Hernias Flashcards
What is divarication of the recti
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
What are epigastric hernia typically secondary to
Raised chronic intra-abdominal pressure, such as with obesity, pregnancy, or ascites
What are paraumbilical hernia typically secondary to
Raised chronic intra-abdominal pressure
Risk factors include obesity and pregnancy
What is a spigelian hernia
Rare form of abdominal hernia that occurs at the semilunar line, around the level of the arcuate line
Clinical significance of spigelian hernia
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
How do patients with obturator hernias typically present
Mass in the upper medial thigh and often patients will have features of small bowel obstruction
What is a howship-romberg sign
Compression of the obturator nerve by a obturator hernia leading to hip and knee pain exacerbated by thigh extension, medial rotation, and abduction
What is littre’s hernia
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
Features of lumbar hernias
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
What is richter’s hernia
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
How do patients with richter’s hernia present
Tender irreducible mass at the herniating orifice and will have varying levels of obstruction
Surgical emergencies due to obstruction
What are direct inguinal hernias
Bowel enters the inguinal canal ‘directly’ through a weakness in the posterior wall of the canal, termed hesselbach’s triangle
In which patients do direct inguinal hernias occur more commonly in?
Older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure
What are indirect inguinal hernias
Bowel enters the inguinal canal via the deep inguinal ring
How do indirect inguinal hernias arise
Arise from incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, therefore are usually deemed congenital in origin
How can inguinal hernias be differentiated at the time of surgery
By identifying the inferior epigastric vessels - indirect hernias will be lateral to the vessels wile direct hernias will be medial to the vessels
Risk factors for developing an inguinal hernia
Male
Increasing age
Raised intra-abdominal pressure, from chronic cough, heavy lifting, or chronic constipation
Obesity
Presentation of an incarcerated inguinal hernia
Painful Tender Erythematous lump in the groin No cough impulse Not reducible
Differentiation of inguinal hernia through clinical exam
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
First line imaging for inguinal hernias
Ultrasound scans
Options for surgical intervention for hernia repair
Open repair
Laparoscopic repair
Serious complications of a hernia that require urgent intervention
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
Post-op complications of hernia repair
Pain, bruising, haematoma, infection, or urinary retention
Recurrence
Chronic pain
Damage to vas deferens or testicular vessels
Where is the deep inguinal ring found
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.
Where is the superficial inguinal ring found
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
What is a hiatus hernia
A hiatus hernia describes the herniation of part of the stomach above the diaphragm.
Types of hiatus hernia
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
Risk factors hiatus hernia
obesity
increased intraabdominal pressure (e.g. ascites, multiparity)
Features of hiatus hernia
heartburn
dysphagia
regurgitation
chest pain
Mx of hiatus hernia
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
