Herniae Flashcards
What is a herniae?
The protrusion of an organ/part of an organ through a defect in the wall of the cavity containing it, into an abnormal position
Define reducible
The contents of the hernia can be completely replaced into the cavity
Define irreducible
The contents of the hernia cannot be completely replaced into the cavity
Define obstructed
Bowel contents cannot pass through the herniated bowel
Define strangulated
There is ischaemic of the contents of the hernia, which unless relieved will lead to gangrene and perforation
Define incarcerated
The contents of the hernia sac are stuck inside by adhesions
What is a direct inguinal hernia?
1/3 inguinal hernia
Acquired
Contents pass through a weakness of the anterior abdominal wall in the inguinal triangle
What is an indirect inguinal hernia?
2/3 inguinal hernia
Congenital
Contents pass through the inguinal canal due to a patent processus vaginalis
Where do indirect inguinal hernias exit the superficial ring?
Inside the cord - often pass into scrotum/labia majorus
Where do direct inguinal hernias exit the superficial ring?
Lateral to the cord
What factors predispose to the development of inguinal hernias?
Patent processus vaginalis (indirect) Chronic cough Straining at micturition/defecation Heavy lifting Smoking
What are the signs of bowel obstruction in a hernia?
Tinkling bowel sounds
Constipation
Build up of faecal matter
Which inguinal herniae are more likely to strangulate?
Indirect inguinal herniae
Which inguinal herniae are covered by the spermatic fascia?
Indirect inguinal herniae
What is a femoral herniae?
Herniation of viscus through the femoral canal
What are the symptoms of a femoral herniae?
50% present as a surgical emergency - obstruction
50% present as a globular lump inferolateral to the pubic tubercle
Cough impulse often absent
What is an umbilical herniae?
Hernia present at the umbilicus
What are the two main types of umbilical herniae?
True umbilical herniae
Paraumbilical herniae
Describe a true umbilical herniae
Occur in 3% of live births Result of a defect in the transversalis fascia at the umbilical ring - incomplete closure of the umbilical cicatrix Covered by skin Generally asymptomatic 90% retract by 2 yrs
Describe a paraumbilical herniae
Acquired herniae above/below umbilicus
Caused by raised IAP
Managed early w/ Mayo’s operation
What are the symptoms of a true umbilical herniae?
Generally asymptomatic
Rarely strangulate/obstruct
What are the symptoms of a paraumbilical herniae?
Localised dragging pain Enlarging herniae over time Tender w/ colic from intermittent obstruction Often reducible Commonly strangulate/obstruct
What are the signs of strangulation?
Nausea/vomiting Fever Sudden pain Change in colour of hernia Inability to pass stool/gas
What are incisional herniae?
Herniae arising due to a weakness in the abdominal wall post surgery
How common are incisional herniae?
10% of herniae
1% of abdominal incisions followed up by a herniae
What are the pre-op risk factors for incisional herniae?
Age Poor nutrition Sepsis Uraemia Jaundice Obesity Steroids
What are the operative risk factors for incisional herniae?
Vertical incisions
Knots too lose/tight
Presence of drains
What are the post-op risk factors for incisional herniae?
Post op ileus
Coughing
Obesity
Wound infection
What are the Sx of an incisional herniae?
Bulge/local discomfort
Subacute bowel obstruction
Adhesions often develop –> irreducible –> obstruction/strangulation
What is an epigastric herniae?
Small protrusions through the linea alba superior to the umbilicus, usually only containing extra peritoneal fat
What are the Sx of an epigastric herniae?
75% asymptomatic
Occasionally painful (worse on exertion/after meals)
-indicates some degree of strangulation
What is a divarification of the rectus muscle?
Rectus muscles do not met in the midline at the linea alba
Muscles split apart when the patient flexes the abdominal muscles
NO SURGICAL INDICATION
What are the management principles for pts with hernias?
Reduce hernia to prevent obstruction/strangulation
If irreducible then elective surgery considered
-lichtenstein repair mesh technique
If obstructed/strangulated
-emergency Hartmann’s
If congenital inguinal hernias
-herniotomy
-ligation of processus vaginalis at 1yr
In which pts are inguinal herniae more common?
Males
-indirect affect a young population
In which pts are femoral herniae more common?
Women
What is the most common type of hernia in women?
Indirect inguinal hernia
What is Richter’s hernia?
Hernia involving only one sidewall of the bowel and not the lumen
- results in strangulation/perforation w/o warning signs
- likely in femoral sac
How is the inguinal canal formed?
Relocation of testes during foetal development
Where is the inguinal canal?
Parallel & medial to inguinal ligament
What does the inguinal canal contain?
3 arteries -testicular/ovarian -artery to vas def -cremasteric artery 3 nerves -genital branch of genitofemoral -ilioinguinal -sympathetic 3 structures -vas def/round ligament of uterus -pampiniform plexus -testicular lymphatics
What are the three fascial coverings of the inguinal canal?
Internal spermatic fascia (from transversalis) Cremasteric fascia (from IO) External spermatic (from EO)
What is the deep inguinal ring?
Entrance to inguinal canal
-just above mid point of inguinal ligament (ASIS-PT)
What is the superficial inguinal ring?
Exit of inguinal canal
-just superolaterla to PT
What are the boundaries of the inguinal canal (MALT)?
Sup wall = 2 MUSCLES -IO -transversalis abdominus Ant wall = 2 APONEUROSES -EO -IO Inf wall = 2 LIGAMENTS -inguinal -lacunar Post wall = 2 T's -transversalis fascia -conjoint tendon
What structures form the femoral triangle?
Sup -inguinal ligament Lat -medial border of sartorius Med -lateral border of adductor longus
What structures does the femoral triangle contain?
Femoral nerve
Femoral artery
Femoral vein
What is the femoral sheath?
Inferior prolongation of transversalis/iliopsoas fascia
- passes deep to inguinal ligament
- allows passage of femoral aa/vv into femoral triangle
What is the femoral canal?
Lies at medial extremity of femoral sheath
Site of femoral hernia
Where does the bowel exit the abdominal cavity?
Through the femoral ring
