Hernias Flashcards
What are the important parts of a lump history?
When was it first noticed
The size of lump and if this has change
Is the lump reducible
Other symptoms such as fevers, night sweats or weight loss
I.e. might indicate TB or cancer
What different factors should you be looking for in a lump assessment?
Site/location
Size (using fruit as reference for size)
Shape = regular or irregular
Surface and skin changes = erythema/swelling/heat
Scars
Colour = can determine vascular status i.e. whether experiencing necrosis
Visible pulse= evidence of aneurysm
What different factors are you looking for when palpation a lump?
- Temperature= determine whether warmer than surroundings i.e. infection
- Tenderness
- Transilluminable= clear fluid enables light to pass through and disperse whereas hard mass or thick fluid would not
Fluctuance
Fixity/tethered= malignant masses invade into underlying structures
LN drainage
Pulsatile
Expansile
Reducible= gently pressing leads to mass returning into cavity of origin
How would you determine whether a lump in invasive or not?
Presence of tethering or fixity indicates that mass has invaded into underlying structures meaning that it is no longer mobile
What characteristic would a lump caused by AAA have?
Pulsatile
Expansile
How can the acronym CAMPFIRE be used to assess features of lumps in a physical examination?
Consistency Attachment Mobility Pulsation Fluctuation Irreducibility Regional lymph node Edge
What is a surgical sieve used for? Using the acronym VITAMIN C, suggests different differentials for a lump.
Approach used to generate different differentials
Vascular= arterial or venous aneurysm
Infective= sebaceous cyst or aneurysm
Traumatic= femoral aneurysm due to angiography
AI
Metabolic= breast lumps or thyroid goitres
Iatrogenic= scar tissue
Neoplastic= skin cancers or lymphomas
Congenital= congenital hernia or undescended testes
What is the definition of a hernia?
Abnormal protrusion of tissue or organ through the wall which normally contains it
What are the different types of external abdominal hernias?
Incisional hernia
-surgical incision causes weakness in muscle wall due to muscle break down post-op= increase risk of herniation
Umbilical hernia
- can occur due to congenital defect
- obesity and ascites cause increased intra-abdominal pressure
Inguinal
-direct or indirect
Femoral
-Bowel enters femoral canal to present as mass in upper medial thigh
What are examples of types of internal hernia?
Hiatus hernia
-stomach passes through oesophageal hiatus
Diaphragmatic hernia
-congenital defect where under-development of diaphragm leads to abdominal contents entering thoracic cavity i.e. leads to poorly developed thoracic organs (small lung on side of underdevelopment)
What structures form the Hesselbachs triangle? What is it’s clinical significance?
Triangle formed from:
- medially= lateral border of rectus abdominis
- superiolaterally= inferior epigastric a and V
- inferiorly= inguinal ligament
Structurally the weakest part of the abdominal wall meaning it is the place inguinal hernias are most likely to protrude through
What is the difference between an indirect and a direct inguinal hernia in terms of location?
Medial to inferior epigastric artery= direct (in Hesselbachs triangle)
Lateral to inferior epigastric artery= indirect
How do indirect and direct hernias differ in terms of which inguinal rings they pass through?
Indirect= passes through deep and superficial
Direct= passes through posterior wall of inguinal canal then through superficial ring
Finish:
What causes the different types of inguinal hernia
Anatomy of deep and superficial ring
Rest of hernia lecture
What causes an indirect inguinal hernia?
Weakness of deep inguinal ring and abdominal muscles
Processus vaginalis remains intact rather than closing like it should. This enables a contents from the peritoneal cavity to herniate through the deep inguinal ring and pass along the inguinal canal
What can be done on examination to differentiate between an indirect and a direct hernia?
Reduce the hernia and apply pressure with 2 fingers to deep inguinal ring (mid-way point of ASIS to pubic tubercle i.e. midpoint of inguinal ligament), hernia will remain reduced in indirect hernia
Why do direct hernias occur? Where would they present?
Weakening of abdominal wall due to increased abdominal pressure can lead to weakening of posterior wall of inguinal ligament which leads to herniation of bowel
Hernia presents in Hesselbachs triangle rather than passing through the inguinal ligament
What is the order of structures located in the femoral triangle lateral to medial?
NAVY-C
Femoral nerve Femoral artery Femoral vein Y fronts Femoral canal
What is the different between the mid-iguinal point and the mid-point of the inguinal ligament?
Mid-inguinal point:
- 1/2 way along theoretical line between ASIS and pubic symphysis
- location of femoral artery
Mid-point go inguinal ligament
- 1/2 way along between ASIS and pubic tubercle i.e. 1/2 way along inguinal ligament
- location of deep inguinal ring
How would you differentiate a femoral hernia from an inguinal hernia?
Femoral hernia is located inferior to inguinal ligament and lateral to pubic tubercle
I.e. structures herniating through femoral ring
Why are femoral hernias high risk for complications and what are these complications?
Femoral ring is very narrow meaning it is more likely for the structures to become compressed by hernia
Complications:
- incarceration
- strangulation
- obstruction
How would someone with hiatus hernia present?
Indigestion
Heart burn
Acid reflux
Bloating halitosis
What are the risk factors for developing hernias and why do they increase the risk?
Male- spermatic cord through inguinal canal means its patent
Age= weakness in abdominal muscles
Premature birth= associated with increased abdominal pressure
Chronic cough= chronic increased in abdo pressure weakens muscles and increases likelihood or hernia in Hesselbachs triangle
Pregnancy (femoral esp)
Constipation
Weight lifting
What are the 3 main forms of complications that can arise with hernias and what are the consequences?
Incarcerated/irreducible
-hernia remains outside the body due to inflammation causing scarring and fibrosis of opening in abdominal wall meaning it is too narrow for hernia to reduce back through
Obstructed
-movement of bowel contents obstructed due to herniation preventing peristaltic action
Strangulated
-progression of obstructed bowel due to tissue oedema and swelling causing compromised blood supply to herniate bowel leading to ISCHAEMIC BOWEL= emergency!!
What feature of a hernia would indicate that it is low risk of complications and can therefore be managed conservatively?
If the hernia has a wide neck
-hernias can be reduced and put back more readily which puts them at lower risk of the 3 main types of complication
What are the 3 main management options for hernias and when is each type indicated?
Conservative = leave hernia alone
- wide neck hernias
- surgery inappropriate due to other co-morbidities
Tension-free repair =mesh placed over the defect by being sutured to tissue on either side of defect
-preferred method= low recurrence rate
Tension-repair= sides of defect sutured together
-not commonly used= high rate of recurrence
What are the possible differentials for femoral hernias?
Lymphadenopathy
- associated with trauma, infection and malignancy
- masses are mobile, multiple, rubbery and bilateral
Psoas abscess
- warm, red, fluctant mass
- associated with elderly ladies as a complications of UTI infection i.e. ureters pass over the psoas muscles
Femoral aneurysm
- pulsatile mass
- can do a duplex USS to differentiate between arterial and venous flow flow
Saphena varix
- torturous dilates saphenous vein at the sapheno-femoral junction
- associated with varicose veins
- disappears when lying supine
- duplex USS can indicate venous blood flow and possible incompetent valves causing problem
Lipoma
- benign tumour of adipose tissue
- diffuse, hard to define borders
- soft and moveable
What are the possible differentials for an inguinal hernia?
Hydrocele
-fluid collecting in tunica vaginalis
-differential from hernia with USS or with translumination
I.e. will be able to transluminate a hernia but not able to with hernia due to being solid mass
Undescended testes
- can be present along inguinal canal
- can use US to differentiate
