Hernias Flashcards
What are the 3 types of groin hernia?
Direct inguinal
Indirect inguinal
Femoral
What anatomy is involved with a direct inguinal hernia?
Protrudes through hesselbach’s triangle
Passes medial to the inferior epigastric artery
What are the borders of the Hesselbach’s triangle?
Medial – lateral border of the rectus abdominis muscle.
Lateral – inferior epigastric vessels.
Inferior – inguinal ligament.
What causes direct inguinal hernias?
Defect or weakness in the transversalis fascia area of the Hesselbach triangle
Who generally gets direct inguinal hernias?
Male adults
What anatomy is involved with a indirect inguinal hernia?
Protrudes through the inguinal ring
Passes lateral to the inferior epigastric artery
Above and medial to pubic tubercle
What causes indirect inguinal hernias?
Failure of the processus vaginalis to close
embryonic developmental outpouching of the parietal peritoneum
Who generally gets indirect inguinal hernias?
Infants
Males
What anatomy is involved in femoral hernias?
Protrudes below the inguinal ligament, lateral to the pubic tubercle
What is worrying about femoral hernias?
High risk of strangulation
Who generally gets femoral hernias?
Adult females
Define hernia
Protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it
What are risk factors for abdominal wall hernias?
obesity
ascites
increasing age
surgical wounds
What are the presenting features of abdominal wall hernias?
palpable lump
cough impulse
pain
obstruction: more common in femoral hernias
strangulation: may compromise the bowel blood supply leading to infarction
What are the different types of abdominal wall hernia?
Inguinal Femoral Umbilical Paraumbilical Epigastric Incisional
What is an umbilical hernia?
Symmetrical bulge under the umbilicus
What is a paraumblical hernia?
Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus
What is a epigastric hernia?
Lump in the midline between umbilicus and the xiphisternum
Most common in men aged 20-30 years
What are congenital inguinal hernias?
Indirect hernias resulting from a patent processus vaginalis
Occur in around 1% of term babies. More common in premature babies and boys
What is incarceration of a hernia?
herniated tissue cannot be reduced
How urgent is hernia strangulation?
Surgical emergency that requires urgent management
How will strangulated hernias present?
tender and likely non-reducible, and may also present with a systemically unwell patient
How can femoral hernias be repaired?
laparoscopically or via a laparotomy
laparotomy only option in emergency
How are hernias diagnosed?
Clinically by observation/palpation
Imaging only when complex e.g. obese
What are some differentials for a groin lump?
Indirect inguinal hernia Direct inguinal hernia Femoral hernia Inguinal lymphadenopathy Psoas abscess Femoral aneurysm
What question do you want to ask about a groin lump?
How long has it been there?
Is the lump always there? Does it reduce when lying down?
Painful? will be if strangulated hernia, groin abscess
Other lumps?
What may cause hernias to increase in size?
Increase intra-abdo pressure e.g. Coughing, straining on loo
How can you differentiate between hernias and lymph nodes?
Swollen lymph lodes are solid
Hernias, aneurysms etc. are softer and can be fluctuant
Aneurysms will be fluctuant
What are the differences in direct and indirect hernias?
Direction of reducibility
Direct - reduce superiorly
Indirect - reduce inferiorly
Why must the rest of the abdomen be examined with an hernia?
Check for masses, ascites, tumour, gross faecal loading
All can raise intra-abdo pressure which can predispose hernia
What bedside test can help confirm whether a hernia is direct or indirect?
Reduce the hernia
Place a finger over the deep ring
Ask pt to cough
If hernia emerges whilst you are occluding the deep ring it must be direct
If only emerges once finger is removed it is indirect
What can a strangulated hernia cause?
Small bowel obstruction
Colicky pain, N+V
What are the management options for a direct inguinal hernia?
Nothing - advise to represent if it becomes symptomatic
Truss - prevents bowel obstruction, only if reducible
Surgery
What are the causes inguinal lymphadenopathy?
Infective Systemic
- HIV
- TB
Infective local
- Lower limb/groin infection/STD
Neoplastic Systemic
- Lymphoma
- Leukaemia
Neoplastic local
- Mets
