Hernias Flashcards
What is the definition of a hernia?
Protrusion of a whole or part of an organ through the wall of the cavity that contains it into an abnormal position.
What is a hiatus hernia?
Protrusion of an organ from the abdominal cavity into the thorax through the oseophageal hiatus. This is typically the stomach.
These are extremely common but usually asymptomatic. Estimated 1/3 of individuals over 50 have a hiatus hernia.
What are the two classifications of hiatus hernias?
Sliding hiatus hernia (80%) - the gastro-oseophageal junction (GOJ), the abdominal part of the oseophagus and frequently the cardia of the stomach move or ‘slides’ upwards through the diaphragmatic hiatus into the thorax.
Rolling in Para-Oseophageal hernia (20%) - upward movement of the gastric fundus occurs to lie alongside a normal GOJ which creates a ‘bubble’ of stomach in thorax. True hernia with peritoneal sac. Proportion of stomach herniating may increase with time and eventually whole stomach could be thorax.
Can also get mixed type hernias.
What are the risk factors for developing a hiatus hernia?
Increasing Age is biggest risk factor
Pregnancy
Obesity
Ascites
What are the clinical features of hiatus hernias?
Vast majority completely asymptomatic
May experience GORD symptoms - often more severe and treatment-resistant
What other signs and symptoms may occur in hiatus hernia?
Vomiting and weight loss (rare but serious)
Bleeding and/or anaemia (secondary to oseophagus ulceration)
Hiccups or palpitations (irritation to diaphragm or pericardial sac)
Swallowing difficulties (oseophageal strictures or rarely incarceration of the hernia)
What my be seen of examination of hiatus hernia?
Typically normal examination
But may here bowel sounds within chest if hernia significant.
What are the differential diagnosis for hiatus hernia?
Cardiac chest pain
Gastric or pancreatic cancer - particularly if signs of gastric outlet obstruction, early satiety or weight loss
GORD
What is the gold standard investigation of a hiatus hernia?
OGD - shows upward displacement of GOJ
What other investigations could be done for a hiatus hernia be found on?
Diagnosed incidentally on CT/MRI
Contrast shallow
What is the conservative management of hiatus hernia?
PPI - taken in morning before food
Weight loss, altered diet, raise head of bed when sleeping
Smoking cessation and reduction in alcohol intake - both inhibit LOS function
When is surgical management indicated in hiatus hernias?
Remaining symptomatic despite maximal medical therapy
Increased risk of strangulation/volvulus (rolling type or mixed hernia or contains other abdominal viscera) - usually require stomach decompression via a NG tube prior to surgery
Nutritional failure - due to gastric outlet obstruction
What are the two aspects of hiatus hernia surgery?
Cruroplasty - hernia reduced from thorax to abdomen. Any large defects may require mesh to strength repair
Fundoplication - gastric fundus wrapped around lower oseophagus and stitched in place - aims to strengthen LOS and keep GOJ below diaphragm - may be full or partial wrap.
What are the complications specific to hiatus hernia surgery?
- Recurrence of hernia
- Abdominal bloating - inability to bleach
- Dysphagia - too tight or too narrow. Common early on due to oedema. Settles with most pts but may enquire revision surgery.
- Fundal necrosis - blood supply via left gastric artery and short gastric vessels disrupted. Surgical emergency, typically requiring major gastric resection.
What are the complication of hiatus hernias?
Incarceration and strangulation - especially rolling type
Gastric volvulus - require prompt surgical intervention
How do the gastric volvulus as a result of hiatus hernias clinically present?
Borchardts traid:
- severe gastric pain
- retching without vomiting
- inability to pass and NG tube
What are inguinal hernias?
When abdominal cavity contents enter into the inguinal canal.
Most common type of hernia.
What are the two main subtypes of inguinal hernias?
Direct inguinal hernias (20%) - through Hesselbachs triangle - often occur in older pts, often from secondary abdominal wall laxity or significant increase in intra-abdominal pressure
Indirect inguinal hernias (80%) - deep inguinal ring - incomplete closure of processus vaginalis
Where are the two types of inguinal hernias located relative to the inferior epigastric vessels?
Indirect - lateral
Direct - medial
What are the risk factors for inguinal hernias?
Male
Increasing age
Raised intra-abdominal pressure - from chronic cough, heavy lifting, chronic constipation
Obesity
What are the borders of the inguinal canal?
Floor - inguinal ligament
Anterior - aponeurosis of the external oblique
Roof - internal oblique and transversus abdominis
Posterior - transversalis fascia
How will a reducible inguinal hernia present?
Lump in groin which will disappear with minimal pressure or when the pt lies down. Moderate discomfort which can worsen with activity or standing.
How will a incarcerated/strangulated inguinal hernia present?
Painful, tender and erythematous
Irreducible
Pain out of proportion to clinical signs
Features of bowel obstruction may be present
What specific feature should be noted on examination of an inguinal hernia?
- Cough impulse - may be absent if irreducible
- Location - inguinal (superomedial to the pubic tubercle) or femoral (inferolateral to pubic tubercle)
- Reducible
- if it enters the scrotum can you get above it?
What is the only definitive way of differentiating between indirect and direct inguinal hernias?
At the time of surgery
What are the differential diagnosis of inguinal hernias?
Femoral hernia Saphena varix Inguinal lymphadenopathy Lipoma Groin abscess Internal iliac aneurysm
If in scrotum then: hydrocele, varicocele or testicular mass
What are the investigations for inguinal hernias?
Usually clinical diagnosis
If diagnostic uncertainty or or exclude other diagnosis:
Ultrasound scan
CT imaging if features of obstruction or strangulation.
What is the indication for surgery in inguinal hernias?
Symptomatic should be offered surgical interventions
Signs of obstruction or strangulation
Which patients are managed conservatively for inguinal hernias?
Asymptomatic - but should be warned about future surgical management and safety netted on signs of strangulation.
What are the two types of inguinal hernia repairs?
Open repair (Lichtenstein technique most commonly used)
Laparoscopic repair (either total extra peritoneal (TEP) or trans abominable pre-peritoneal(TAPP)).
When are open mesh repairs performed in inguinal hernias?
Primary inguinal hernias
When is laparoscopic approach used in inguinal hernias repair?
Bilateral or reccurent inguinal hernias
Certain pts with primary unilateral hernia - those at high risk of chronic pain or in females due the risk of presence of femoral hernia.
What are the main complications of inguinal hernias?
Incarceration
Strangulation
Obstruction
What are the post-op complications in inguinal hernia repairs?
Pain, bruising, haematoma, infection or urinary retention
Recurrence
Chronic pain
Damage to vas deferens or testicular vessels - ischaemic orchitis
What are femoral hernias?
Abdominal viscera or omentum passes through the femoral ring and into the potential space of the femoral canal. Relatively uncommon and high rate of strangulation. More common in females.
What are the risk factors for femoral hernias?
Female
Pregnancy - higher incidence in multiparous women
Raised intra-abdominal pressure
Increasing age
What are the clinical feature of femoral hernias?
Small lump in groin - asymptomatic aside from lump - unlikely to be reducible
May just present with vomiting - should have groins examined
30% present as emergency either obstruction or strangulation
On examination of hernias how would you differentiate femoral and inguinal hernias?
Femoral - found inferno-lateral to pubic tubercle (and medial to femoral pulse)
Inguinal - supero-medial to pubic tubercle
Femoral hernias can roll up in front of inguinal ligament and are often misdiagnosed as inguinal.
What are the differential diagnosis for femoral hernias?
Inguinal hernia Lipoma Lymph node Saphena varix Femoral artery aneurysm Athletic pubalgia
What are the investigations for femoral hernias?
All need surgery - so pre-op investigations
Clinically diagnosis but often additional imaging required:
- ultrasound
- CT abdomen-pelvis scan
What is the management of femoral hernias?
All should be managed surgically within 2 weeks due to high risk of strangulation.
What does a surgery for femoral hernias involve?
Reducing the hernia
Narrowing the femoral ring - with sutures or mesh plug
What are the two approaches that can be taken in femoral hernia surgery?
Low approach - below inguinal ligament - does not interfere with inguinal structures but does limit space for removal of any compromised bowel.
High approach - above the inguinal ligament - preferred in emergency - easier access
What are the complications of femoral hernias?
Strangulation
Obstruction
What is an incisional hernia?
Reducible, non-tender swelling at or near the site of a surgical incision.
