Hernia

Question 1

Inguinal hernia

Answer 1

The most common type of hernia
- Occurs when part of the bowel protrudes through the abdominal wall

Question 2

Direct inguinal hernia

Answer 2

Bowel enters only through superficial ring
- Comes straight from bowel
- Enters medial to the epigastric vessels

Causes
- Weakness in abdominal wall

Question 3

Indirect inguinal hernia

Answer 3

Bowel enters the deep inguinal ring and superficial ring
- Enters lateral to the epigastric vessels
- Usually congenital cause

Question 4

Deep inguinal ring
- Description
- Location + Surrounding structures
- Variation

Answer 4

Made up of the transversals evagination
- Origin of the spermatic cord in males and round ligament of uterus in females

Location
- Just above midway of inguinal ligament
- Medial to the Inferior epigastric vessels

Larger in males than females

Question 5

Superficial inguinal ring
- Description
- Location + surrounding structures
- Variation

Answer 5

Triangular opening that acts as an exit for the inguinal canal
- Created from external oblique aponeurosis
- Contains the spermatic cord in men and round ligament of the uterus in women
- Contains ilii-inguinal nerve

Location
- Immediately above pubic crest
- Superolateral to pubic tubercle

Question 6

Hernia deifinition
- Reducible
- Irreducible
- Strangulated

Answer 6

Protrusion of part of a viscus through the wall containing its cavity

Reducible
- Protrusion can return to the abdominal cavity spontaneously or through manipulation

Irreducible
- Protrusion cannot be return despite pressure/ manipulation

Strangulated
- When the blood supply contents is compromised due to pressure.

Question 7

Sliding hernia
- Definition

Answer 7

Where part of the sac in the protrusion is formed from bowel.

Question 8

Maydl’s hernia

Answer 8

When the herniated bowel is a double loop

Question 9

Littre’s hernia

Answer 9

A hernia sac containing Meckel’s diverticulum

Question 10

Risk factors for inguinal hernia

Answer 10

Male (9:1)
Caucasian
Weak abdominal wall

Previous hernias

Smoking

Old age

Question 11

Clinical features of inguinal hernia

Answer 11

Lump in the groin
- Exacerbated by straining/ coughing
- Cough have occurred after a strenuous event

Abdominal discomfort

Constipation

Question 12

Complications of hernias

Answer 12

Incarceration

Bowel obstruction

Strangulation

Question 13

Non-surgical management of inguinal hernias

Answer 13

If small and asymptomatic
- Watchful waiting= inform Pt to see medical attention if they develop red flag signs

Question 14

Red flag signs of hernia

Answer 14

Abdominal pain

Nausea

Vomiting

Constipation

Abnormal colour

Question 15

Management of strangulated/ incarcerated hernia

Answer 15

Viable bowel
- Tension free mesh repair

Strangulation
- Open surgical repair

Non-viable bowel/ contamination
- Bowel resection, non-primary tissue repair

Adjunct
- Prophylactic antibiotic

Question 16

Management of a large/ symptomatic uncomplicated hernia

Answer 16

Open mesh repair
- Lichtenstein technique
- Under spinal, GA or LA

Adjunct- prophylactic antibiotics

Question 17

Lichtenstein technique

Answer 17

Tension-free mesh repair method

Primary surgical method in UK

Complications
- Post-op pain
- Infection

Question 18

Lap surgery for hernias

Answer 18

Transabdominal preperitoneal repair (TAPP)
- Access via peritoneal cavity
- Mesh is inserted through peritoneum when it is placed before closing the peritoneum

Totally extraperitoneal repair (TEP)
- Hernia site is accessed without entering the peritoneal cavity.
- Via per peritoneal plane
- More difficult than TAPP.

Question 19

Femoral hernia
- Definition
- Epidemiology
- cause

Answer 19

Protrusion of viscus via femoral canal

F>M
- Middle age/ elderly
- Femal canal is larger in females
- 50% risk of strangulation within a month

Cause
- Increased intra-abdominal pressure

Question 20

Clinical features of femoral hernia

Answer 20

Painless groin lump
- Neck is infer-lateral to pubic tubercle.

• Often reducible

Obstruction/ strangulation
- Tender, red and hot
- Abdo pain
- Vomiting, constipation

Question 21

Femoral canal
- Contents
- Borders

Answer 21

The smallest, most medial compartment of the femoral sheath.

Contains lymphatic vessels and nodes.

Borders
- Anterosuperiorly= inguinal ligament
- posterior= Pectineal ligament
- Medially= lacunar liagment
- Lateral= femoral vein

Question 22

Femoral sheath

Answer 22

Compartment in the leg containing

Lateral= femoral artery, femoral branch of genitofemoral

Intermediate= Femoral Vein

Medial= Femoral canal

-

Question 23

Femoral triangle
- Borders
- Content

Answer 23

Compartment in the anterior upper third of thing.
- Below inguinal ligament

Borders
- Lateral= sartorius muscle
- Superior= inguinal ligament
- Medially= Adductor longus
- Floor= pectinous, adduct longus (medial), Iliopsoas (lateral)

• Rootf= fascia lata

Contents
- Femoral sheath= (lat to med) femoral artery, femoral vein, femoral canal

• Femoral nerve (Lateral)