Hernia Flashcards

1
Q

Define what is meant by hernia.

A

Abnormal protrusion of a viscus through its coverings/the walls of its containing cavity

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2
Q

What are the borders of the femoral canal?

A

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
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3
Q

Describe the pathogenesis of femoral hernias.

A

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

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4
Q

What is meant by reducible?

A

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

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5
Q

What is meant by irreducible?

A

Cannot be pushed back into right place. Painless with no other symptoms

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6
Q

What is meant by incarcerated?

A

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

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7
Q

What is meant by strangulated?

A

Constriction of the neck of the hernia by the hernial orifice leading to ischaemia of the contents of the hernial sac

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8
Q

How does a strangulated hernia present?

A
  • 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
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9
Q

What is meant by sliding?

A

Contains a partially extra-peritoneal structure with the sac not completely surrounding the contents

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10
Q

Describe an umbilical hernia.

In which group of people do umbilical hernias usually occur?

A

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
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11
Q

Describe a paraumbilical hernia.

A

Occurs around the umbilicus

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12
Q

Describe an epigastric hernia.

A

Occurs through the linea alba, just superior to the umbilicus

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13
Q

Describe an incisional hernia.

A

Occurs following a breakdown of muscle just after the closure of surgery/ incompletely healed surgical wound

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14
Q

Describe a parastomal hernia.

A

Protrusion of abdominal contents through an abdo wall defect created when constructing the stoma

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15
Q

Explain the difference between direct, indirect and pantaloon inguinal hernias.

A

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

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16
Q

What are the causes and associated etiological factors of umbilical hernias?

A
  • Congenital malformation of the navel

- Increased intra-abdominal pressure

17
Q

What are the causes and associated etiological factors of paraumbilical hernias?

A
  • Defect in midline near umbilicus

- Omphalocele

18
Q

What are the causes and associated etiological factors of incisional hernias?

A
  • Incompletely healed surgical wound

- Increased intra-abdominal pressure

19
Q

What are the causes and associated etiological factors of parastomal hernias?

A
  • Size of stoma
  • Obesity/ increased intra-abdominal pressure
  • Age
  • Nutrition
  • Infection after stoma surgery
20
Q

How can you tell the difference between an inguinal and femoral hernia upon inspection?

A

Inguinal hernia = superomedial to pubic tubercle

Femoral hernia = inferolateral to pubic tubercle

21
Q

What is the pathogenesis of indirect inguinal hernias?

A
  • 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
22
Q

What is the pathogenesis of direct inguinal hernias?

A
  • 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
23
Q

What is the pathogenesis of strangulated hernias?

A
  • 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
24
Q

What are the potential complications of strangulated hernias?

A
  1. Ischaemia = arterial supply is interrupted
  2. Perforation = gangrene ensues and perforation occurs
  3. Sepsis
25
Q

How are hernias diagnosed?

A
  • Primarily clinical
  • Abdo exam
  • Testicular exam
  • Assessment of inguinal lymph nodes
  • Imaging: US + CT
26
Q

What is the conservative management for a hernia?

A
  1. Lifestyle advice - lose weight, stop smoking
  2. Watch + wait
    - warn patients about S+S of incarceration (abdo pain, nausea, vomiting, absolute constipation)
27
Q

How are inguinal hernias managed operatively?

A
  1. Open mesh repair + prophylactic abx therapy
    - Lichtenstein technique (reinforce posterior inguinal canal)
  2. Laparoscopic mesh repair
    - for pts with recurrence after open-mesh, or bilateral herniae
  3. May require small bowel resection if strangulated
28
Q

How are femoral hernias managed operatively?

A
  1. Excision of hernia sac:
    - Low approach (Lockwood’s)
    - Trans-inguinal (Lotheissen’s)
    - High approach (McEvedy’s)
  2. Open mesh repair
  3. Laparoscopic repair
  4. May require small bowel resection
29
Q

How are strangulated hernias managed?

A
  • triple abx therapy in case of secondary peritonitis
  • NG suction
  • IV fluid to correct hypovolaemia + electrolyte deficiencies