hernias Flashcards
def hernia
The protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.
irreducible - contents can’t be pushed back into place
obstructed - bowel contents cannot pass - features of intestinal obstruction
strangulated - ischemia occurs, pt requires urgent surgery
incarceration - contents of the hernial sac are stuck inside by adhesions. Care must be taken with reduction as it is possible to push an incarcerated hernia back into the abdominal cavity, giving the initial appearance of successful reduction.
inguinal hernia
a loop of bowel or mesentery protrudes out from the abdomen via the deep inguinal ring, enters the inguinal canal first into the inguinal area and then into the scrotum.
indirect hernia
protrusion of the hernial sac through deep inguinal ring with coverings of spermatic cord, following path of inguinal canal
pass through internal ring and if large out of external ring
direct inguinal hernia
push their way directly forward through the transversalis fascia and posterior wall of the inguinal canal into a defect in the abdo wall (Hesselbach’s triangle, MEDIAL to the inferiro epigastric vessels and lateral to the rectus abdominus)
only pass through the superficial ring
femoral hernia
abnormal protusion of a peritoneal sac often with abdominal contents through the femoral canal
aetiology inguinal hernia
male > female
prematurity
age
obesity
bladder outflow obstruction
chronic cough
constipation
urinary obstruction
heavy lifting
ascites
past abdo surgery (eg damage ot the iliohypogastric nerve during appendectomy)
Indirect inguinal hernias are associated with a patent processus vaginalis, an invagination of the embryonic parietal peritoneum into the scrotum. This results in the formation of the inguinal canal which permits the testes to subsequently enter the scrotum from the abdomen. - usually closes but in some people stays open
muscle weakening can also explain why hernias are also more common at the sites of surgical incisions, ie. surgical scars. These are known as incisional hernias, and can easily be demonstrated on the abdomen, if present, by asking a patient to lift their torso off the examination couch without using their hands (almost as if they are doing a sit-up). The increased pressure within the abdomen will cause the viscera involved to pop outwards at the surgical scar.
aetiology direct hernia
acquired
weakening of transversalis fascia
- secondary to conditions resulting in increased intraabdominal pressure (e.g., chronic obstructive pulmonary disease with chronic coughing, constipation)
- long term glucocorticoid use
Hernial sac protrudes directly through the posterior wall of the inguinal canal (without involvement of the spermatic cord or round ligament of the uterus)
Only surrounded by the external spermatic fascia
through hesselbach triangle - inguinal ligament, inferior epigastric vessel, rectus abdominus
aetiolofgy indirect inguinal hernia
congenital
Most commonly results from incomplete obliteration of processus vaginalis during fetal development (but can also be acquired).
May not become apparent until adulthood despite being present since birth.
Surrounded by the external spermatic fascia, cremasteric muscle fibers, and internal spermatic fascia
aetiology femoral hernia
advancing age and female (wider angle between inguinal ligament and pectineal part of pubic bone, and wider femoral canal)
increased intra-abdominal pressure
- obestity
- constipation
- chronic cough
- straining during micturition (due to prostatic hypertrophy)
- straining due to prostatism
multiparity
previous abdo surgeries - especially thise involving the inguinal region
almost always acquired
protrusion of intraperitoneal contents along with the transverse abdominal fascia through the femoral ring into the femoral canal
aetiology miscellaneous hernia
weakness in the abdominal wall (eg due to obesity or previous surgery) and increased intraabdominal pressure eg coughing and straining allows formation of the hernial sac
RF hernia
obesity
abdominal distension eg ascites
post-op wound infection
path
inguinal pathology
- indirect, direct and a combination ‘pantaloon’ hernia
- indirect R more common than L - R testis descends later
femoral pathology
- narrow margins of canal predispose to incarceration of hernia contents - omentum, bowel, extraperitoneal fat or ovary
- vascular supply compromised - tissues become ischemic/gangrenous
epi hernia
inguinal - more in men than women, commonest type of hernia in both, 55-85yrs. 10 elective repairs per 10000 population in UK/yr
indirect > direct
femoral - occur more often in female, especially in middle age (40-70) and the elderly
indirect inguinal hernia occurs in approx. 2% infants, 4% of male births
sx inguinal hernia
visible, palpable groin protusion or bulge
inguinal pain - doesnt always correlate to the size of the hernia
Increase of symptoms during physical activity (walking or standing, coughing, sneezing, abdominal pressure)
disappears when pt lies down
irreducibility
epi miscellaneous hernia
incisional, epigastric and paraumbilical hernias are relatively common
umbilical hernias commonly seen in newborns - especially afro-caribbeans
sx femoral hernia
non complicated femoral
- a globular, subcutaneous swelling in groin - inferior to inguinal ligament, lateral to pubic tubercle and medial to femoral vein
- swelling enlarges with coughing
- possible non-specific dragging pain
- lower abdo discomfort
small so often present with strangulation/obstruction = surgical emergency
- pain
- abdo distension
- nausea
- vom
- absolute constipation
sx miscellaneous hernia
may be asymptomatic
pts may notice lump themselves
may present because of discomfort, irreducibility, increase in size, pain or for cosmotic reasons
strangulated hernias - painful, red and swollen
obstruction - constipation, colicky abdo pain, nausea, vomiting.
Richter hernias have symptoms of obstruction but still pass flatus as the bowel lumen is still patent.
sign femoral
bowel enters the femoral canal - presents as mass in upper medial thigh or above the inguinal ligament pointing down leg
likely to be irreducible and strangulate because of the rigidity of the borders of the femoral canal
swelling in groin below and lateral to pubic tubercle - if large may spread up and over the inguinal ligament
absence of cough reflex over inguinal ring
if incarcerated/strangulated = tender
signs of bowel obstruction - distention, high pitched bowel sounds
sign inguinal
points to the groin
Indirect inguinal hernia may be associated with a communicating hydrocele
groin lump - may extend to scrotum or labia
emerge above and medial to pubic tubercle
standing hernia associated with cough impulse
indirect may be controlled by pressure over deep ring
auscultation might show bowel sounds in hernia
may be irreducible if incarcerated
very tender if strangulated
signs of complications - bowel obstruction, systemic upset, pyrexia and tachycardia
deep (internal) ring
midpoint of the inguinal ligament approx 1.5cm above the femoral pulse which crosses the mid inguinal point
superficial (external) ring
split in the external oblique aponeurosis just superior and medial to pubic tubercle - the bony prominence forming medial attachment of the inguinal ligament
sign, miscellaneous hernia
have a cough reflex (owing to transmitted pressure from the abdomen)
can be reduced (pushed back) into the abdomen.
abnormal swelling that increases in size with coughing or abdominal straining
often non-tender and soft
may become tender and irreducible if incarcerated or strangulated
assess for bowel sounds, or signs of obstruction in acute presentation
inguinal hernia ix
look for previous scars
feel other side - more common on R
examine external genitalia
ask if the lump is visible, if so ask the patient to reduce it - if they cant make sure not a scrotal lump
if no lump visible feel for cough impulse
repeat exam with ot standing
FBC, U&Es, CRP, clotting, G&S if operation likely
ABG indicate bowel ischemia in hernia - met acidosis and high lactate
US - visualisation of the hernial orifice and hernial contenst may be possible, exclude other groin lumps
erect CXR and AXR
CT/MRI - to distinguish from ddx in difficult cases
however typically diagnosed on history and exam
distinguishing direct from indirect
reduce the hernia and occlude the deep ring with 2 fingers (midpoint of inguinal ligament - between ASIS and pubic tubercle)
ask pt to cough or stand
if hernia is restrained it is indirect, if not it is direct
gold standard for determining is at surgery - direct are medial to inferior epigastric vessels, indirect are lateral
ix femoral
mainly clincal diagnosis
FBC, U&Es, clotting G&S
ABG
AXR - may show small bowel obstruction
groin US used when ddx is inconclusive
difficult to palpate in obese pts - do US
ix miscellaneous
may be diagnosed on clinical examination
or if in doubt - USS, CT
on an acute abdo
- AXR
- erect CXR
bloods - FBC, U&Es clotting, G&S, ABGs (metabolic acidosis of vascular compromise to hernias)
If incarcerated lactate will have increased - acidotic
Mx femoral hernia
emergency
- resus important - rehydration and correction of electrolyte imbalance
- NG tube if vom
- AB if sepsis
surgical repair is recommended
principles involve dissection of the sac, observing and reducing the contents, excising the sac and repairing the defect, usually by approximation of the inguinal and pectineal ligaments using non-absorbable sutures
- low transverse incision over hernia
- transinguinal incision above and parallel to inguinal ligament, through external oblique, inguinal canal and transversalis fascia (may have higher recurrence rate)
- high - oblique, paramedial or unilateral Pfannenstiel incision opening the rectus sheath, retracting rectus medially and dividing transversalis to expose femoral canal
- if strangulation suspected
- sac opened and contents inspected
- if viable = reduced
- if non-viable = resected
herniotomy is ligation and excision of the sac
herniorrhaphy is repair of the hernial defect
use mesh for non-complicated
for complicated - herniorrhaphy (non-mesh repai
Mx inguinal hernia
weight loss if overweight, smoking cessation pre-op
warn that hernias may reoccur and warn of chronic pain post op possibilities
surgical - elective repair for uncomplicated hernias - LA, epidural, spinal or GA
emergency
- in obstructed or strangulated hernia
- laparotomy with bowel resection may be indicated if gangrenous bowel present
- mesh might not be suitable
mesh techniques (eg lichtenstein repair) have replaced older methods
- a polypropylene mesh reinforces the posterior wall
- recurrence rate is less than with other methods
- contraindications: strangulated hernias, contamination with pus/bowel contents
- oblique incision over inguinal lig, open external oblique aponeurosis and free spermatic cord
- indirect sac is dissected from the cord, opened (herniotomy) and contents reduced
- sac is excised and defect repaired - mesh reinforce defect in transversalis fascia
LA and day case techniques reduce cost
laproscopic repair gives similar recurrence rates, earlier recovery and return to life
- transabdominal pre-peritoneal (TAPP) - the peritoneum is entered and the hernia is repaired
- Totally extraperitoneal (TEP) decreases risk of visceral injury
inguinal return to work
depend ofn the surgical approach and the patient
rest for 4wks and convalescence over 8wks for open repair
in lapro - might be able to return <2wks if all well
mx irreducible hernia
try and reduce them to prevent strangulation and necrosis which would demand prompt laparotomy
use the flat of hand and direct hernia from below, up towards the contralateral shoulder
mx miscellaneous hernia
conservative - asymptomatic hernias with large neck might need no treatment
surgical - elective correction is indicated for umbilical hernias persisting past 2 yrs of age, narrow necked hernias, irreducible hernias
- the hernial sac is excised adn repair can be reinforced with a mesh
- emergency operation may be indicated in incarcerated or strangulated cases
complications inguinal
if loop of bowel or mesentary gets stuck
tehn wont be reducible and no cough reflex
GI contents wont be able to pass through = intestinal obstruction (MECHANICAL SMALL BOWEL DILATATION - bowel sounds increased ie tinkling - surgical management)
- cause accumulation of fluid in 3rd space = hypovolaemia and shock
this is INCARCERATION
hernia may feel hard
blood drainage and blood supply to and from the viscus can be comprimised = ischemia = infarction
- this is STRANGULATION
- there is tenderness over hernia
- signs and symptoms of peritonitis caused by bacteria/colonic material escaping from the necrotic bowel if this enters the abdo cavity
the patient will eventually have to go to theatre in order to free the bowel from the hernial oricfice. If any bowel has infarcted, it will need to be resected at the same time.
Maydl’s hernia (strangulated W-shaped small bowel loop)
Richter’s hernia (strangulation of only part of the bowel wall circumference).
mx incarcerated hernia
cannula
ox and IV fluid
urethral catheter with a urimeter
NG tube
sx of strangulation
symptoms of bowel obstruction
symptoms of intestinal necrosis
ischemia and gangrene
possible intestinal perforation and/or peritonitis
possible systemic inflammatory response syndrome
complications femoral
Incarceration: irreducible femoral hernia due to trapped hernia contents in hernia sac
Richter hernia: herniation of only a part of the circumference of the bowel wall.
Strangulation: ischemic necrosis of contents within the hernia sac as blood flow is compromised due to incarceration (dont reduce otherwise cause generalised peritonitis)
Features of paralytic ileus supervene once bowel perforation and/or peritonitis develop
Possibly fever, leukocytosis, and hemodynamic instability
Features of mechanical bowel obstruction
Warm, tender, and erythematous/discolored swelling
complications miscellaneous
strangulation of bowel, bowel obstruction
epigastric hernias and obturator hernias are most likely to strangulate due to narrow necks
complication femoral surgery
lacunar ligament can be incised - occaisionally causing bleeding from an aberrent obturator artery medially
complication inguinal surgery
- pain
- wound infection
- haematoma
- penile or scrotal oedema
- nerve damage or neuroma formation
- osteitis pubis
- mesh infection
- testicular ischemia
- recurrence
Px hernia
miscellaneous
- majority of umbilical hernias regress by 2yrs of age
- other hernias dont and they generally enlarge
inguinal
- slowly enlarge if left alone
- annual risk of strangulation 0.3-3%
- surgical mesh repair good outcome with recurrence <5% cases
femoral
- outcome generally good with prompt and appropriate surgery
- recurrence after repair <3%
