hernias

Question 1

def hernia

Answer 1

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.

Question 2

inguinal hernia

Answer 2

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.

Question 3

indirect hernia

Answer 3

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

Question 4

direct inguinal hernia

Answer 4

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

Question 5

femoral hernia

Answer 5

abnormal protusion of a peritoneal sac often with abdominal contents through the femoral canal

Question 6

aetiology inguinal hernia

Answer 6

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.

Question 7

aetiology direct hernia

Answer 7

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

Question 8

aetiolofgy indirect inguinal hernia

Answer 8

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

Question 9

aetiology femoral hernia

Answer 9

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

Question 10

aetiology miscellaneous hernia

Answer 10

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

Question 11

RF hernia

Answer 11

obesity

abdominal distension eg ascites

post-op wound infection

Question 12

path

Answer 12

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

Question 13

epi hernia

Answer 13

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

Question 14

sx inguinal hernia

Answer 14

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

Question 15

epi miscellaneous hernia

Answer 15

incisional, epigastric and paraumbilical hernias are relatively common

umbilical hernias commonly seen in newborns - especially afro-caribbeans

Question 16

sx femoral hernia

Answer 16

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

Question 17

sx miscellaneous hernia

Answer 17

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.

Question 18

sign femoral

Answer 18

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

Question 19

sign inguinal

Answer 19

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

Question 20

deep (internal) ring

Answer 20

midpoint of the inguinal ligament approx 1.5cm above the femoral pulse which crosses the mid inguinal point

Question 21

superficial (external) ring

Answer 21

split in the external oblique aponeurosis just superior and medial to pubic tubercle - the bony prominence forming medial attachment of the inguinal ligament

Question 22

sign, miscellaneous hernia

Answer 22

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

Question 23

inguinal hernia ix

Answer 23

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

Question 24

distinguishing direct from indirect

Answer 24

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

Question 25

ix femoral

Answer 25

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

Question 26

ix miscellaneous

Answer 26

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

Question 27

Mx femoral hernia

Answer 27

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

Question 28

Mx inguinal hernia

Answer 28

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

Question 29

inguinal return to work

Answer 29

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

Question 30

mx irreducible hernia

Answer 30

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

Question 31

mx miscellaneous hernia

Answer 31

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

Question 32

complications inguinal

Answer 32

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).

Question 33

mx incarcerated hernia

Answer 33

cannula

ox and IV fluid

urethral catheter with a urimeter

NG tube

Question 34

sx of strangulation

Answer 34

symptoms of bowel obstruction

symptoms of intestinal necrosis

ischemia and gangrene

possible intestinal perforation and/or peritonitis

possible systemic inflammatory response syndrome

Question 35

complications femoral

Answer 35

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

Question 36

complications miscellaneous

Answer 36

strangulation of bowel, bowel obstruction

epigastric hernias and obturator hernias are most likely to strangulate due to narrow necks

Question 37

complication femoral surgery

Answer 37

lacunar ligament can be incised - occaisionally causing bleeding from an aberrent obturator artery medially

Question 38

complication inguinal surgery

Answer 38

• pain
• wound infection
• haematoma
• penile or scrotal oedema
• nerve damage or neuroma formation
• osteitis pubis
• mesh infection
• testicular ischemia
• recurrence

Question 39

Px hernia

Answer 39

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%