hernias Flashcards
What is an umbilical hernia?
Defect in anterior abdominal wall - umbilical ring fails to close ( abdominal contents herniates through this )
APPEARANCE / FEATURES
0 Bulge at umbilicus - overlying skin intact
0 Present since birth
0 easily reducible hernial sac - on digital exam.
RISK FACTORS
- Low birth weight
- African American ancestry.
Umbilical ring - ring surrounds the umbilicus at birth and during development. (supposed to close shortly after birth)
Diagnosis and treatment of umbilical hernia ?
Diagnosis - clinical
TREATMENT
0 Incarcerated hernia
1ST LINE
- surgical repair following attempted reduction (reduction attempted if absence of peritonitis)
(if individual suspected with incarcerated hernia with/ out strangulation treated immediately regardless of size and age.
- if reduced admitted for observation of peritonitis ) ——-> surgical repair next day.
- not reduced - emergency repair.
KEY TERMS
- Incarcerated - abdominal contents trapped in protruding hernial sac.
Strangulation - blood supply compromised causing ischemia.
0 Large or symptomatic hernia
- > 1.5 to 2cm - unlikely to close.
- Surgical repair (elective , outpatient)
0 Small / asymptomatic
< 1.5 cm until 4 to 5 years - 80 % will have closed by then.
(IF INCARCERATES DURING THIS TIME - REFER TO INCARCERATED MANAGEMENT)
1ST LINE - Observation 2ND LINE -Surgical repair (IF PERSIST BEYOND 4 TO 5)
What is an inguinal hernia ?
MOST COMMON
Abdominal contents enters into inguinal canal. creating a easily palpable bulge.
TYPES
0 Direct - entry through weakness in posterior wall of canal
(abdominal wall laxity (looseness or increased inta - abdominal pressure)
0 Indirect - more common - entry through deep inguinal ring.
(NORMALLY CONGINETAL - Processus vaginalis (PV) fails to close/oblierate - hernia occurs)
PV - outpouching of peritoneum attached to testicle as it descends during development)
Clinical test to differentiate :
Indirect - press on deep ring (mid line of inguinal ligament) - you can control the indirect hernia which has been reduced
Direct - same thing is done, but hernia still protrudes indicates it is merging through posterior inguinal wall defect.
APPEARENCE / FEATURES
0 Bulge Superiomedal to pubic tubercle
0 groin mass / discomfort
RISK FACTORS
0 Male sex - more common
0 Old age
0 Smoking (leads to generalized defects in groin leading to hernias
———- also smoke activates leukocytes ——–> increaseds levels of zymogen poteases ——–> all this and toxins————> peripheral collagenolysis. )
0 Abdominal aortic aneurysm - increased leukocytes and protelytic activity - same as smoking)
0 Previous right lower Q incision e.g Appendectomy (increased risk of right sided H)
0 Premature babies
0 FHx of hernias
0 Marfan/ Ehlos Danlos syndpme
(connective tissue disorders)
0 Chronic coughing e.g Chronic bronchitis , emphysema
0 Defective Transveralis fascia (final barrier preventing inguinal hernia)
0 Lathyrism - neurotoxic disease associted with connective tissue abnormalities and groin herniation.
( causes by consumption of some types legumes)
Diagnosis of Inguinal hernias ?
Diagnosis - Clinical
Ultrasound/ MRI if uncertain
- CT scan - in obese patients - valsalva maneuver can been also done during imaging.
Treatment of Inguinal hernias
INCARCERATED / STRANGULATED -
0 1ST LINE
- Surgical repair
( if strangulated - always open surgery vs Laproscopic)
- mesh repair sould not be used if contamination found during surgery e.g gangrenous - risk of mesh infection)
ADJUNCT - PROPHYLACTIC ANTIBIOTIC THERAPY.
Cefazolin - IM/IV - recommended but others can be used
- Vancomycin added - if patient known to have MRSA
SMALL , ASYMPTOM
- Watchful waiting
LARGE , SYMPTOMATIC -
unilateral hernia
0 1ST LINE - open mesh or laparoscopic repair
ADJUNCT - Proph antibiotic T
bilateral hernia
0 1ST LINE
Laproscopic mesh repair - also with reoccurance after open surgery
- NO ANTIBIOTIC PROPH FOR THIS - NOT RECOMMENDED.
NON SURGICAL CANDID
1ST LINE
TRUSS or observation.
- TRUSS - device compresses tissue over inguinal canal after it has been reduced and symptoms been alleviated.
(hernia can become strangulated in TRUSS)
What is a femoral hernia?
LIE INFEROLATERAL TO PUBIC TUBERCLE (vs supermedial - inguinal)
Femoral hernia - Abdominal contents pokes through weakness in abdominal wall into groin via femoral ring & canal
APPEARANCE - painful lump in inner thigh / groin
- Inferiorlateral to pubic tubercle
CAUSES
- strain on stomach e.g constipation / carrying heavy loads
RISK FACTORS
more common in men but in women this the most common type.
- Age - especially older women (wider shape of female pelvis)
- Pregnancy - higher incidence in multiparous women.
Treatment of Femoral hernia?
Surgery almost always recommended straight away - (within 2 weeks ) high risk of complications
(OBSTRUCTION - bowel stuck in femoral canal - cause nausea and vomiting ,painful lump.
HIGH RATE OF STRANGULATION
- 30% present as am emergency
- unlikey to be reducible bcc of the tightness of the femoral ring.
Femoral hernia Diagnosis ?
Clinical
diagnosis
Imaging can be done to confirm
- ulrasound
- CT abdomen pelvic scan
What is a hiatal hernia ?
Abdominal contents (commonly - Stomach , less commonly- Transverse C , omentum , small I , Spleen ) protrudes through enlarged esophageal hiatus of stomach.
SIGNS
- Heartburn
(Sliding hernia - mostly , may or may not happen with other type) - Regurgatation
Uncommon
Shortness of breath
(lung compression - space occupied by hernia)
Acid reflux - cause oesophageal irritation lead to: 0 Haematemesis - Cause Oesophagitis -----> leads to : 0 odynophagia (painful swallowing) 0 Dysphagia - Cause oesphageal spasm -----> lead to ; Chest pain (can be mistaken for cardiac pain)
other things like wheezing , fever, chills , confusion - complicated hiatal hernia.
Types of hiatal hernia ?
Sliding hernia - (80%) stomach/ section of esophagus attached to stomach - slide up through hiatus
(RISK FACTOR FOR GORD)
Paraoesophageal / rolling - stomach fundus goes through hiatus and sits along side esophagus. (bubble of stomach in thorax)
RISK FACTORS of hiatal hernia?
0 Obesity 0 increased intra abdominal pressure. 0 Male 0 abnomalities of hiatus or ligaments. 0 History other hernia (not femoral) 0 Iatrogenic - previous gastro- oesphagael (e.g hiatal repair.
Diagnsosis & Investigation of hiatal hernia ?
0 CXR
0 Upper gastrointestinal series - standard criterion test for moderate to severe symptoms.
Treatment of hiatal hernia ?
Hiatal hernia + upper GI haemorrage
0 Resuscitation & urgent surgical repair
Irreversible organ ischemia /necrosis
- resection of damage organ , supportive care.
if GORD present - PPI , Lifestyle changes.
