Hernia

Question 1

How is a hernia caused?

Answer 1

weak point in a cavity wall, usually affecting the muscle or fascia. This weakness allows a body organ (e.g., bowel) that would normally be contained within that cavity to pass through the cavity wall.

Question 2

Typical presentation of a hernia:

Answer 2

A soft lump protruding from the abdominal wall

The lump may be reducible (it can be pushed back into the normal place)

The lump may protrude on coughing (raising intra-abdominal pressure) or standing (pulled out by gravity)

Aching, pulling or dragging sensation

Question 3

3 main complications of hernia’s

Answer 3

Incarceration
Obstruction
Strangulation

Question 4

What happens in incarceration?

Answer 4

hernia cannot be reduced back into the proper position (it is irreducible). The bowel is trapped in the herniated position. Incarceration can lead to obstruction and strangulation of the hernia.

Question 5

What is obstruction?

Answer 5

hernia causes a blockage in the passage of faeces through the bowel. Obstruction presents with vomiting, generalised abdominal pain and absolute constipation

Question 6

What happens in strangulation?

Answer 6

where a hernia is non-reducible (it is trapped with the bowel protruding) and the base of the hernia becomes so tight that it cuts off the blood supply, causing ischaemia. This will present with significant pain and tenderness at the hernia site.

Surgical emergency

Bowel will die quickly

Question 7

What is an inguinal hernia?

Answer 7

Inguinal hernias present with a soft lump in the inguinal region (in the groin).

Question 8

2 types of inguinal hernia’s:

Answer 8

Indirect inguinal hernia
Direct inguinal hernia

Question 9

Differential diagnoses for lumps in the inguinal region:

Answer 9

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 10

What is the inguinal canal?

Answer 10

tube that runs between the deep inguinal ring (where it connects to the peritoneal cavity), and the superficial inguinal ring (where it connects to the scrotum).

Question 11

Males and the inguinal canal

Answer 11

Inguinal canal is what allows the spermatic cord and its contents to travel from inside the peritoneal cavity, through the abdominal wall and into the scrotum.

Question 12

Female inguinal canals

Answer 12

round ligament is attached to the uterus and passes through the deep inguinal ring, inguinal canal and then attaches to the labia majora.

Question 13

What is an indirect inguinal hernia?

Answer 13

where the bowel herniates through the inguinal canal.

Question 14

Indirect inguinal hernia pathophysiology

Answer 14

• inguinal ring remains patent, and the processus vaginalis remains intact.
• This leaves a tract from the abdominal contents, through the inguinal canal and into the scrotum.
• The bowel can herniate along this tract, creating an indirect inguinal hernia.

Question 15

What is a direct inguinal hernia

Answer 15

• Direct inguinal hernias occur due to weakness in the abdominal wall at Hesselbach’s triangle
• hernia protrudes directly through the abdominal wall, through Hesselbach’s triangle
• Pressure over the deep inguinal ring will not stop the herniation.

Question 16

HESSELBACH’s triangle (RIP mnemonic)

Answer 16

R – Rectus abdominis muscle – medial border
I – Inferior epigastric vessels – superior / lateral border
P – Poupart’s ligament (inguinal ligament) – inferior border

Question 17

What is a femoral hernia?

Answer 17

Femoral hernias involve herniation of the abdominal contents through the femoral canal.

This occurs below the inguinal ligament, at the top of the thigh.

Question 18

What is the opening between peritoneal cavity and femoral canal?

Answer 18

Femoral ring

Question 19

What is the femoral ring?

Answer 19

femoral ring is the proximal opening of the end of the femoral canal which leaves only a narrow opening for femoral hernias, putting femoral hernias at high risk of:

Incarceration
Obstruction
Strangulation

Question 20

Boundaries of femoral canal (FLIP mnemonic)

Answer 20

F – Femoral vein laterally
L – Lacunar ligament medially
I – Inguinal ligament anteriorly
P – Pectineal ligament posteriorly

Question 21

What is the femoral triangle?

Answer 21

larger area at the top of the thigh that contains the femoral canal. You can remember the boundaries with the SAIL mnemonic

Question 22

SAIL mnemonic

Answer 22

S – Sartorius – lateral border
A – Adductor longus – medial border
IL – Inguinal Ligament – superior border

Question 23

NAVY-C mnemonic for contents of femoral triangle from lateral to medical across top of the thigh:

Answer 23

N – Femoral Nerve
A – Femoral Artery
V – Femoral Vein
Y – Y-fronts
C – Femoral Canal (containing lymphatic vessels and nodes)

Question 24

What is an incisional hernia?

Answer 24

occur at the site of an incision from previous surgery.

Question 25

What are incisional hernias due to?

Answer 25

due to weakness where the muscles and tissues were closed after a surgical incision.

The bigger the incision, the higher the risk of a hernia forming.

Question 26

Treatment of incisional hernia’s

Answer 26

Incisional hernias can be difficult to repair, with a high rate of recurrence.

They are often left alone if they are large, with a wide neck and low risk of complications, particularly in patients with multiple co-morbidities.

Question 27

Umbililcal hernias

Answer 27

Umbilical hernias occur around the umbilicus due to a defect in the muscle around the umbilicus.

Umbilical hernias are common in neonates and can resolve spontaneously. They can also occur in older adults.

Question 28

What is an epigastric hernia?

Answer 28

An epigastric hernia is simply a hernia in the epigastric area (upper abdomen).

Question 29

What is a hiatus hernia?

Answer 29

refers to the herniation of the stomach up through the diaphragm

Question 30

Pathophysiology of hiatus hernia

Answer 30

• The diaphragm opening should be at the level of the lower oesophageal sphincter and should be fixed in place.
• A narrow opening helps to maintain the sphincter and stop acid and stomach contents refluxing into the oesophagus.
• When the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus.

Question 31

4 types of hiatus hernia:

Answer 31

Type 1: Sliding
Type 2: Rolling
Type 3: Combination of sliding and rolling
Type 4: Large opening with additional abdominal organs entering the thorax

Question 32

What is type 1: Sliding hiatus hernia?

Answer 32

where the stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax.

Question 33

What is type 2 rolling hiatus hernia?

Answer 33

separate portion of the stomach (i.e. the fundus), folds around and enters through the diaphragm opening, alongside the oesophagus

Question 34

Type 4 hiatus hernia:

Answer 34

refers to a large hernia that allows other intra-abdominal organs to pass through the diaphragm opening (e.g., bowel, pancreas or omentum).

Question 35

Key risk factors for hiatus hernia?

Answer 35

Increasing age
Obesity
Pregnancy