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MBBS Surgery > Hernia > Flashcards

Hernia Flashcards

1
Q

Give most common to least common hernias

A 
Inguinal
Paraumbilical
Incisional
Femoral
Divarication of recti
Umbilical 
Parastomal 
Spigelian
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2
Q

Name the complications of hernias

A 
Incarceration
Small bowel obstruction
Strangulation
Small bowel perforation
Peritonitis
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3
Q

4 features of healthy bowel

A

Pink

Peristalsis

Peritoneal sheen

Pulsation of the mesenteric arteries

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4
Q

Why do you get adhesions?

A

Result of trauma to the peritoneum

Manipulation of tissue including abrasion, thermal injury from electro cautery, particles such as sutures, or mesh

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5
Q

How can u avoid formation of adhesions? (Before, during and after surgery)

A

Before surgery- recommend laparoscopic surgery, prophylactic antibiotics

During- use warm packs when bowel handling and avoid handling bowel excessively, irrigation

After - antibiotics

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6
Q

How would you manage patients with adhesions on the surgical ward ?

A

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

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7
Q

What is a sliding hernia ?

A

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)

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8
Q

How do you differentiate a direct hernia from an indirect hernia ? Clinically

A

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

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9
Q

How do you differentiate a direct from an indirect hernia? Anatomically

A

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
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10
Q

How do you differentiate an inguinal hernia from a femoral hernia ? Anatomically

A

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

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11
Q

How do you differentiate an inguinal from a femoral hernia ? Clinically

A

Inguinal- superior and medial to the pubic tubercle

Femoral- inferior and lateral to the pubic tubercle

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12
Q

Which wall of the inguinal canal is weak to allow a hernia to just “bulge through”

A

Posterior wall

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13
Q

Why is the posterior wall so weak?

A

Transversalis fascia is weak

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14
Q

What are the risk for a man (that you should ask in the history) that may have cause the hernia?

A

Heavy lifting
Smoking
Constipation
History of BPH or Prostate cancer

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15
Q

Is a femoral hernia more common than an inguinal hernia in women?

A

No

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16
Q

Why do women get femoral hernias more than men? 3 reasons

A
  • femoral ring is larger in females
  • stretching of the ligaments in pregnancy
  • wider female pelvis
17
Q

Hernia definition

A

A protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abdominal position

18
Q

Hernias risk factors

A

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

19
Q

Hernia differentials

A

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
20
Q

Hernia examination

A

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

21
Q

Mid-inguinal point vs midpoint of the inguinal ligament

A

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

22
Q

What investigation could be performed if unsure if hernia

A

Ultrasound

23
Q

What is the mx of hernia

A

Repair as there is a risk if the hernia becoming strangulated - unless there are contraindications to surgery

24
Q

Spigelian hernia

A

Hernia through the linea semilunaris

25
Q

Pantaloon hernia

A

Hernia sac exists as both a direct and indirect hernia

26
Q

Richter’s hernia

A

Incarcerated or strangulated hernia involving only one sidewall of the bowel

27
Q

Boundaries of hesselbach’s triangle

A

Lateral - inferior epigastric vessels
Inferior- inguinal ligament
Medial- lateral margin of rectus sheath
Floor consist of internal obligue and the transversus abdominus muscle

28
Q

Inguinal canal anatomy

A
  • 4cm long
  • passes downward from lateral to medial, deep to superficial
  • from the internal (deep) inguinal ring to the external (superficial) inguinal ring
  • parallel to and directly above the inguinal ligament
  • anatomical landmark of the deep ring is 1-2 cm above the midpoint if the inguinal ligament (I.e 1-2cm above the femoral pulse)
  • transmits the spermatic cord in men, round ligament in women. And the ilioinguinal nerve
29
Q

Inguinal canal boundaries

A

Anterior : by the external and internal oblique aponeurosis

Superior: by the internal oblique and transversus abdominis muscule

Inferior: by the inguinal ligament

Posterior: by the transversalis fascia and conjoint tendon

30
Q

Femoral canal borders

A

~1.5cm in length

Anterior- inguinal ligament

Medial: sharp edge of the lacunar part of the inguinal ligament (gimbernat’s ligament)

Posterior: pectineal ligament of astley cooper

Lateral: femoral vein contains a plug of fat and the lymph node if cloquet

From lateral to medial : nerve , artery,vein, empty spa ca, lymph node

31
Q

Lttre’s hernia

A

A meckel’s diverticulum lies within the hernia sac

32
Q

What is in the spermatic cord

A

3 arteries

  • artery to vas deferens ( from inferior vesicular artery)
  • testicular artery (from aorta)
  • cremasteric artery (from inferior epigastric)

3 nerves

  • ilioinguinal nerve (L1)
  • nerve to cremaster
  • autonomic nerve(L10)

3 other structures

  • vas deferens
  • Pampiniform plexus of veins (drains right testis into inferior vena cava and left testis into renal vein)
  • Lymphatics
33
Q

Indications for an open hernia repair

A 
Complicated hernias
Previous preperitoneal surgeries 
Presence of Ascites
Inability to undergo surgery under general anesthesia
Recurrent hernia
34
Q

Indications for laparoscopic hernia repair

A 
Bilateral hernia
Recurrent hernia( if previous was an open )
35
Q

Most common hernia surgical procedures - close vs open

A

Open

: Lichtenstein- reinforcement by implementation of a synthetic mesh between the abdominal internal oblique muscle and the aponeurosis of the abdominal external oblique muscle

: shouldice repair - doubling of the transverse fascia and fixation if the abdominal internal oblique muscle and transverse muscle at the inguinal ligament by suture (a non mesh repair)

Close

: transabdominal preperitoneal repair ( TAPP)- laparoscopic, preperitoneal mesh implementation between the parietal peritoneum and transverse fascia

: Total extraperitoneal repair (TEP) - laparoscopic, extraperitoneal mesh implementation between parietal peritoneum and transverse fascia

MBBS Surgery (11 decks)

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