in front of the femoral vessels.
Lockwood approach is used in
It is a Low approach (below inguinal ligament) use in open hernioplasty used in uncomplicated femoral hernia
Examples of high approach in open hernioplasty are
Mcevdy : in obstructed and strangulated hernia ..
Lotheissen’s : Trans inguinal approach
Ventral hernia are
• They are abdominal wall hernias and are as follows
• Epigastric.
• umbilical.
• paraumbilical.
• Traumatic.
• Spigelian.
• Lumbar.
• Parastomal.
• Incisional:
MC ventral hernia is
Incisional hernia: forms in the region of incision.
MC hernia overall is
Indirect Inguinal hernia
Which mgt Is preferred in ventral hernia
Hernioplasty
Onlay repair
If mesh is kept above the rectus sheath
between skin, subcutaneous tissue and anterior rectus sheath.
Inlay repair
If the mesh is merged with the anterior rectus sheath/at the same level.
Retromuscular repair
If the mesh is placed behind the rectus muscle.
• Preperitoneal/ sublay repair
If the mesh is kept between the peritoneum and sheath.
Intraperitoneal repair
Called as IPOM /Intraperitoneal placement of mesh. used in laparoscopic repair. To prevent fecal fistula and adhesion (bowel-mesh adherance) PTFE meshes are used.
IPOM Procedure
ventral hernia defect is dissected -> content of the hernia (preperitoneal fat globule) is pulled down -> defect visualized -> mesh placed after adequate dissection -> Covering atleast 4-5cm across the defect -> to avoid mesh shrinkage. mesh is anchored to the abdominal wall using tackers or staplers to prevent movement of mesh.
What is remirez component separation technique
Done in complex incisional hernias . where incisional hernia volume is >25% of abdominal volume
What is the location of epigastric hernia/fatty hernia of linea alba
It can be seen anywhere in between xiphisternum to umbilicus. Scene in young fit males > females.
epigastric hernia comes through
Transverse split in the median Raphe
Most common content of epigastric hernia is
Preperitoneal fat
What is the most distinguish clinical features of epigastric hernia?
Pain which mimics pain of peptic ulcer
High rate of obstruction and strangulation seen in which kind of hernia
Paraumbilical hernia
Which hernia is more common in premature babies
Umbilical hernia
Management of umbilical hernia in children
Conservative management wait for 2 to 3 years of age if defect does not close by itself do mesh repair surgery after 2 to 3 years
Management of paraumbilical hernia
Open laparoscopic hernioplasty
What is omphalocele
Defect through the umbilicus in which bowel fails to return inside during embryogenesis, covered with peritoneal sac. Liver can also herniate .
Omphalocele is associated with
Associated with Beckwith weidmann syndrome (wilms tumor), trisomy 13, 18, 21.
Management of omphalocele and gastroschisis
management is done after ruling out other congenital abnormalities.
Pushing bowel inside the abdomen can cause abdominal compartment syndrome.
Silo/cylinder is created using mesh -> defect covered
Child reviewed periodically -> reduce the height of silo -> gradually push bowel into abdomen across multiple visits.
Once it reaches the level of rectus sheath, the contents are pushed inside and abdomen is closed..
What kind of lumber hernia are common?
Secondary(to trauma ,sx nephrectomy)
Majority of lumber hernias are come out through
Inferior lumbar triangle of petit
Boundaries of inferior lumber triangle of petit
• Inferiorly: lliac crest
• Laterally: Exteral oblique
• medially: Latissimus dorsi
Boundaries of superior lumber triangle of grynfelt
• Superiorly: 12th rib
• Laterally: Internal oblique
• medially: Sacrospinalis
Which repair is used specifically to treat lumbar hernia
Dowd-Ponca repair
spigelian hernia / Intra-parietal hernia comes out through
It comes out through spigelian fascia (modification of fascia tranversalis).
MC location of Spigelian hernia / Intra-parietal hernia
Below the umbilicus but above the arcuate line (midpoint between umbilicus and pubic symphysis) along the outer border of rectus.
Below the arcuate line, posterior rectus sheath is absent.
What is Intraparietal hemia
Sac lies at the outer border of rectus and in between the muscle layers (invisible). usually detected when obstruction or strangulation occurs.
It is a small defect in young children, whereas in adults it is large defect.
What is obturator hernia / french hernia
Little old lady’s hernia.
common in elderly, multiparous woman.
It comes out through narrow defect/obturator canal, hence prone to obstruction and strangulation.
They can also develop Richter’s hernia
What is Howship Romberg sign.
Shooting pain along obturator nerve during abduction and medial rotation of hip.
What is Hannington Kiff sign
Absent adductor reflex in “the presence of a positive patellar reflex because of obturator nerve compression. Swelling is usually not felt, and so diagnosed late.
What is Ritchter’s hernia
There is a very narrow defect resulting in herniation of only a portion of bowel wall, while the rest of the bowel lumen continuity is maintained -> no features of obstruction like vomiting/distension/obstipation-> vigorous bowel contractions -> early presentation is gastroenteritis -> peritonitis/ strangulation.
Hernias with narrow defect can give rise to Richter’s hernia. They are
• Femoral hemia.
• Paraumbilical hernia.
• Obturator hernia.
Early repair is mandated in thse hernias.
What is Maydl’s hernia
Defect is very wide, multiple loops of bowel can go through causing a W’ shaped hernia.
If strangulation is to occur, it occurs in the intraperitoneal portion.
Significance: Intra-abdominal strangulation may be missed as normal bowel is seen upon incision.
What are the two types of CDH?
• Bochdalek (65-709).
• morgagni.
What is bochdalek hernia
more common
Left posterolateral
Defective development of pleuroperitoneal canal/ membrane of diaphragm stomach, spleen and transverse colon can herniate.
What is morgagni hernia
Less common
Right anteromedial
Defective central tendon of diaphragm.
Transverse colon usually herniates.
Most common cause of death in CDH patient
Pulmonary hypoplasia
Second, most common cause of death impatient with CDH
Pulmonary hypertension
 Best ventilation in patient with CDH
IPPV ;; if IPPV fails ECMO .
Bag and mask ventilation is contraindicated .
Which medicine has revolutionized the treatment of diaphragmatic hernia
Inhaled nitrates as they can mange pulmonary hypertension
What is definitive mgt of CDH
Sx (circumferential incision around the diaphragm) 
What is stemmer’s hernia:
Through transverse mesocolon window after Roux en y gastrojejunostomy.
What is Peterson’s hernia
Behind the roux limb after sure
What is Left paraduodenal hernia
Through fossa of Landzert, due to defective fusion of descending colon mesentery. As descending colon is supplied by inferiormesenteric vessels, the hernia lies behind the inferior mesenteric vessels.
What is Right duodenojejunal hernia
: This is due to defective fusion of ascending colon mesentery. As ascending colon is supplied by superior mesenteric vessels, the hernia lies behind the superior mesenteric vessels.
What are the two main types of mesenteric cyst?
Chylolymphatic and Enterogenous
What is Tillaux triad and sign
Moves at right angles to attachment of mesentery but not along the line of attachment of mesentery. Line of attachment of the mesentery: From the DJ flexure to the right sacro-iliac joint.
This is Tillaux sign.
Transverse band of resonance over the swelling (transverse colon goes over it).
What is IOC of mesenteric cyst
Contrast enhanced CT scan
Mgt of Chylolymphatic cyst
Sx -> enucleation without damaging the bowel (independent blood supply).
What is mgt of Enterogenous cyst -
Sx > resection and anastomosis (shared blood supply with bowel
What is misty mesentary
Seen secondary to pancreatitis, edema, hemorrhage, cancer. Should be differentiated from medenteric panniculitis ( inflammation of fat) which is manifestation of weber Christian disease
Borchardt’s triad seen in
Gastric volvulus
Borchardt’s triad consists of
• consists of unproductive retching.
• Epigastric pain and distention.
• Inability to pass a nasogastric tube.
What is the serious complication of hernia
Strangulated
