Hernias Flashcards
Define hernia
A hernia occurs when an organ/tissue protrudes through the wall of the cavity containing it
Describe the epidemiology of hernias
Inguinal: Very common!! M»_space;> F
Umbilical: Children
Hiatus: Very common - 10-20%
Femoral: F > M
Identify the types of hernias
Inguinal Femoral Umbilical Hiatus Incisional Spigelian Obturator Epigastric
Describe the types of inguinal hernia
Inguinal hernias can be 2 types
1) Direct: do not pass through the deep inguinal ring, herniates through weakness in the abdo wall at Hesselbach’s triangle
2) Indirect: pass through the inguinal canal
Describe the boundaries of the inguinal canal
Anterior: aponeurosis of the external oblique
Posterior: transversalis fascia
Floor: inguinal ligament (rolled apon. of EO)
Roof: transversalis fascia, IO, transversus abdominus
Describe the anatomy of the inguinal rings
Deep inguinal ring: above the midpoint of the inguinal ligament
Superficial inguinal ring: superior to the pubic tubercle
Describe the location of the mid-inguinal point and the midpoint of the inguinal ligament + relevance
Mid-inguinal point: halfway between pubic symphysis and ASIS. Palpate femoral pulse
Midpoint of the inguinal ligament: halfway between the pubic tubercle and ASIS. Location of the deep inguinal ring
Describe the normal contents of the inguinal canal
M: spermatic cord
F: round ligament
Nerves
Describe the pathophysiology of inguinal hernias
Indirect:
Patent processus vaginalis -> pathway for abdominal viscera to reach the scrotum
Direct:
Weakness in transversalis fascia -> protrusion of viscera
How do you differentiate between two types of inguinal hernias on examination?
Reduce the hernia, then cover the deep inguinal ring
Valsalva -> protrusion of a direct hernia NOT indirect
What is a Richter’s hernia?
Occurs when only one side of the bowel herniates through an opening, causing only one part to become ischaemic if strangulated
What is a Maydl’s hernia?
Herniation of two loops of bowel through the abdominal wall
Describe the boundaries of the femoral triangle
Sartorius muscle- laterally
Aductor longus- medially
Inguinal ligament- superiorly
Describe the contents of the femoral triangle
Lateral -> medial Femoral nerve Femoral artery Femoral vein Femoral canal
Describe the difference between inguinal and femoral hernias on examination
Femoral: inferolateral to the pubic tubercle
Inguinal: superomedial to the pubic tubercle
Define strangulation and incarceration of hernias
Incerceration: when the contents of a hernia are no longer reducible
Strangulation: when the contents of a hernia loses its arterial supply and risks ischaemia
Describe the presentation of abdominal hernias
May be asymptomatic lump on the abdominal wall
-Can have dull dragging discomfort
Or present w strangulation:
- Severe colicky abdo pain
- Tender, red, irreducible lump
- Vomiting + abdo distension
Describe the investigation for hernias
Clinical diagnosis
Imaging if unclear: USS -> CT
Describe the management of hernias
Conservative:
- Lifestyle: weight loss, exercises
- Watchful waiting: minimal symptoms/asymp, unsuitable for Sx
Surgical: definitive Mx
- Open mesh repair (low risk, v effective)
- Laparoscopic surgical repair
Describe the types of hiatus hernia
1) Sliding: protrusion of the GOJ + stomach through the oesophageal hiatus
2) Rolling: herniation of the fundus/body of stomach through oesophageal hiatus
3) Sliding + rolling
4) Herniation of multiple organs
Describe the presentation of hiatus hernia
May be asymptomatic
Most commonly GORD + heartburn, possibly exacerbated by bending over, etc
-Difficulty swallowing, early satiety, bloating
Describe the investigations for hiatus hernia
Diagnosis by investigation only
- CXR
- Upper gi contrast series is best (contrast swallow + XR)
Describe the management of hiatus hernia
Conservative:
-Lifestyle: weight loss, diet, raising head of the bed, etc
Medical:
-PPIs/H2RA
Surgical: for recurrent/persistent
-Laparoscopic fundoplication, reduction, mesh repair etc
Describe the complications of hernias
Strangulation/incarceration- rare in inguinal, ^ in femoral + Spigelian
Hiatus: Barrett’s, Ca, gastric volvulus
Surgical complications
Recurrence following surgery
Describe the signs of hernia on examination
Bulge/lump on abdominal wall (can extend into scrotum if inguinal)
Soft and smooth, non-tender, unable to get above the lump, reducible (unless incarcerated)
After reduction can be elicited with Valsalva
