Hernias

Question 1

What is divarication of the recti

Answer 1

Cosmetic condition caused by the weakening and widening of the linea alba

Key difference between hernia and divarication of the recti is that the linea alba is stretched and weakened but is intact

Question 2

What are epigastric hernia typically secondary to

Answer 2

Raised chronic intra-abdominal pressure, such as with obesity, pregnancy, or ascites

Question 3

What are paraumbilical hernia typically secondary to

Answer 3

Raised chronic intra-abdominal pressure

Risk factors include obesity and pregnancy

Question 4

What is a spigelian hernia

Answer 4

Rare form of abdominal hernia that occurs at the semilunar line, around the level of the arcuate line

Question 5

Clinical significance of spigelian hernia

Answer 5

Present as a small tender mass at the lower lateral edge of the rectus abdominus

High risk of strangulation, and so should be repaired urgently

Question 6

How do patients with obturator hernias typically present

Answer 6

Mass in the upper medial thigh and often patients will have features of small bowel obstruction

Question 7

What is a howship-romberg sign

Answer 7

Compression of the obturator nerve by a obturator hernia leading to hip and knee pain exacerbated by thigh extension, medial rotation, and abduction

Question 8

What is littre’s hernia

Answer 8

Rare form of abdominal hernia, whereby there is herniation of a meckel’s diverticulum

most commonly occurs in the inguinal canal and many will become strangulated

Question 9

Features of lumbar hernias

Answer 9

Rare posterior hernias, typically occur spontaneously or iatrogenically following surgery(classically following open renal surgery)

Present as a posterior mass, often with associated back pain

Question 10

What is richter’s hernia

Answer 10

Partial herniation of bowel, whereby the anti-mesenteric border becomes strangulated, therefore only part of the lumen of the bowel is within the hernial sac

Question 11

How do patients with richter’s hernia present

Answer 11

Tender irreducible mass at the herniating orifice and will have varying levels of obstruction

Surgical emergencies due to obstruction

Question 12

What are direct inguinal hernias

Answer 12

Bowel enters the inguinal canal ‘directly’ through a weakness in the posterior wall of the canal, termed hesselbach’s triangle

Question 13

In which patients do direct inguinal hernias occur more commonly in?

Answer 13

Older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure

Question 14

What are indirect inguinal hernias

Answer 14

Bowel enters the inguinal canal via the deep inguinal ring

Question 15

How do indirect inguinal hernias arise

Answer 15

Arise from incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, therefore are usually deemed congenital in origin

Question 16

How can inguinal hernias be differentiated at the time of surgery

Answer 16

By identifying the inferior epigastric vessels - indirect hernias will be lateral to the vessels wile direct hernias will be medial to the vessels

Question 17

Risk factors for developing an inguinal hernia

Answer 17

Male
Increasing age
Raised intra-abdominal pressure, from chronic cough, heavy lifting, or chronic constipation
Obesity

Question 18

Presentation of an incarcerated inguinal hernia

Answer 18

Painful 
Tender 
Erythematous lump in the groin 
No cough impulse 
Not reducible

Question 19

Differentiation of inguinal hernia through clinical exam

Answer 19

Reduce the hernia and then place pressure over the deep inguinal ring, before asking patient to cough

If hernia protrudes despite occlusion of the deep inguinal ring, this indicates a direct hernia, if the hernia does not protrude, this indicates an indirect hernia

Question 20

First line imaging for inguinal hernias

Answer 20

Ultrasound scans

Question 21

Options for surgical intervention for hernia repair

Answer 21

Open repair

Laparoscopic repair

Question 22

Serious complications of a hernia that require urgent intervention

Answer 22

Irreducible/incarcerated - the contents of the hernia are unable to return to their original cavity

Obstruction - bowel lumen has become obstructed, leading to clinical features of bowel obstruction

Strangulation - compression of the hernia has compromised the blood supply, leading to the bowel becoming ischaemic

Question 23

Post-op complications of hernia repair

Answer 23

Pain, bruising, haematoma, infection, or urinary retention

Recurrence

Chronic pain

Damage to vas deferens or testicular vessels

Question 24

Where is the deep inguinal ring found

Answer 24

Above the midpoint of the inguinal ligament, which is lateral to the epigastric vessels

The ring is created by the transversalis fascia, which invaginates to form a covering of the contents of the inguinal canal.

Question 25

Where is the superficial inguinal ring found

Answer 25

marks the end of the inguinal canal, and lies just superior to the pubic tubercle. It is a triangle shaped opening, formed by the evagination of the external oblique, which forms another covering of the inguinal canal contents. This opening contains intercrural fibres, which run perpendicular to the aponeurosis of the external oblique and prevent the ring from widening

Question 26

What is a hiatus hernia

Answer 26

A hiatus hernia describes the herniation of part of the stomach above the diaphragm.

Question 27

Types of hiatus hernia

Answer 27

sliding: accounts for 95% of hiatus hernias, the gastroesophageal junction moves above the diaphragm

rolling (paraoesophageal): the gastroesophageal junctions remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus

Question 28

Risk factors hiatus hernia

Answer 28

obesity

increased intraabdominal pressure (e.g. ascites, multiparity)

Question 29

Features of hiatus hernia

Answer 29

heartburn
dysphagia
regurgitation
chest pain

Question 30

Mx of hiatus hernia

Answer 30

all patients benefit from conservative management e.g. weight loss
medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias