Hernia Flashcards
Define hernia
protrusion of a viscus/organ through a defect of the wall containing cavity into an abnormal position
Describe the following hernias:
Epigastric
Umbilical
Femoral
Inguinal
Incisional
Epigastric: passes through the linea alba, above the umbilicus
Umbilical: organ protrudes through the umbilicus (commonly paediatric)
Femoral: bowel enter the femoral canal and presents as a mass in the upper thigh/above inguinal ligament
- INFERIOR and LATERAL to the pubic tubercle
Inguinal: Contents of the abdominal cavity protrude through the inguinal canal (Most common)
- SUPERIOR and MEDIAL to the pubic tubercle
Incisional: contents herniate through a scar from a previous surgery
What is hernial incarceration
Hernia cannot be reduced → reduces venous and lymphatic flow → swelling and oedema
Too much swelling → strangulation (obstruction of arterial blood supply) → ischaemia and tissue necrosis
Risk factors for hernias
Male (inguinal), female (femoral)
Chronic cough
Constipation
Urinary obstruction
Heavy lifting
Ascites
Past abdominal surgery
Aetiology of femoral hernias
Abdominal contents pass through the femoral canal (medial to the femoral vein, lateral to the lacunar ligament)
Can herniate through the femoral sheath
Border by the lacunar ligament - high risk of strangulation
INFERIOR and LATERAL to the pubic tubercle
Epidemiology of femoral hernias
uncommon, more common in middle aged and elderly females, incidence increases with age + association with pregnancy
Symptoms and signs of femoral hernias
Asymptomatic
Mass in upper medial thigh or above inguinal ligament
Abdominal pain
Strangulated = Hot, painful, irreducible
Aetiology of Inguinal hernias
Most common in males (inguinal canal being larger and more prominent)
Often due to increased abdominal pressure e.g. coughing, heavy lifting
Indirect: assess through the internal/deep inguinal ring with herniation lateral to the inferior epigastric vessels
Direct: Passes directly through the posterior wall of the inguinal canal and through the external inguinal ring in HESSELBACH’S triangle with herniation medial to the inferior epigastric vessels
SUPERIOR and MEDIAL to the pubic tubercle
Epidemiology of inguinal hernias
Males,
Indirect - childhood + young adults
Direct - middle aged and elderly
Symptoms and signs of inguinal hernias
Asymptomatic
Abdominal pain
Lump/mass in groin
Intermittent/constant
Painless/painful
Uncomfortable
Reducible/irreducible
Constipation or change in bowel habit
Scrotal swelling
may extend to scrotum
Indirect: herniation LATERAL to inferior epigastric vessels, restrained once reduced and patient coughs with finger over deep ring
Direct: herniation MEDIAL to the inferior epigastric vessels, NOT restrained once reduced and patient asked to cough with fingers over the deep ring
Investigations for hernias
Physical exam + clinical diagnosis
ABG: metabolic acidosis + raised lactate in strangulation
USS: visualise contents
CT/MRI: rule out other diagnoses
management for hernias
Small and asymptomatic:
Watchful waiting + Weight loss, smoking cessation
Large or symptomatic:
Prophylactic antibiotic e.g. cefazolin
Open mesh or lap. repair
Inguinal → repair (even if asymptomatic; can be routine)
Femoral → repair (urgent repair; Lockwood Low or McEvedy high)
ELECTIVE: Lockwood Low approach (low incision over hernia with herniotomy/herniorrhaphy)
What are the surgical options for hernia repair
Herniotomy = ligation and excision of hernial sac
Herniorrhaphy = repair of abdominal wall defect
Hernioplasty = mesh implant
Mesh technique e.g. Lichtenstein (mesh to reinforce the posterior wall)
- Preferable for unilateral primary hernias
- Reduced recurrence rate
Laparoscopic:
Transabdominal pre-peritoneal (TAPP) = peritoneum entered + hernia repaired
Totally extraperitoneal (TEP) - decreases risk fo visceral injury
- Preferable for primary unilateral INGUINAL hernias
What incisions are done during hernia repair and what is the post-op advice
Gridiron / McBurney’s: oblique
Lanz: transverse incision (hidden in skin crease)
Both carry a risk of damage to Iliohypogastric and ilioinguinal nerves
Must pass urine before discharge
Mobilise early (work in 1-2 weeks; ≥6 weeks if work involves heavy lifting)
Adequate analgesia and avoid constipation (lactulose prescription)
Keep area clean and dry
Can bathe immediately
Management of incarcerated/strangulated hernias
Emergency surgery
1. Abx e.g. cefalozin
1. Surgical repair
- EMERGENCY: McEvedy High approach (via inguinal region to inspect and resect non-viable bowel)
