Herniae Flashcards
What is a hernia?
A hernia is defined as the protrusion of a whole or part of an organ through the wall of the cavity that contains it into an abnormal position.
What is hiatus hernia?
A hiatus hernia describes the protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus, typically the stomach
how are hiatus hernias classified?
Sliding (80%) - the gastro-oesophgeal junction and the cardia slide upwards through the diaphragmatic hiatus into the thoarx
Rolling (20%)- upward movement of the fundus which lies alongside the gastro-oesophageal junction, creates a bubbleof stomach in the thorax
How does a hiatus hernia present
Most are asymptomatic
may present with reflux symptoms e.g. burning epigastric pain
Other signs and symptoms that may occur are
- vomiting and weight loss (a rare but serious presentation)
- Bleeding/anaemia (secondary to oesophageal ulceration)
- hiccups or palpitations (if hernia is big enough it can irritate the diaphragm and the pericardium)
- Swallowing difficulties (strictures)
What are the differentials for a patient presenting with epigastric pain
GORD
Hiatus hernia causing reflux
Cardiac pain
Gastric or pancreatic cancer if there is also early satiety, vomiting, weight loss - evidence of gastric outlet obstruction
How is a suspected hiatus hernia investigated?
OGD - gold standard
Contrast swallow - less commonly used
Breath test to rule out H.pylori for GORD
Bloods - if bleeding check for anaemia
How are hiatus hernias managed?
Conservatively
- Weight loss
- Low fat diet, smaller portions, earlier meals
- Smoking cessation
- Reduce alcohol
- Reduce spicy food
- PPIs to reduce gastric acid secretions
Surgical
- curoplasty - hernia is reduced back into the abdomen and hiatus reapproximated to the correct size
- fundiplication - gastric fundus is wrapped around the lower oesophagus making the LOS stronger
When should PPIs be taken and why
in the morning before food because otherwise the drug binding sit becoms internalised and ineffective
What are the complications of surgery for a hiatus hernia
Recurrence
Abdominal bloating - unable to belch, so increased flatus
Dysphagia - if fundus is wrapped too tight around the oesophagus
Fundal necrosis - if the blood supply from the left gastric and short gastrics have been disrupted
What are the complications of having a hiatus hernia?
Rolling type is prone to strangulation and incarceration
Gastric volvulus can occur - stomach twists 180 degrees leading to obstruction and tissue necrosis
How does a gastric volvulus present?
Typically by Borchadts Triad
- severe epigastric pain
- retching without vomiting
- inability to pass a NG tube
What are the two types of inguinal herniae
Direct - bowel enters directly into the inguinal canal through a weakness in Hasslebachs triangle
Indirect - bowel enters inguinal canal via deep inguinal ring
Which patients are more likely to develop direct inguinal herniae
Elderly due to laxity in abdominal wall or significant increases in intra-abdominal pressure
What is the cause of an indirect inguinal hernia
Incomplete closure of the processus vaginalis - an outpouching of the peritoneum allowing for embryonic testicular descent (deemed congenital in origin)
Where will a direct inguinal hernia be in relation to the inferior epigastric vessels
Direct herniae will be medial
Where will an indirect inguinal hernia be in relation to the inferior epigastric vessels
Indirect herniae will be lateral to the vessels
What are the risk factors for developing an inguinal hernia
Male
Increasing Age
Raised intra-abdominal pressure - chronic cough, heavy lifting, chronic constipation
Obesity
What is the most common presentation of an inguinal hernia
Lump in groin
if reducible will disappear on lying down or minimal pressure
Mild-moderate discomfort which can worsen with activity or standing
How would a incarcerated inguinal hernia present
Erythematous, painful and tender
Bowel may become blocked - presents as bowel obstruction - abdominal distension, vomiting and absolute constipation
Which specific features should be examined in a patient with an inguinal hernia
Cough impulse - irreducible hernia may not have a cough impulse
Location - inguinal - superomedial to the pubic tubercle
Reducible - on lying down and with or without minimal pressure
If it enters the scrotum can you get above it/is it separate from the testis
What are the differentials for an inguinal hernia
Femoral hernia Saphena varix Lymphadenopathy Lipoma Groin abscess Internal iliac artery aneurysm
If enters the scrotum consider hydrocele, variocele or a testicular mass
How are inguinal hernias managed
Surgical repair - if significant discomfort or mass
If evidence of strangulation then urgent surgical exploration needed
What are the symptoms of a strangulated hernia
Irreducible tender lump Pain often out of proportion to clinical presentation May be clinical features of obstruction - abdo pain and distension - vomiting - absolute constipation
What are the main complications of an inguinal hernia
Obstruction
Strangulation
incarceration
What are the post op complications of inguinal hernia repair
Infection VTE Anaesthetic effects - nausea and vomiting, allergy Haematoma and bruising Pain Recurrence Chronic pain Damage to vas deferens or testicular vessels
