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General surgery > Hernia > Flashcards

Hernia Flashcards

1
Q

Types of hernia

A
  1. Internal
  2. External
    Inguinal
    Femoral
    Incisional
    Obturator
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2
Q

Litres hernia

A

Meckels diverticulum within the defect

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3
Q

Predisposing

A
  1. Weakness in abdominal wall

2. Increased intrabdominal pressure

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4
Q

Weaknesses in abdominal wall mechanisms

A 
1. Congenital
Patent umbilical ring
Patent oricessus vaginalis
Canal of nuck
Diaphragmatic defect
2. Where normal structure pass through
Esophageal hiatus
Diaphragm
Obturator
Sciatic foramen
3. Acquired
Surgical scar
Incision
Muscle wasting
Fatty infiltration
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5
Q

Causes of + intra-abdominal pressure

A 
Coughing
Vomiting
Pregnancy
Ascites
Organomegaly
Obesity
COAD
Heavy lifting
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6
Q

Complications

A
  1. Irreducibility
  2. Obstruction
  3. Strangulation
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7
Q

Irreducibility

A

Should be operated on ASAP->obstruction and pain

  1. Adhesions between the contents and the sac
  2. Fibrosis leading to narrowing of neck, or sudden ++IAP contents moves through and content move back
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8
Q

Obstruction

A

Occlusion of the lumen contained within the sac

Signs of intestinal obstruction->vomiting, constipation, distension, tender

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9
Q

Strangulation

A

Lymph and venous congestion->++Pressure, reduced arterial supply= ischemic, necrosis, perforation->peritonitis

Needs surgery

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10
Q

How is the integrity of the inguinal canal maintained

A

Shutter mechanism
Oblique orientation
Posterior wall

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11
Q

Indirect hernia: cause, types

A

Failure of processus vaginalis to completely obliterate

  1. Bubonocele= within canal
  2. Funicular= to superficial ring
  3. Complete= within scrotum/labia majora
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12
Q

Inguinal hernias in children are always what type

A

Indirect

Due to patent ductus vaginalis

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13
Q

In children, what side is more common

A

Right

Descent is slightly later

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14
Q

What is a direct hernia

A

Through posterior wall of inguinal canal

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15
Q

Do direct hernias occur in children

A

No

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16
Q

Principles of treatment

A
  1. Correct the defect
  2. Correct causes of +intra-abdominal pressure
    - lose weight, lose ascites, lose baby
    - Better COPD/asthma management
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17
Q

Attempts to reduce hernia

A
  1. Elevate end of the bed
  2. After 20-30 mins firm manual pressure
  3. Provide analgesia prior to attempt
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18
Q

Management of uncomplicated hernia

A
  1. No treatment->+morbidities, not tolerate surgery, Truss
  2. Watchful waiting->small, asymptomatic. Reassess in 6 months. No harm in waiting
  3. Operative
  4. Diet, stop smoking
19
Q

Management in comlpicated

A 
Always surgery
1. ABC, cannula
2. IVF, 
3. Investigations
FBC, Group and hold, LFTs, UEC, glucose
ECXR->perforation
AXR->Obstruction
3. Keep NBM
4. Surgical consult
5. Analgesia
6. NGT
7. Prophylaxis antibiotics: cephazolin 2g
8. Consent and book
9. Admit
20
Q

Purpose of surgical management

A
  1. Reduce the hernial contents
  2. Excise the sac->herniotomy, most cases
  3. Repair and close the defect->restore normal anatomy (herniorrhaphy), or insert additional material (hernioplasty)
21
Q

Herniorraphy

A
  1. Strengthening of posterior wall and repair of EO aponeurosis in front of canal
    a. Nylon darn repair
  2. Bassini
  3. Shouldice
22
Q

Hernioplasty

A
  1. Insertion of prosthetic mesh

2. Two arms encircle deep ring, sutured to posterior wall

23
Q

Ilioinguinal nerve

A

Traverses the inguinal canal near the external inguinal ring. Provides unilateral sensory innervation to the pubic region and the upper portion of the scrotum or the labia majora. This is the nerve most commonly injured during open herniorrhaphy

24
Q

Iliohypogastric nerve

A

Passes superior to the internal inguinal ring and provides sensory innervation to the skin superior to the pubis

25
Q

Genitofemoral nerve

A

The genital branch of the genitofemoral nerve travels within the spermatic cord to provide sensation to the scrotum and the medial thigh. The femoral branch of this nerve supplies sensation to the skin of the anterior thigh.

26
Q

Consenting for hernia

A
  1. You have an inguinal hernia->bowel and the sac pushed through muscle layer of abdominal wall. Surgery to avoid strangulation.
  2. Laparoscopic (3 incisions)->push bowel back through to abdominal wall, a mesh sutured over the top. Non absorbable permanent sutures. Quick and effective, does require GA.
  3. IV line and catheter
  4. Stay in hospital 1-2 days.
  5. Fast from midnight, arrive on day.
  6. After operation->not to strain/heavy lifting, avoid driving 1 weeks, avoid sex for several weeks, work leave 1-6 weeks, judge exercise by pain and confidence
  7. General risks:
    Nausea, vomiting, diarrhea, allergy (GA)
    Infection
    Bleeding
    Atelectasis ->Pain and mobilise
    Wound infection, dishiscience
    MI, stroke, DVT/PE
    Death
  8. Specific
    Change to laparotomy
    Damage to bladder, GIT
    Gas causing complications
    Urinary retention, ileus
    Swelling of testicle and scrotum, hematoma
    Epididymis damage->may reduce fertility
    Ilioinguinal nerve damage->long term burning and aching
    Testiuclar atrophy->damage to testicular artery
    Adhesions
    Scar
    Recurrence
    Incisional hernia
  9. Agree and consent, transfusion?
27
Q

Management following hernia repair

A
  1. Simple analgesia
  2. Mobilising
  3. DVT prophylaxis
  4. Avoid heavy lifting, driving, straining 6-8 weeks. Off work 2-4 weeks
28
Q

Femoral hernia: presentation, etiology, epidemiology

A
  1. Bulge at femoral canal
  2. Transversalis fascia disrupted
  3. Most common site for richters, localised weak at femoral ring, +IA pressure
  4. Epidemiology:
    Women, older, parous
29
Q

Management of femoral hernia

A
  1. Advise surgery

2. Open and empty sac->sutures between inguinal and pectineal ligaments

30
Q

Umbilical hernia in children: epidemiology, prognosis, management

A
  1. Found in 5-10% children
  2. 1/3 close within a month, rarely persist >3-4 months
  3. Rarely irreducible, rarely strangulates
  4. Generally do nothing as most will resolve
  5. Look to treat when ++size or presents at school age
31
Q

Incisional hernias: what, predisposing, management

A
  1. Protrusion at site of scar, 5% in 5 years
  2. Poor surgical, local wound complications, impaired wound healing, +IA pressure
  3. Needs repair->difficult to repair when large, risk of irreducibility and complications
32
Q

Presenttaion of epigastric hernia

A

Young fit males presenting with epigastric discomfort
Defect in linea alba
May be confused with peptic ulcer
USS can be used to visualise

Mayo or keel repair

33
Q

Location of deep inguinal ring

A

Mid point of inguinal ligament, 1 1/2 cm above femoral pulse

34
Q

Location of superficial inguinal ligament

A

Superior and medial to pubic tubercle

35
Q

Differential for groin pain

A
  1. Hernia
  2. Muscle strain
  3. Adenopathy
  4. Testicular torsion
36
Q

Obturator hernia: define, epiD, examination findings

A
  1. Herniation through the obturator canal alongside the obturator vessels and nerves. 2. This hernia occurs mostly in women, particularly multiparous women with a history of recent weight loss.
  2. A mass may be palpable in the medial thigh, particularly with the hip flexed, externally rotated, and abducted
    (Howship-Romberg sign).
37
Q

What makes up the anterior wall of hasselbachs triangle

A

In this triangle, the peritoneum and transversalis fascia are the only components of the anterior abdominal wall.

38
Q

Physiology of wound healing

A
  1. Inflammatory: immediate->few days->sterilise, +growth factors, fibroblasts and keratinocytes
  2. Proliferation: fibrin-fibrinogen, collagen, wound matrix and +strength
  3. Remodelling: capillary regression= less vascularised, +in wound tensile strength
39
Q

Clinical factors affecting wound healing

A
  1. Infection: delayed fibroblast proliferation/matrix/deposition
  2. Nutrition->vitamin C and A (fibroB, collagen cross linking, epithelial)
  3. Oxygenation
  4. Corticosteroids
  5. DM
40
Q

Time of highest risk of evisceration and wound dishiscence

A

At 7 days

41
Q

Technical factors relating to abdominal closure failure

A
  1. INadequate tissue incorporation
  2. Inappropriate sutures
  3. Excessive tension
  4. Inadequate patient relaxation
  5. Inappropriate suture placement
42
Q

When to suspect fascial defects

A

Drainage of serous or serosanguinous fluid from otherwise normal wound

43
Q

Most common form of incisional hernia repair

A

Mesh

General surgery (36 decks)

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