Hernia Flashcards
Define what is meant by hernia.
Abnormal protrusion of a viscus through its coverings/the walls of its containing cavity
What are the borders of the femoral canal?
Anteriorly: inguinal ligament
Medially: lacunar ligament (+ pubic bone)
Laterally: femoral vein (+ iliopsoas)
Posteriorly: pectineal ligament + pectinous
- canal contains a plug of fat and Cloquet’s node
Describe the pathogenesis of femoral hernias.
Occurs when the peritoneum protrudes downwards into the potential space of the femoral canal
The bowel enters this space and commonly strangulates
Typically occurs in:
- women
- elderly
- people with lax ligaments
- people who have lost weigh t
What is meant by reducible?
Can be pushed back into the right place.
Presents with a lump that disappears on lying down, not painful, might be some discomfort and has a cough impulse
What is meant by irreducible?
Cannot be pushed back into right place. Painless with no other symptoms
What is meant by incarcerated?
The contents of the hernial sac are stuck inside by adhesions - either to the wall or to itself making a loop that is larger than the neck
What is meant by strangulated?
Constriction of the neck of the hernia by the hernial orifice leading to ischaemia of the contents of the hernial sac
How does a strangulated hernia present?
- severe pain (colicky)
- vomiting
- absolute constipation
- blood in stool
- distension of the abdomen
- tender, tense, inflamed, palpable mass with no cough impulse
- irreducible
- malaise with or without fever
- burning/hot sensation around the hernia
What is meant by sliding?
Contains a partially extra-peritoneal structure with the sac not completely surrounding the contents
Describe an umbilical hernia.
In which group of people do umbilical hernias usually occur?
When part of the intestine (usually midgut) protrudes through a defective opening in the abdominal wall muscles
- most common in infants where they usually close spontaneously by 2 years of age if <1.5cm
- if found in adults or children >3y/o then surgical repair is required
- common in obese, multiparous, middle aged women
- prone to strangulation and often irreducible
Describe a paraumbilical hernia.
Occurs around the umbilicus
Describe an epigastric hernia.
Occurs through the linea alba, just superior to the umbilicus
Describe an incisional hernia.
Occurs following a breakdown of muscle just after the closure of surgery/ incompletely healed surgical wound
Describe a parastomal hernia.
Protrusion of abdominal contents through an abdo wall defect created when constructing the stoma
Explain the difference between direct, indirect and pantaloon inguinal hernias.
Direct: through the abdominal wall (Hesselbach’s triangle) to bulge through the superficial inguinal ring; medial to the epigastric vessels
- weakness/defect in transversals fascia area of Hesselbach triangle
Indirect: through the deep inguinal ring; lateral to epigastric vessels
- persistent patent processus vaginalis
Pantaloon: simultaneous direct and indirect hernia on the same side; hernia sac are divided by the epigastric vessels
What are the causes and associated etiological factors of umbilical hernias?
- Congenital malformation of the navel
- Increased intra-abdominal pressure
What are the causes and associated etiological factors of paraumbilical hernias?
- Defect in midline near umbilicus
- Omphalocele
What are the causes and associated etiological factors of incisional hernias?
- Incompletely healed surgical wound
- Increased intra-abdominal pressure
What are the causes and associated etiological factors of parastomal hernias?
- Size of stoma
- Obesity/ increased intra-abdominal pressure
- Age
- Nutrition
- Infection after stoma surgery
How can you tell the difference between an inguinal and femoral hernia upon inspection?
Inguinal hernia = superomedial to pubic tubercle
Femoral hernia = inferolateral to pubic tubercle
What is the pathogenesis of indirect inguinal hernias?
- account for ⅔ of inguinal hernias
- can be congenital
- M:F = 25:1
- have a small orifice therefore can strangulate easily
- persistent processus vaginalis –> failure of normal closure
- empty peritoneal sac lies in inguinal canal
- abdominal canal fills and enlarges empty sac
What is the pathogenesis of direct inguinal hernias?
- degeneration and fatty changes in aponeurosis of transversals fascia that constitutes inguinal floor or posterior wall in Hesselbach’s triangle
- most direct hernias do not have a true peritoneal lining, mainly contain peritoneal fat and occasionally bladder
What is the pathogenesis of strangulated hernias?
- most commonly occurs in indirect inguinal and femoral hernias
- segments of intestine prolapse through the defect
- fluid is sequestered in the lumen of the herniated bowel
- lymphatic + venous drainage are impaired = compound swelling
What are the potential complications of strangulated hernias?
- Ischaemia = arterial supply is interrupted
- Perforation = gangrene ensues and perforation occurs
- Sepsis
How are hernias diagnosed?
- Primarily clinical
- Abdo exam
- Testicular exam
- Assessment of inguinal lymph nodes
- Imaging: US + CT
What is the conservative management for a hernia?
- Lifestyle advice - lose weight, stop smoking
- Watch + wait
- warn patients about S+S of incarceration (abdo pain, nausea, vomiting, absolute constipation)
How are inguinal hernias managed operatively?
- Open mesh repair + prophylactic abx therapy
- Lichtenstein technique (reinforce posterior inguinal canal) - Laparoscopic mesh repair
- for pts with recurrence after open-mesh, or bilateral herniae - May require small bowel resection if strangulated
How are femoral hernias managed operatively?
- Excision of hernia sac:
- Low approach (Lockwood’s)
- Trans-inguinal (Lotheissen’s)
- High approach (McEvedy’s) - Open mesh repair
- Laparoscopic repair
- May require small bowel resection
How are strangulated hernias managed?
- triple abx therapy in case of secondary peritonitis
- NG suction
- IV fluid to correct hypovolaemia + electrolyte deficiencies
