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General Surgery > Hernias > Flashcards

Hernias Flashcards

1
Q

What is the definition of a hernia?

A

Protrusion of a whole or part of an organ through the wall of the cavity that contains it into an abnormal position.

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2
Q

What is a hiatus hernia?

A

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.

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3
Q

What are the two classifications of hiatus hernias?

A

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.

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4
Q

What are the risk factors for developing a hiatus hernia?

A

Increasing Age is biggest risk factor
Pregnancy
Obesity
Ascites

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5
Q

What are the clinical features of hiatus hernias?

A

Vast majority completely asymptomatic

May experience GORD symptoms - often more severe and treatment-resistant

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6
Q

What other signs and symptoms may occur in hiatus hernia?

A

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)

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7
Q

What my be seen of examination of hiatus hernia?

A

Typically normal examination

But may here bowel sounds within chest if hernia significant.

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8
Q

What are the differential diagnosis for hiatus hernia?

A

Cardiac chest pain

Gastric or pancreatic cancer - particularly if signs of gastric outlet obstruction, early satiety or weight loss

GORD

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9
Q

What is the gold standard investigation of a hiatus hernia?

A

OGD - shows upward displacement of GOJ

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10
Q

What other investigations could be done for a hiatus hernia be found on?

A

Diagnosed incidentally on CT/MRI

Contrast shallow

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11
Q

What is the conservative management of hiatus hernia?

A

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

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12
Q

When is surgical management indicated in hiatus hernias?

A

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

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13
Q

What are the two aspects of hiatus hernia surgery?

A

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.

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14
Q

What are the complications specific to hiatus hernia surgery?

A
  • 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.
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15
Q

What are the complication of hiatus hernias?

A

Incarceration and strangulation - especially rolling type

Gastric volvulus - require prompt surgical intervention

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16
Q

How do the gastric volvulus as a result of hiatus hernias clinically present?

A

Borchardts traid:

  • severe gastric pain
  • retching without vomiting
  • inability to pass and NG tube
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17
Q

What are inguinal hernias?

A

When abdominal cavity contents enter into the inguinal canal.

Most common type of hernia.

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18
Q

What are the two main subtypes of inguinal hernias?

A

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

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19
Q

Where are the two types of inguinal hernias located relative to the inferior epigastric vessels?

A

Indirect - lateral

Direct - medial

20
Q

What are the risk factors for inguinal hernias?

A

Male
Increasing age
Raised intra-abdominal pressure - from chronic cough, heavy lifting, chronic constipation
Obesity

21
Q

What are the borders of the inguinal canal?

A

Floor - inguinal ligament
Anterior - aponeurosis of the external oblique
Roof - internal oblique and transversus abdominis
Posterior - transversalis fascia

22
Q

How will a reducible inguinal hernia present?

A

Lump in groin which will disappear with minimal pressure or when the pt lies down. Moderate discomfort which can worsen with activity or standing.

23
Q

How will a incarcerated/strangulated inguinal hernia present?

A

Painful, tender and erythematous
Irreducible
Pain out of proportion to clinical signs
Features of bowel obstruction may be present

24
Q

What specific feature should be noted on examination of an inguinal hernia?

A
  • 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?
25
Q

What is the only definitive way of differentiating between indirect and direct inguinal hernias?

A

At the time of surgery

26
Q

What are the differential diagnosis of inguinal hernias?

A 
Femoral hernia 
Saphena varix 
Inguinal lymphadenopathy 
Lipoma 
Groin abscess 
Internal iliac aneurysm

If in scrotum then: hydrocele, varicocele or testicular mass

27
Q

What are the investigations for inguinal hernias?

A

Usually clinical diagnosis

If diagnostic uncertainty or or exclude other diagnosis:
Ultrasound scan

CT imaging if features of obstruction or strangulation.

28
Q

What is the indication for surgery in inguinal hernias?

A

Symptomatic should be offered surgical interventions

Signs of obstruction or strangulation

29
Q

Which patients are managed conservatively for inguinal hernias?

A

Asymptomatic - but should be warned about future surgical management and safety netted on signs of strangulation.

30
Q

What are the two types of inguinal hernia repairs?

A

Open repair (Lichtenstein technique most commonly used)

Laparoscopic repair (either total extra peritoneal (TEP) or trans abominable pre-peritoneal(TAPP)).

31
Q

When are open mesh repairs performed in inguinal hernias?

A

Primary inguinal hernias

32
Q

When is laparoscopic approach used in inguinal hernias repair?

A

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.

33
Q

What are the main complications of inguinal hernias?

A

Incarceration
Strangulation
Obstruction

34
Q

What are the post-op complications in inguinal hernia repairs?

A

Pain, bruising, haematoma, infection or urinary retention
Recurrence
Chronic pain
Damage to vas deferens or testicular vessels - ischaemic orchitis

35
Q

What are femoral hernias?

A

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.

36
Q

What are the risk factors for femoral hernias?

A

Female
Pregnancy - higher incidence in multiparous women
Raised intra-abdominal pressure
Increasing age

37
Q

What are the clinical feature of femoral hernias?

A

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

38
Q

On examination of hernias how would you differentiate femoral and inguinal hernias?

A

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.

39
Q

What are the differential diagnosis for femoral hernias?

A 
Inguinal hernia 
Lipoma
Lymph node 
Saphena varix 
Femoral artery aneurysm 
Athletic pubalgia
40
Q

What are the investigations for femoral hernias?

A

All need surgery - so pre-op investigations

Clinically diagnosis but often additional imaging required:

  • ultrasound
  • CT abdomen-pelvis scan
41
Q

What is the management of femoral hernias?

A

All should be managed surgically within 2 weeks due to high risk of strangulation.

42
Q

What does a surgery for femoral hernias involve?

A

Reducing the hernia

Narrowing the femoral ring - with sutures or mesh plug

43
Q

What are the two approaches that can be taken in femoral hernia surgery?

A

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

44
Q

What are the complications of femoral hernias?

A

Strangulation

Obstruction

45
Q

What is an incisional hernia?

A

Reducible, non-tender swelling at or near the site of a surgical incision.

General Surgery (20 decks)

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