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GI (Gastroenterology) > Hernias > Flashcards

Hernias Flashcards

1
Q

What is a Hernia?

A

A weakness or discontinuity in a cavity wall (usually of the muscle or fascia) allows a body organ e.g. bowel to protrude through that cavity wall where it normally would be continued into an abnormal position.

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2
Q

What is an Irreducible Hernias?

A

A hernia that has contents that cannot be pushed back into place.

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3
Q

What is an Obstructed Hernia?

A

A hernia where bowel contents cannot pass.

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4
Q

What is a Strangulated Hernia?

A

A hernia where ischaemia occurs as the hernia is irreducible and the base becomes so tight that it cuts off the blood supply - it is a surgical emergency.

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5
Q

What is an Incarcerated Hernia?

A

A hernia where the contents of the hernia are stuck inside by adhesions -it cannot be reduced back (and therefore can lead to the other 2 complications).

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6
Q

Give 4 risk factors for abdominal wall hernias.

A
  1. Obesity.
  2. Ascites.
  3. Increasing Age.
  4. Surgical Wounds.
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7
Q

Clinical Presentation of Hernias.

A

Soft palpable lump that may be reducible, protrude on coughing (raised intra-abdominal pressure) or on standing (pulled out on gravity). Patients typically report an aching/dragging sensation.

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8
Q

What is a Herniotomy?

A

Ligation and excision of the sac.

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9
Q

What is Herniorraphy?

A

Repair of the Hernia Defect.

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10
Q

What management is appropriate in broad-based hernias?

A

Conservative management, due to low risk of complications.

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11
Q

What is Tension Repair?

A

Surgery where the muscles and tissues either side of the defect are sutured back together and the hernia is held closed to heal there by sutures (applying tension).

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12
Q

Disadvantages of Tension Repair (2).

A
  1. Pain.
  2. High Recurrence Rates.
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13
Q

What is Tension Free Repair?

A

A mesh is placed over the defect to cover the hernia - the mesh is sutured to muscles and tissues on either side of the defect.

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14
Q

Advantage of Tension Free Repair (1).

A
  1. Lower Recurrence Rates than Tension Repair.
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15
Q

Complications of Hernias (3).

A

IOS :-
1. Incarceration.
2. Obstruction.
3. Strangulation.

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16
Q

Risk Factors of Inguinal Hernias (7).

A
  1. Male (8:1).
  2. Chronic Cough.
  3. Constipation.
  4. Urinary Obstruction.
  5. Heavy-Lifting.
  6. Ascites.
  7. Past Abdominal Surgery.
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17
Q

Differential Diagnoses of Inguinal Hernia (8).

A
  1. Femoral Hernia.
  2. Enlarged Cloquet’s Node (Lymph Node).
  3. Saphena Varix.
  4. Femoral Aneurysm.
  5. Abscess.
  6. Undescended/Ectopic Testis.
  7. Kidney Transplant.
  8. Spigelian Hernias.
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18
Q

What is Saphena Varix?

A

Dilation of the Saphenous Vein at the Junction with the Femoral Vein in the Groin.

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19
Q

Epidemiology of Inguinal Hernias (4).

A
  1. Account for 75% of Abdominal Wall Hernias.
  2. 95% are male.
  3. Direct is commoner in male adults; Indirect are commoner in male infants.
  4. Direct - 20%; Indirect - 80%.
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20
Q

Clinical Presentation of Inguinal Hernias.

A

A large inguinal hernia may extend down into the male scrotum (and so will not transilluminate).

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21
Q

Symptoms of Strangulated Inguinal Hernias (7).

A
  1. Pain.
  2. Fever.
  3. Increased Size of Hernia.
  4. Erythema of Overlying Skin.
  5. Peritonitis Features e.g. Guarding, Tenderness.
  6. Bowel Obstruction - Nausea, Vomiting, Distension.
  7. Bowel Ischaemia e.g. Bloody Stoolls.
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22
Q

Function of Inguinal Canal.

A

Allows the spermatic cord and its contents to travel from inside the abdominal cavity to outside the cavity within the scrotum,

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23
Q

Passage of Inguinal Canal.

A

From Deep (Internal) Ring (Entrance to Abdominal Cavity) to Superficial (External) Ring (Exit to Scrotum).

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24
Q

Boundaries of Inguinal Canal (3).

A

RIP (Hesselbach’s Triangle) :-
1. Rectus Abdominis (Medial).
2. Inferior Epigastric Vessel (Superio-Lateral).
3. Inguinal/Poupart’s Ligament (Inferior).

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25
Q

Boundaries of Femoral Triangle (3).

A

SAIL :-
1. Sartorial (Lateral).
2. Adductor Longus (Medial).
3. Inguinal Ligament (Superior).

26
Q

Where is the Deep (Internal) Ring?

A

Midpoint of the Inguinal Ligament - 1.5cm above the femoral pulse.

27
Q

What is the Superficial (External) Ring?

A

A split in the External Oblique Aponeurosis just superior and medial to pubic tubercle.

28
Q

Contents of Inguinal Canal (5 x 3).

A
  1. Fascia Covering Cord : External Spermatic (External Oblique), Cremasteric (Internal Oblique + Transverses Abdominus) and Internal Spermatic (Transversalis).
  2. Arteries of Spermatic Cord (Arteries to the Vas, Cremaster, Testis).
  3. Tubes of Spermatic Cord (Vas Deferens, Obliterated Processus Vaginalis, Lymphatics).
  4. Veins of Spermatic Cord (Pampiniform Plexus + Veins of Vas, Cremaster, Testis).
  5. Nerves (Genital Branch of Genitofemoral Nerve (cord), Sympathetic Nerves (cord) and Ilioinguinal Nerve (anterior to cord)).
29
Q

What is found instead in a female in the inguinal canal?

A

Instead of male structures, the round ligament of the uterus.

30
Q

Aetiology of Direct Inguinal Hernia.

A

Weakness in abdominal wall around Hesselbach’s Triangle in the Transversalis Fascia allows protrusion directly through abdominal wall through Hesselbach’s Triangle, passing medial to Inferior Epigastric Artery.

31
Q

Aetiology of Indirect Inguinal Hernia.

A
  1. Weakness in the rings leads to herniation through the canal into the scrotum.
  2. Normally, the deep ring closes and the Processus Vaginalis is obliterated but it can be open.
  3. Lateral to Inferior Epigastric Artery.
32
Q

What can cause an Indirect Inguinal Hernia to remain reduced?

A

Pressure applied (with 2 fingers) to deep inguinal ring at midpoint of ASIS to Pubic Tubercle.

33
Q

How to distinguish between Direct and Indirect Inguinal Hernia in examination?

A

Restrained when patient coughs or stands - indirect.

34
Q

Investigations of Inguinal Hernias (3).

A
  1. Unclear - Ultrasound/Herniogram.
  2. Strangulated and Suspected Obstruction - AXR/CT.
  3. FBC - Leukocytosis and Raised Lactate.
35
Q

Management of Inguinal Hernias (5).

A
  1. 1st time - Open Inguinal Hernia Repair.
  2. Mesh Repair (lower recurrence but high infection risk over sutures).
  3. Hernia Truss (for those not fit for surgery).
  4. Treat patients even if they are asymptomatic.
  5. Recurrent/Bilateral - Laparoscopic.
36
Q

What is Open Inguinal Hernia Repair? (3)

A
  1. Open inguinal canal.
  2. Reduce Hernia.
  3. Repair defect by placing prosthetic mesh posterior to cord structures.
37
Q

Clinical Presentation of Umbilical Hernias.

A

Symmetrical bulge under Umbilicus.

38
Q

Epidemiology of Femoral Hernias.

A

Commoner in female adults.

39
Q

Boundaries of Femoral Canal (4).

A

FLIP :-
1. Femoral Vein (Lateral).
2. Lacunar Ligament (Medial).
3. Inguinal Ligament (Superior).
4. Pectineal Ligament (Posterior).

40
Q

Contents of the Femoral Triangle (5).

A

NAVEL :-
1. Femoral Nerve.
2. Femoral Artery.
3. Femoral Vein.
4. Empty Space.
5. Lymph Nodes.
*4 + 5 are part of the Femoral Canal.
** 1, 2 + 3 are part of the Femoral Sheath.

41
Q

Aetiology of Femoral Hernias.

A

Occurs below the inguinal ligament, lateral to the pubic tubercle. due to weakness around the opening of the femoral canal.

42
Q

Why are Femoral Hernias associated with a greater risk of complications?

A

Narrower base.

43
Q

Epidemiology of Epigastric Hernias.

A

Commoner in men between 20-30.

44
Q

Clinical Presentation of Epigastric Hernias.

A

Lump in Midline between Umbilicus and Xiphisternum.

45
Q

Epidemiology of Obturator Hernias.

A

Commoner in women, usually older age, after multiple pregnancies or vaginal deliveries.

46
Q

Clinical Features of Obturator Hernias.

A
  1. Often asymptomatic.
  2. Irritation to Obturator Nerve.
  3. Howship-Romberg Sign.
47
Q

What is Howship-Romberg Sign?

A

Pain extends from inner thigh to the knee when the hip is internally rotated due to compression of Obturator Nerve.

48
Q

Aetiology of Obturator Hernias.

A

Herniation of abdominal/pelvic contents through the Obturator Foramen due to a defect in the pelvic floor.

49
Q

Name and Epidemiology of Spigelian Hernias.

A

Name : Lateral Ventral Hernias.
Rare, mainly older patients.

50
Q

Aetiology of Spigelian Hernias.

A

Herniation through abdominal wall between Lateral Border of Rectus Abdominis and Linda Semilunaris through Spigelian Fascia (Aponeurosis).

51
Q

Clinical Presentation of Paraumbilical Hernias.

A

Symmetric bulge - half the sac is covered by skin of the abdomen directly above/below the Umbilicus.

52
Q

Management of Paraumbilical Hernias.

A

Mayo Repair - Repair of Rectus Sheath.

53
Q

Anatomy of Diaphragmatic Hiatus.

A

Diaphragm opening is usually fixed at level of the LOS and narrow sphincter stops acid and gastric contents refluxing.

54
Q

Types of Hiatus Hernias (4).

A
  1. Type I - Sliding (Stomach slides up along with Oesophagus through Diaphragm) - 95%.
  2. Type II - Rolling (Separate Portion of Stomach e.g. Funds folds around and enters through the Diaphragm opening along with the Oesophagus).
  3. Type III - Combination of Sliding and Rolling.
  4. Type IV - Large Hernia allowing other intra-abdominal organs to pass through the diaphragmatic opening.
55
Q

Difference between Sliding and Rolling Hiatus Hernias in terms of GOJ.

A

GOJ remains below the Diaphragm in Rolling Hernias but moves above the Diaphragm in Sliding Hernias.

56
Q

Management of Hiatus Hernias.

A

Conservative (medical management of reflux) or surgical (if severe symptoms or high risk of complications).

57
Q

Aetiology of Incisional Hernias.

A

Hernia occurring at the site of an incision from previous surgery due to inadequate closure of muscle and tissues after incision.

58
Q

Aetiology of Richter’s Hernias.

A

The anti-mesenteric border of the bowel herniates through the fascial defect - only a portion of the bowel wall herniates (so high risk of complications).

59
Q

What is a Diastasis Recti?

A

A gap between the Rectus Abdominis created when the Lines Alba (aponeurosis of Rectus Abdominis) is stretched (pregnancy, obesity) and broad. Also known as Rectus Abdominis Diastasis and Recti Divarication.

60
Q

Clinical Presentation of Diastasis Recti.

A

Most prominent when patient lies on back and does a crunch - appears as a protruding bulge in middle of abdomen.

GI (Gastroenterology) (32 decks)

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