Hernia Flashcards
Definition
•A hernia occurs when an internal organ or other body part protrudes through the wall of muscle or tissue that normally contains it.
Main groups of Hernias are:
➢Abdominal Hernias
➢Hiatus Hernias
Abdominal hernias
Abdominal hernias can be classified as :
•Complicated / Reducible hernia which is a hernia with a bulge that flattens out when you lie down or push against it gently.
•Non-Complicated / Non-reducible hernia which occurs when the loop of the intestine becomes trapped and you lose the ability to make the bulge flatten out.
Types of Abdominal hernias
Epigastric upper abdomen at midline
Incision-at the side of previous surgical incision
Umbilical-at the navel
Femoral-femoral canal
Inguinal (direct and indirect )
Symptoms of Non-Complicated Hernias
•A noticeable lump or bulge that can be pushed back in, or that can disappear when lying down.
•Increased pain at the site of the bulge
•Pain or discomfort especially when bending over, coughing or lifting
•Increase in the bulge size over time
•A dull aching sensation
•A sense of feeling full or signs of bowel obstruction
•Absence of pain e.g. Umbilical Hernia in children (abdominal discomfort in adults)
Symptoms of Complicated Hernias
•Nausea
•Vomiting
•Sudden Pain that quickly intensifies
•Fever
•Rapid heart rate (tachycardia)
• A Hernia bulge that turns red, purple or dark
Clinical Picture of Non-Complicated Hernias
INSPECTION :
➢ The presence of hernia prolapse i.e. bulge ( its form and size changes at exertion and various body positions e.g. standing or laying.)
•PALPATION :
➢ Tenderness is revealed
➢ Prolapse consistency is soft-elastic
➢ The contents are reduced into the abdominal cavity
➢ Detection of hernia hilus
➢ Cough tremor symptom is positive ( i.e.. hernia gets tensed and expands on coughing which results in increase of abdominal wall pressure, so you put your hand on the swelling and cough ) PERCUSSION :
➢ Tympanic sound at the intestine presence in the hernia
➢ Femoral sound at the omentum presence
•AUSCULTATION :
➢ Reveals peristaltic intestinal sounds at the intestine presence in the hernia
➢ Absence of peristaltic intestinal sounds at the omentum presence
Clinical Picture of Complicated Hernias
INSPECTION :
➢ Presence of hernia prolapse i.e. bulge
➢Presence of discoloration e.g. red, purple or dark
➢ Swelling of abdomen
• PALPATION :
➢ Tenderness
➢ Irreducibility
➢ Negative cough impulse
PERCUSSION:
➢ Tympanic percussion sound at the intestinal presence in hernia
•ASCULATION :
➢ Absence of bowel sounds
Clinical Picture of Complicated Hernias
INSPECTION :
➢ Presence of hernia prolapse i.e. bulge
➢Presence of discoloration e.g. red, purple or dark
➢ Swelling of abdomen
• PALPATION :
➢ Tenderness
➢ Irreducibility
➢ Negative cough impulse
PERCUSSION:
➢ Tympanic percussion sound at the intestinal presence in hernia
•ASCULATION :
➢ Absence of bowel sounds
Hiatus Hernias
A Hiatal Hernia occurs when part of thee e stomach pushes upward the diaphragm
Symptoms of Hiatus Hernias
o Heartburn
o Belching
o Difficulty swallowing
o Chest or abdominal pain
o Indigestion
o Frequent regurgitation
o Vomiting blood or passing black stools
Clinical Picture of Hiatus Hernia
•INSPECTION :
o No visible bulges or protrusions
•PALPATION :
o Place fingers on solar Plexus, just below the breastbone. Then take a deep breath. You should feel the solar plexus expand and move outward. If there is no movement at the solar plexus and you have to lift your chest and shoulders to take a deep breath, then you probably have a hiatal hernia.
•PERCUSSION :
o Dullness
•ASCULTATION :
o Absence of breath sounds
oPresence of bowel sounds
Complication of hernia
Strangulated hernia is a condition in which the blood supply to the herniated tissue is compromised. Strangulation stems from herniated bowel contents passing through a restrictive opening that eventually reduces venous return and leads to increased tissue edema, which further compromises circulation and stops the arterial supply.
Strangulated hernia
Strangulation can occur in any hernia, the most common i)the oblique inguinal hernia
ii) femoral hernia
iii) paraumbilical hernia
A strangulation hernia cuts of the blood supply to the intestines and tissues in the abdomen.
Symptoms
)Excruciating pain near a hernia that gets worse very quickly.
2)Redness or blue discoloration around the hernia buldge(inflammation and colour changes in the skin near the hernia, the inflammation may lead to burning sensation around the hernia
3) nausea, vomiting, fatigue, fever and rapid heart rate
4)swollen, round abdomen which is a sign that food is not passing through the bowel therefore the patient may experience constipation
5) Bloody stools
6) Hernia that does not move back into the abdomen
Causes of S.H
Weakening of e muscle tissue of the abdomen makes it easier for tissues from the intestines to push through the muscle tissue. This can lead to intestines being trapped by the abdominal lining which can pinch off (constrict) a bit of the intestinal tissues aswell as the blood vessels therefore leading to strangulation.
Strangulation will occur if 1)the defect that leads to a hernia is narrow is sharp edged therefore has a constricting effect of the contents of the hernia. 2)Neck of the sac of the hernia is also narrower than the defect and usually fibrosed therefore it will be the constrincting agent, impeding blood supply of the contents therefore leading to strangulation.
PREDISPOSING FACTORS TO STRANGULATION
Irreducibility (inability of contents to freely return back from the hernia) this is usually due to adhesions between the hernia sac and contents therefore the adhesions maybe constricting agents obstructing blood supply to the contents, resulting in strangulation.
2)Inflammated hernia- due to the inflammation we see congestion,edema and swelling of contents of the hernia inside the sac leading to pressure build up, this increased pressure inside the sac is the blood supply obstructing agent resulting in strangulation
)Obstruction of hernia- leads to congestion, inflammation , oedema of contents leading to high pressure inside the sac which as I have mentioned ,high pressure ultimately becomes obstructing agent of the blood supply.
4)Attacks of bronchial asthma- with and severe strenuous effect therefore leading to sudden continued expulsion of new contents into the hernia sac, leading to sudden high pressure inside the sac therefore compression of blood supply of contents resulting in strangulation.
CLASSIFICATION OF STRANFULATION
1)According to mechanism of strangulation; i) elastic- elevation of the intraabdominal pressure leads to enlargement of the neck(hernia hilus) so that a large amount of contents can pass into the hernia sac, after the contents have passed through the hernia hilus returns to its normal size , this leads to strangulation because it constricts the contents as they have become larger.
ii)fecal- accumulation of large contents in the intestinal loop with an increase in volume applies pressure on the herinial hilus resulting in strangulation.
Classification of strangulated
According to the degree of closure of intestinal strangulated loop lumen
i)Complete- compression of the intestinal section in the sac of the hernia aswell as the passage of intestinal contents
ii)Parietal (Richter’s hernia)- only a part of the intestinal wall is strangulated but the passage of intestinal contents is not.
3)According to localization of the strangulated intestinal loop
i) Orthograde- only one intestinal loop is located in the hernia sac and is subjected to necrosis due to its strangulation as its mesentery is suppressed, therefore we see an occurrence of acute intestinal obstruction(intestinal necrosis, hernia sac phlegmon may develop)
ii)Retrograde- the hernia sac contains two or more intestinal loops, while the connecting loops is in the abdominal cavity, the loops in the sac undergo necrosis as well but not as much as the one in the abdominal cavity due to all mesentery loop suppression including that of the loop in the abdominal cavity. Therefore we may see acute intestinal obstruction, where there is necrosis of the loops, early peritonitis may also occur.
Treatment of strangulated hernia
First Laparascopy is conducted to asses the state of the hernia to see the viability of the organs.
If organ is no longer viable- EMERGENCY surgery is conducted
First, the surgeon will need to reduce the size of the hernia. The surgeon gently applies pressure to the hernia in an attempt to push the trapped tissues back into the abdominal cavity. They must work quickly to prevent the tissue from being permanently damaged.
After this, the surgeon will remove any damaged tissues.
A HERNIOTOMY is conducted where the band of tissue constricting the strangulated hernia is cut(removal of hernia sac only)
Once this is complete, the surgeon may repair the weak area of muscle where the hernia pushed through. If the hernia is small, the surgeon may be able to do this with stitches. With large hernias, a surgeon may need to add flexible surgical mesh or tissue for added support to help keep the hernia from recurring (Abdominal wall plasty)
If the organ is still viable , the same treatment steps may be conducted but under planned surgery,not under emergency situations.
SURGICAL TREATMENT OF HERNIA
SURGICAL OPERATION IS USUALLY DONE FOR THE CORRECTION OF A HERNIA- A BULGING OF INTERNAL ORGANS OR TISSUES THROUGH THE WALL THAT CONTAINS IT AND IT LASTS 30-45 MINUTE
SURGICAL TREATMENT OF HERNIA
IT CAN BE OF TWO DIFFERENT TYPES: HERNIORRHAPHY OR HERNIOPLASTY.
HERNIOPLASTY IS WHEN AUTOGENOUS OR HETEROGENEOUS MATERIAL IS USED FOR REINFORCEMENT DURING HERNIAL SURGICAL TREATMENT, WHEREAS IN HERNIORRHAPHY NO AUTOGENOUS OR HETEROGENEOUS MATERIAL LIKE PROLENE MESH IS USED FOR REINFORCEMENT.
Surgical method
LAPAROSCOPIC INTERVENTION
OPEN INTERVENSIONS
LAPAROSCOPIC INTERVENTION
PERFORMANCE OF THE SURGICAL ACCESS
•ALLOCATION OF THE HERNIAL SAC
•ALLOCATION AND REVISION OF THE HERNIAL CONTENTS
•REDUCTION OF THE HERNIAL CONTENTS INTO THE ABDOMINAL CAVITY
•PLASTY OF HERNIAL HILUS WITH EITHER POLYMERIC MATERIALS OR AUTOTISSUES.
