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Gastro + Gen Surg > Hernias > Flashcards

Hernias Flashcards

1
Q

What are the important parts of a lump history?

A

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

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2
Q

What different factors should you be looking for in a lump assessment?

A

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

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3
Q

What different factors are you looking for when palpation a lump?

A
  • 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

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4
Q

How would you determine whether a lump in invasive or not?

A

Presence of tethering or fixity indicates that mass has invaded into underlying structures meaning that it is no longer mobile

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5
Q

What characteristic would a lump caused by AAA have?

A

Pulsatile

Expansile

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6
Q

How can the acronym CAMPFIRE be used to assess features of lumps in a physical examination?

A 
Consistency 
Attachment 
Mobility 
Pulsation 
Fluctuation 
Irreducibility 
Regional lymph node 
Edge
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7
Q

What is a surgical sieve used for? Using the acronym VITAMIN C, suggests different differentials for a lump.

A

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

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8
Q

What is the definition of a hernia?

A

Abnormal protrusion of tissue or organ through the wall which normally contains it

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9
Q

What are the different types of external abdominal hernias?

A

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

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10
Q

What are examples of types of internal hernia?

A

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)

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11
Q

What structures form the Hesselbachs triangle? What is it’s clinical significance?

A

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

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12
Q

What is the difference between an indirect and a direct inguinal hernia in terms of location?

A

Medial to inferior epigastric artery= direct (in Hesselbachs triangle)

Lateral to inferior epigastric artery= indirect

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13
Q

How do indirect and direct hernias differ in terms of which inguinal rings they pass through?

A

Indirect= passes through deep and superficial

Direct= passes through posterior wall of inguinal canal then through superficial ring

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14
Q

Finish:

A

What causes the different types of inguinal hernia

Anatomy of deep and superficial ring

Rest of hernia lecture

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15
Q

What causes an indirect inguinal hernia?

A

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

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16
Q

What can be done on examination to differentiate between an indirect and a direct hernia?

A

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

17
Q

Why do direct hernias occur? Where would they present?

A

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

18
Q

What is the order of structures located in the femoral triangle lateral to medial?

A

NAVY-C

Femoral nerve
Femoral artery 
Femoral vein
Y fronts 
Femoral canal
19
Q

What is the different between the mid-iguinal point and the mid-point of the inguinal ligament?

A

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
20
Q

How would you differentiate a femoral hernia from an inguinal hernia?

A

Femoral hernia is located inferior to inguinal ligament and lateral to pubic tubercle
I.e. structures herniating through femoral ring

21
Q

Why are femoral hernias high risk for complications and what are these complications?

A

Femoral ring is very narrow meaning it is more likely for the structures to become compressed by hernia

Complications:

  • incarceration
  • strangulation
  • obstruction
22
Q

How would someone with hiatus hernia present?

A

Indigestion
Heart burn
Acid reflux
Bloating halitosis

23
Q

What are the risk factors for developing hernias and why do they increase the risk?

A

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

24
Q

What are the 3 main forms of complications that can arise with hernias and what are the consequences?

A

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!!

25
Q

What feature of a hernia would indicate that it is low risk of complications and can therefore be managed conservatively?

A

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

26
Q

What are the 3 main management options for hernias and when is each type indicated?

A

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

27
Q

What are the possible differentials for femoral hernias?

A

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
28
Q

What are the possible differentials for an inguinal hernia?

A

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

Gastro + Gen Surg (45 decks)

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