Hernia and Abdominal Wall Problems Flashcards
1 hernia in both male AND females?
indirect inguinal
Hernia general info
Protrusion of a viscus through an abnormal opening in the wall of a cavity in which it is contained
10% of population develops some sort in life. 3-4% current male population
50% indirect inguinal
25% direct (mostly people over 50)
15% femoral
Abdominal wall hernia is #1 condition requiring major surgery
External hernia
Sac protrudes completely through the abdominal wall. Ex = inguinal (indirect and direct), femoral, umbilical, epigastric
Internal hernia
sac is within the visceral cavity.
Ex = diaphragmatic (congenital or acquired), small intestine herniating in the paraduodenal pouch
Intraparietal hernia
sac is contained within abdominal wall
Ex = spigelian hernia
Reducible vs irreducible
Irreducible = incarcerated
Cannot be returned to abdomen
Strangulated
vascularity of viscus is compromised
surgical emergency
Layers of abdominal wall
skin subq fat camper's Scarpa's External oblique Internal oblique transversalis abdominis transversalis fascia peritoneal fat peritoneum
Inguinal canal
Length = 4cm
Anterior = ext oblique aponeurosis
Posterior = transverse abdominal muscle aponeurosis and transversalis fascia
Spermatic cord
Begins at deep ring and contains:
Vas Deferens and its artery
1 testicular artery
2-3 veins
lymphatics
Autonomic nerves
Fat
Genital nerve
Travels along with cremaster vessels to form neurovascular bundle
From L1 and L2
Motor and sensory
Innervates cremaster, skin of side of scrotum and labia
May sub for ilioinguinal nerve if it doesn’t work
Iliohypogastric, ilioinguinal nerves, genital branch of genitofemoral nerve
Iliohypogastric and ilioinguinal intertwine
originate from T12 and L1
Sensory to groin skin, base of penis, medial upper thigh
Genital branch of genitofemoral nerve is located on top of spermatic cord in 60% of people but can be found behind or within the cremaster muscle. Often cannot be found or is too small to be seen
Femoral canal structures
Lateral to medial = NAVEL
Nerve Artery Vein Empty space LN
Hesselback’s triangle
lower abdominal wall
site of direct inguinal hernias
Inferior = inguinal ligament
Medial = rectus abdominis
Lateral = Inferior epigastric vessels (lateral umbilical fold)
Triangle of Grynfeltt
“superior lumbar triangle”
Bounded by 12th rib superiorly
Internal oblique anteriorly
Floor = fibers of quadratus lumborum muscle
Triangle of Petit
“inferior lumbar triangle”
Posterior = Lat Anterior = ext oblique
Inferior = iliac crest
Floor = fibers from int oblique and transversus ab
Inguinal hernia - general
Hernias arising above the abdominocrural crease
Most common site for abdominal hernias
Male:Female = 25:1
Males: Indirect > direct (2:1)
Female: Direct is rare
Incidence, strangulation, and hospitalization all increase with age
Cause 15-20% of intestinal obstructions
Risk factors for inguinal hernia
1) Abdominal wall hernias occur in areas where aponeurosis and fascia are devoid of protecting support of striated muscle
2) They can be congenital or acquired by surgery or muscle atrophy
3) Female predisposition to femoral hernias: increased diameter of the true pelvis as compared to men, proportionally widens the femoral canal
4) Muscle deficiency of the internal oblique muscles in the groin exposes the deep ring and floor of inguinal canal, which are further weakened by intra-abdominal pressure
5) Connective tissue destruction (transverse aponeurosis and fascia): caused by physical stress 2/2 intra-abdominal pressure; smoking; aging; connective tissue disease; systemic illness; fracture of elastic fibers; alterations in structure, quantity and metabolism of collagen
6) Other: Abdominal distention, ascites with chronic increase in intra-abdominal pressure, peritoneal dialysis
Symptoms of inguinal hernia
Asymptomatic sometimes
Symptomatic - nonspecific discomforts vary by patient
Pain: Worse at the end of the day and relieved at night when patient lies down (bc hernia reduces)
Groin hernias do NOT usually cause testicular pain. Likewise, testicular pain doesn’t usually indicate the onset of a hernia
Dx of inguinal hernia
PE
In standing position, have patient strain or cough. Hernia sac will enlarge and transmit a palpable impulse
Hydroceles can resemble an irreducible groin hernia. To distinguish, transilluminate (hernia will not light up)
Ddx of inguinal hernia
Abdominal wall mass
Desmoids
Neoplasm
Adenopathy
Rectus sheath hematoma
Radiology role in inguinal hernias
diagnosis is clinical
imaging only used in special cases like when obesity limits clinical exam (US/CT)
Management of inguinal hernia
Principles of Tx:
1) Tension-free repair of hernia defect
2) Repair using fascia, aponeurosis or mesh
3) Suture material used should hold until fibrous tissue is formed over it
4) Resuscitation in case of strangulated hernia with gangrene with shock or with intestinal obstruction
Nonsurgical:
1) No role for medical management in patient who can tolerate surgery
2) Can be considered in moribound patients
3) Hernia truss is a device to keep a reducible hernia contained by external pressure
Surgical:
1) Treatment of choice
2) Herniotomy is when hernia sac is ID’d, freed, its neck ligated and the sac is reduced. May be enough in young, muscular person and in kids
3) Herniorrhaphy and hernioplasty are herniotomy along with repair of posterior wall of inguinal canal and internal ring
Complications of surgical repair
Ischemic orchitis with testicular atrophy
Residual neuralgia
Both: more common with anterior groin hernioplasty bc of the nerves and spermatic cord dissection and mobilization
Prognosis following surgery
Expert surgeons 1-3% in 10y follow up
Caused by excessive tension on repair, deficient tissue, inadequate hernioplasty or overlooked hernias
Decreased with relaxing incisions
More common with direct hernias
Direct inguinal hernia
A direct hernia enters inguinal canal through its weakened posterior wall. The hernia does NOT pass through internal ring
- Lies posterior to spermatic cord
- Practically never enters scrotum
- wide neck (strangulation rare)
- almost all in men
- common in older age groups
- common in smokers due to weakened connective tissue
- predisposing factors = hard labor, cough, straining, and so on
- can lead to damage to ilioinguinal nerve
Symptoms:
- bulge in groin
- Dull dragging pain in inguinal region referred to testis
- Pain increases with hard work and straining
Indirect inguinal hernia
Herniation through internal ring traveling to external ring. If complete, it can enter the scrotum while exiting external ring
If congenital, associated with patent processus vaginalis
B/l in 33% of cases
Most common hernia in men AND women
Occurs at all ages
More common in men
In first decade of life, the right-sided hernia is more common than left bc of late descent of R testis
Femoral hernia def
Form of indirect hernia arising out of the femoral canal beneath the inguinal ligament (medial to femoral vessels)
Female: Male = 2:1
Males affected are in younger group
Rare in children
Uncommon - 2.5% of all groin hernias
Left side 1:2 right side 2/2 sigmoid colon tamponading the left femoral canal
Common in elderly patients
High incidence of incarceration due to narrow neck
22% strangulate after 3 months
45% after 21 months
Anatomy of femoral hernia
Femoral canal is 1.25cm long and arises from femoral ring to the saphenous opening
Femoral sac originated from femoral canal through defect on the medial side (common) or anterior (rare) side of femoral sheath
Symptoms of femoral hernia
Dull dragging pain in groin with swelling
If obstructed, can cause vomiting and constipation
If strangulated, can lead to severe pain and shock
Swelling arises from below the inguinal ligament
Ddx for femoral hernia
Inguinal hernia
Saphenous varix
Enlarged femoral lymph node
Lipoma
Femoral artery aneurysm
Psoas abscess
Acquired umbilical hernia
Abdominal contents herniate through defect in the umbilicus
Common site of herniation, esp in women
A/w ascites, obesity, repeated pregnancies
Complications = strangulation of colon and omentum is common
- rupture occurs in chronic ascitic cirrhosis. emergency portal decompression needed
tx = surgical
- small partial defect - closed by loosely placed polypropylene suture
- large parital defect - managed with a prosthesis repair
- mayo hernioplasty is classical repair
Pediatric umbilical hernia
2/2 fascia defect in linea alba with protruding abdominal contents, covered by umbilical skin and subq tissue
Caused by failure of timely closure of umbilical ring, and leaves a central defect in linea alba
Common in infants
Incarceration is rare and reduction is contraindicated
Management of pediatric umbilical hernia
Usually close spontaneously within 3 years if the defect is 2cm
Child > 3-5yrs old
Protrusion is disfiguring and disturbing to child or parents
Esophageal hiatal hernia
Hernia in which an anatomical part (such as stomach) protrudes through esophageal hiatus in diaphragm
3 types:
1) Sliding hernia, type 1 = upward dislocation of cardia in the posterior mediastinum
2) Rolling or paraesophageal hernia, type 2 = upward dislocation of gastric fundus alongside a normally positioned cardia
3) Combined sliding-rolling or mixed hernia, type 3 - upward dislocation of both cardia and gastric fundus
End stage of type 1 and 2 hernias occurs when whole stomach migrates up into chest by rotating 180 degrees around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation, the abnormality is usually referred to as an intrathoracic stomach
Sliding esophageal hernia (type 1)
GE junction and stomach herniate into thoracic cavity
Accounts for 90% of hiatal hernias
Can lead to reflux and esophagitis that can predispose to Barrett’s
Management can be done medically with antacids and head elevation
Only 15% require surgery, consisting of wrapping of the stomach fundus around the LES (Nissen)
Paraesophageal hiatal hernia (type 2)
herniation of stomach into thorax by way of esophageal hiatus, without disruption of GEJ
Rare (
Richter’s hernia
Only part of intestine wall circumference is in hernia
May strangulate without obstruction
Seen in femoral and obturator hernias
Littre’s hernia
Hernial sac contains Meckel’s diverticulum. May become inflamed
Garengoff’s hernia
Hernial sac has the appendix
Importance is that it may form an inflamed hernia
Pantaloon hernia
Combo of direct and indirect straddling inferior epigastrics
Madyl’s hernia
W type of intestinal loop herniates
May strangulate with the gangrenous part being inside the abdomen, or may be reduced into the abdomen without noticing the gangrenous part
Spigelian hernia
Sac passes through the spigelian or semilunaris fascia
Sliding inguinal hernia
Any hernia in which part of the sac is the wall of a viscus. On the right, the cecum, ascending colon, or appendix is commonly involved.
In left, sigmoid is involved
Cooper’s hernia
involves femoral canal and tracts to the labia majora in females and to scrotum in males
Lumbar hernia
Divided into congenital, spontaneous, traumatic and incisional
Can pass through triangle of Grynfeltt, through inferior lumbar triangle, or previous incision
Perineal hernia
located through pelvic diaphragm, anterior (passes through labia majora) or posterior (male: enters the ischirectal fossa; females: close to vagina) to superficial transverse perineal muscle
Incisional hernia
from surgical complication
Could enlarge beyond repair
Associated with obesity, diabetes, and infection
Eventration hernia
loss of integrity of abdominal wall, reducing the intraabdominal pressure and resulting in external herniation of bowel
