Herniae

Question 1

What is a hernia?

Answer 1

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.

Question 2

What is hiatus hernia?

Answer 2

A hiatus hernia describes the protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus, typically the stomach

Question 3

how are hiatus hernias classified?

Answer 3

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

Question 4

How does a hiatus hernia present

Answer 4

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)

Question 5

What are the differentials for a patient presenting with epigastric pain

Answer 5

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

Question 6

How is a suspected hiatus hernia investigated?

Answer 6

OGD - gold standard
Contrast swallow - less commonly used
Breath test to rule out H.pylori for GORD
Bloods - if bleeding check for anaemia

Question 7

How are hiatus hernias managed?

Answer 7

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

Question 8

When should PPIs be taken and why

Answer 8

in the morning before food because otherwise the drug binding sit becoms internalised and ineffective

Question 9

What are the complications of surgery for a hiatus hernia

Answer 9

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

Question 10

What are the complications of having a hiatus hernia?

Answer 10

Rolling type is prone to strangulation and incarceration

Gastric volvulus can occur - stomach twists 180 degrees leading to obstruction and tissue necrosis

Question 11

How does a gastric volvulus present?

Answer 11

Typically by Borchadts Triad

• severe epigastric pain
• retching without vomiting
• inability to pass a NG tube

Question 12

What are the two types of inguinal herniae

Answer 12

Direct - bowel enters directly into the inguinal canal through a weakness in Hasslebachs triangle
Indirect - bowel enters inguinal canal via deep inguinal ring

Question 13

Which patients are more likely to develop direct inguinal herniae

Answer 13

Elderly due to laxity in abdominal wall or significant increases in intra-abdominal pressure

Question 14

What is the cause of an indirect inguinal hernia

Answer 14

Incomplete closure of the processus vaginalis - an outpouching of the peritoneum allowing for embryonic testicular descent (deemed congenital in origin)

Question 15

Where will a direct inguinal hernia be in relation to the inferior epigastric vessels

Answer 15

Direct herniae will be medial

Question 16

Where will an indirect inguinal hernia be in relation to the inferior epigastric vessels

Answer 16

Indirect herniae will be lateral to the vessels

Question 17

What are the risk factors for developing an inguinal hernia

Answer 17

Male
Increasing Age
Raised intra-abdominal pressure - chronic cough, heavy lifting, chronic constipation
Obesity

Question 18

What is the most common presentation of an inguinal hernia

Answer 18

Lump in groin
if reducible will disappear on lying down or minimal pressure
Mild-moderate discomfort which can worsen with activity or standing

Question 19

How would a incarcerated inguinal hernia present

Answer 19

Erythematous, painful and tender

Bowel may become blocked - presents as bowel obstruction - abdominal distension, vomiting and absolute constipation

Question 20

Which specific features should be examined in a patient with an inguinal hernia

Answer 20

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

Question 21

What are the differentials for an inguinal hernia

Answer 21

Femoral hernia 
Saphena varix 
Lymphadenopathy
Lipoma 
Groin abscess
Internal iliac artery aneurysm 

If enters the scrotum consider hydrocele, variocele or a testicular mass

Question 22

How are inguinal hernias managed

Answer 22

Surgical repair - if significant discomfort or mass

If evidence of strangulation then urgent surgical exploration needed

Question 23

What are the symptoms of a strangulated hernia

Answer 23

Irreducible tender lump
Pain often out of proportion to clinical presentation 
May be clinical features of obstruction 
- abdo pain and distension 
- vomiting 
- absolute constipation

Question 24

What are the main complications of an inguinal hernia

Answer 24

Obstruction
Strangulation
incarceration

Question 25

What are the post op complications of inguinal hernia repair

Answer 25

Infection 
VTE 
Anaesthetic effects - nausea and vomiting, allergy 
Haematoma and bruising 
Pain 
Recurrence 
Chronic pain 
Damage to vas deferens or testicular vessels