Hernia Flashcards
Give most common to least common hernias
Inguinal Paraumbilical Incisional Femoral Divarication of recti Umbilical Parastomal Spigelian
Name the complications of hernias
Incarceration Small bowel obstruction Strangulation Small bowel perforation Peritonitis
4 features of healthy bowel
Pink
Peristalsis
Peritoneal sheen
Pulsation of the mesenteric arteries
Why do you get adhesions?
Result of trauma to the peritoneum
Manipulation of tissue including abrasion, thermal injury from electro cautery, particles such as sutures, or mesh
How can u avoid formation of adhesions? (Before, during and after surgery)
Before surgery- recommend laparoscopic surgery, prophylactic antibiotics
During- use warm packs when bowel handling and avoid handling bowel excessively, irrigation
After - antibiotics
How would you manage patients with adhesions on the surgical ward ?
Admit to ward
Keep NPO, IV fluid resuscitate
NGT & Foley’s catheter with I/O monitoring
Adequate analgesics
Antibiotics (is strangulation likely)
If no complications , continue 48-72hr conservative observation
Consider laparoscopic adhesiolysis if conservative Mx fails
What is a sliding hernia ?
A hernia is which a portion of the wall is made up of a hollow viscus (usually sigmoid on the left, cecum on the right)
How do you differentiate a direct hernia from an indirect hernia ? Clinically
Direct - not controlled after reduction by pressure over the internal inguinal ring
- readily reduces on lying down
- does not descend into the scrotum
Indirect- controlled after reduction by pressure over the deep inguinal ring
-can & often does descend into the scrotum
How do you differentiate a direct from an indirect hernia? Anatomically
Direct- originates through Hasslebach’s Triangle
- neck lies medial to the inferior epigastric artery
Indirect- originates in the inguinal
- neck lies lateral to the inferior epigastric artery
- hernia sac enters the inguinal canal with the spermatic cord
How do you differentiate an inguinal hernia from a femoral hernia ? Anatomically
Inguinal- appears through the superficial ring
-passes above and medial to the public tubercle
Femoral- appears through the femoral canal
-passes below and lateral to the public tubercle
How do you differentiate an inguinal from a femoral hernia ? Clinically
Inguinal- superior and medial to the pubic tubercle
Femoral- inferior and lateral to the pubic tubercle
Which wall of the inguinal canal is weak to allow a hernia to just “bulge through”
Posterior wall
Why is the posterior wall so weak?
Transversalis fascia is weak
What are the risk for a man (that you should ask in the history) that may have cause the hernia?
Heavy lifting
Smoking
Constipation
History of BPH or Prostate cancer
Is a femoral hernia more common than an inguinal hernia in women?
No
Why do women get femoral hernias more than men? 3 reasons
- femoral ring is larger in females
- stretching of the ligaments in pregnancy
- wider female pelvis
Hernia definition
A protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abdominal position
Hernias risk factors
Congenital abnormality (patent processus vaginalis)
Genetic weakness of collagen
Sharp or blunt trauma
Weakness due to pregnancy and ageing
Previous hernia repair
Primary neurological and muscle disease
Excessive intra abdominal pressure - due to chronic cough, constipation, straining, Ascites, heavy lifting
Hernia differentials
Approach this systematically
Skin- sebaceous cysts Subcutaneous-lipoma, fibroma Arterial-femoral pseudo/aneurysm Venous- saphenus varix Lymphatic- lymphadenopathy Psoas abscess Hernia-Inguinal, femoral Ectopic testis
Hernia examination
Always start with patient standing
Inspection
- exposure : from umbilicus to knees
- look at groin for evidence of a swelling (if can’t see as k patient which side they have noticed a lump
- look for evidence of previous hernia surgery (oblique scar often well hidden in pubic hair line )
- any obvious skin changes, swellings, lumps that be relevant
- ask the patient to look over their shoulder and cough
- as they cough look at the lump to see if there is a cough impulse
Palpate
- palpate sweeping
-can you get above it : yes (scrotal swelling)
No (hernia)
-does it feel soft, fluctuating , pulsatile etc
-ask patient again to cough , palpating for a cough impulse
-ensure that you feel the opposite side, as bilateral hernias are very common
Auscultation
Lie patient down
Inspection
- again inspect the groin
- palpate abdominal
Palpation
-having identify a hernia, assess if it is indirect or direct
-ask patient if they can reduce the hernia
-palpate the groin to assess if the hernia has completely reduced
-warn patient you will be palpating some bony points
- feel for the anterior superior iliac spine and the pubic tubercle
-palpate the midpoint if the inguinal ligament (the surface landmark for the deep inguinal ring) and ask the patient to cough
-if hernia is controlled by pressure over the deep inguinal ring, it suggests that the hernia is indirect
-in order to confirm that you were in fact controlling the hernia, ask patient to cough without pressure to ensure that the hernia now appears
Offer to examine the scrotum, where you should palpate the testis and epididymis
Offer to examine the abdomen for masses
Mid-inguinal point vs midpoint of the inguinal ligament
Mid-inguinal point : halfway between the pubic symphysis and the anterior superior iliac spine. The femoral pulse can be palpated her
Midpoint of the inguinal ligament : halfway between the pubic tubercle and the anterior superior iliac spin. The opening to the inguinal canal is located just above this point
What investigation could be performed if unsure if hernia
Ultrasound
What is the mx of hernia
Repair as there is a risk if the hernia becoming strangulated - unless there are contraindications to surgery
Spigelian hernia
Hernia through the linea semilunaris
