Hernias Flashcards
Direct and indirect inguinal hernias
- Direct: directly through the posterior wall of the inguinal canal. Medial to inferior epigastric vessels.
- Indirect: into the inguinal canal through the deep inguinal ring. Lateral to inferior epigastric vessels.
Perineal hernias
Obturator hernias
- Most common in women, particularly those with a history of recent weight loss
- Palpable in mid-thigh when the hip is flexed, externally rotated, and abducted (lithotomy position)
- Howship-Romberg sign: Positive in 50% of cases of obturator hernias. Pain along the inner thigh produced by the above movement (hip flexion, abduction, external rotation). Effective obturator neuralgia produced by nerve entrapment.
Sciatic hernias
Lumbar hernias
Spigelian hernia
Epigastric hernia
__ is indicated for all patients with acutely complicated inguinal hernia
Open surgical repair is indicated for all patients with acutely complicated inguinal hernia
The vast majority of congenital umbilical hernias . . .
. . . will spontaneously resolve by age 5
Presentation of uncomplicated vs incarcerated hernia
- Uncomplicated: “Heaviness”, “discomfort” in an area chronically
- Incarcerated: Acute occurence of pain (the incarceration event)
Subtle difference between inguinal and femoral hernias
- The femoral hernia will appear below the inguinal ligament
- The direct inguinal hernia will appear above the inguinal ligament
- The indirect inguinal will appear at the scrotum or labia
Littre hernia
- Hernia that contains a Meckel diverticulum
- Congenital
- Aka “persistent omphalomesenteric duct hernias”
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Amyand’s hernia
When an inguinal hernia contains the appendix
De Garengeot’s hernia
When a femoral hernia contains the appendix
Richter’s hernia
Herniation of the bowel through any hernia defect
The three triangles (Hesselbach’s, Pain, Doom)
Sliding hernia
- Indirect inguinal hernia which contains colon (L) or cecum (R)
- High ligation of the sac without knowing its contents can cause ischemic injury to the intestine within the sac
Hesselbach’s triangle
Femoral canal
Which type of inguinal hernia has the highest rate of incarceration/obstruction?
Femoral
Due to the small diameter of the femoral canal and the rigidity of its surrounding structures
That is why watchful waiting is not indicated for femoral hernias
Inguinal hernias: Which do you watch and which do you send to the OR?
- Any hernia that is incarcerated: Urgent OR
- Any hernia that is strangulated: Emergent OR
- Femoral hernia: Elective OR
- Moderately symptomatic hernia: Elective OR
- Asymptomatic or minimally symptomatic direct or indirect inguinal henria (NOT femoral): Watch and wait
Chronic pain following hernia repiar
- A significant complication of the procedure
- More common in young adults and in women
- Possible etiologies:
- Hernia recurrence (1-5%)
- Mesh-related pain (tends to be motion-related, treat w/ anti-inflammatories. If severe, remove mesh)
- Nerve irritation (treat w/ gabapentinoids)
- Infection
If you are going to repair a hernia with mesh, you should also. . .
. . . cut the ilioinguinal nerve, to avoid the likely complication of ilioinguinal neuritis.
Or at least offer this to the patient.
Inguinal hernias tend to occur on the __ side, because __
Inguinal hernias tend to occur on the right side, because
Telling apart inguinal hernias
You can tell apart femoral from true inguinal, but you cannot distinguish direct from indirect inguinal on exam. Both direct and indirect inguinal can go to the groin.
Inguinal canal nerves
Ilioinguinal
Iliohypogastric
Genital branch of genitofemoral
Contraindications to inguingal hernia repair
- Pregnancy
- Infection
- Ascites
Nerves in the triangle of pain
Lateral femoral cutaneous nerve (on psoas muscle)
Genital branch of genitofemoral
Structures in triangle of doom
Iliac vessels
Tension free repair
New paradigm for hernia repair
If tension is left, it will just tear again!
Below the arcuate line, there is no. . .
. . . posterior sheath
Transverse section of abdominal wall
