Hernia

Question 1

Hernia : Definition

Answer 1

A hernia is defined as the protrusion of a whole or part of an organ through the wall of the cavity that normally contains it into an abnormal position.

Question 2

Haitus Hernia : Definition

Answer 2

1. Protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus
2. Typically the stomach herniating, although less commonly other structures, such as small bowel, colon, or omentum can herniate through

Question 3

Haitus Hernia : Types

Answer 3

1. Type I, Sliding Hernia :
   * gastro-oesophageal junction - abdominal part of stomach
   * Cardia of Stomach
   Move upwards through the diaphragmatic hiatus into the thorax
2. Type 2, Rolling hernia
   * Fundus of the stomach moves up
   * Sits next to the Oesogus’s GOJ
   * creates a ‘bubble’ of stomach in the thorax

Question 4

Haitus Hernia : Risk factors

Answer 4

1 . Age - main risk factor for developing a hiatus hernia
* Age-related loss of diaphragmatic tone

2 .Increasing intrabdominal pressures
(e.g. repetitive coughing), and an increased size of diaphragmatic hiatus.
Pregnancy, obesity, and ascites are also risk factors,

3. Weakening of abdominal muscles
   Previous oesophageal and stomach surgery also increase the risk of developing hiatus hernia, due to the disruption to the oesophageal hiatus.

Question 5

Haitus Hernia : Clinical presentation

Answer 5

Gastro-oesophageal reflux disease, mainly epigastric pain, made worse by lying flat

• Hiccups or palpitations (due to irritation of the diaphragm or pericardial sac),
• Vomiting, swallowing difficulties
• Anaemia (secondary to oesophageal ulceration or bleeding from gastric body in hernia*)

Question 6

Haitus Hernia : Investigations

Answer 6

Diagnosis : upper GI endoscopy (OGD) - show an upward displacement of the GOJ - the ‘Z-line’

Oesophageal manometry – measures the pressure within the oesophagus during swallowing

Question 7

Haitus Hernia : Management

Answer 7

1 . Conservative : PPI and alteration of diet, avoid meals 2-3 hours before bed time
* Smoking cessation and reduce alcohol intake

2 . Surgical intervention
Indicated if ; ongoing GORD, increased risk of complications

• Cruroplasty followed by fundoplication
• reduction of hernia back into abdomen and resited with sutures
• Gastric fundus is wrpped around lower oesophagus and stitched into place

Question 8

Haitus Hernia : Complication

Answer 8

Gastric Volvulus : stomach twists on itself by 180 degrees, leading to obstruction of the gastric passage and tissue necrosis

Clinical sx : (1) sudden severe epigastric pain
(2) retching without vomiting
(3) inability to pass a nasogastric tube.

Investigation
urgent CT scan is required and often needing emergency surgery

Question 9

Inguinal hernia : Definition

Answer 9

. Inguinal herniae involve abdominal contents passing into the inguinal canal (and can continue into the scrotum)

Question 10

Direct inguinal hernia : Physiology

Answer 10

**Bowel herniates through a weakness in the inguinal triangle, and enters the inguinal canal. **

Bowel can then exit the canal via the superficial inguinal ring and form a ‘lump’ in the scrotum or labia majora.

Direct hernias are acquired (usually in adulthood), due to weakening in the abdominal musculature.

a direct inguinal hernia occurs medially to the inferior epigastric vessels (through the inguinal triangle)

Question 11

Indirect inguinal hernia

Answer 11

Congenital tract opening - between the deep inguinal and superficial inguinal ring

• incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, therefore are usually deemed congenital in origin

occurs laterally to the inferior epigastric vessels

Answer 12

lump in the groin, which (for reducible herniae) will initially disappear with minimal pressure or when the patient lies down.
When examining any groin lump, specific features to note for any suspected inguinal hernia include:

Cough impulse – remember that an irreducible hernia may not have a cough impulse
Location – inguinal herniae appear superomedial to the pubic tubercle* (whilst femoral herniae appear inferolateral to the pubic tubercle)
Reducible – On lying down or with gentle pressure
If it enters the scrotum, can you get above it / is it separate from the testis

Answer 13

Surgical Intervention
Hernia repairs can be performed via open repair or laparoscopic repair*; laparoscopic repairs are associated with longer operating times but quicker post-operative recovery, fewer complications, and less post-operative pain:

Open mesh repairs are preferred for those with primary inguinal hernias and are deemed the most cost-effective technique in this patient group; they can be performed under general, spinal or local anaesthesia, dependent on patient fitness and surgeon preference
Lichtenstein technique (with a mesh) is the most commonly technique used, whilst repair options without mesh include the Bassini or Shouldice methods