Hernias Flashcards
Name 7 differences between direct and indirect inguinal hernia
• Neck lies medial to inferior epigastric artery within Hesselbach’s triangle vs lateral and outside
• reduces upwards and straight backwards vs up, lateral and back
• controlled after reduction by pressure over superficial ring (go through superficial only) vs deep ring (go through deep then superficial)
• less commonly in scrotum vs more commonly
• rarely strangulate due to wide hernia neck vs may strangulate at superficial ring (narrow)
• readily reduces on lying down vs not
• more common in old men vs young adults and infants
Inguinal vs femoral hernia location
• inguinal above and medial to pubic tubercle
• Femoral inferior and lateral
Most common cause indirect inguinal hernia?
Congenital -patent processus vaginalis and weakened fascia at deep ring
Where does indirect inguinal hernia enter the inguinal canal?
Deep inguinal ring (and commonly through superficial ring into scrotum)
Most common cause direct inguinal hernia?
Weak abdominal muscles and comorbid conditions causing raised intra-abdominal pressure
Where does direct inguinal hernia herniate?
Through posterior wall of inguinal canal through Hesselbach’s triangle then through superficial ring
Name 5 types external hernias in order of how common they are
• Inguinal 80%
• Incisional 10%
• femoral 5%
• umbilical
• epigastric
Name the borders of Hesselbach’s triangle
• Lateral: inferior epigastric artery
• medial: lateral border rectus abdominis
• inferior: inguinal ligament
Name symptoms inguinal hernia (2)
• Heavy discomfort around gut
• constipation
Name clinical presentation inguinal hernia (3)
• Intermittent bulge in groin related to exertion or long standing periods
• valsalva maneuver or cough can reproduce symptoms of discomfort and lump enlargement
• may be uncomfortable on examination
Name 8 risk factors inguinal hernia
• History hernia
• elderly
• male
• Caucasian
• chronic cough
• chronic constipation
• smoking
• abdominal wall trauma
4 CS : cirrhosis, cardiac failure, cancer, catheter (dialysis)
Surface anatomy of deep inguinal ring?
2 cm above midpoint of inguinal ligament
Surface anatomy of superficial inguinal ring?
Above and medial to pubic tubercle
Differential diagnosis for groin lump? (10)
• Hernia: femoral, inguinal
• Vascular: femoral artery aneurysm, saphenous varix, varicocele
• lymph: inguinal lymphadenopathy, lymphoma
• soft tissue/bone: lipoma, groin abscess, rhabdomyosarcoma, bone tumour
• nerves: neuroma
• other: undescended testes, hydrocele of spermatic cord undescended
Define richter’s hernia
Segment of bowel wall is trapped and ischaemic but lumen is patent
Treatment inguinal hernia? (7)
• To prevent recurrence: decrease intra-abdominal pressure by weight loss, avoid heavy lifting., treat chronic cough and constipation
• surgically reduce bowel, excise hernia sac and reinforce posterior wall by:
- open herniotomy: remove hernia sac only. Do in kids
-Open herniorrhaphy: herniotomy and repair of posterior wall of inguinal canal ie shouldice repair (non- mesh technique- a continuous back and forth sutures with permanent sutures)
-Open hernioplasty: re-inforce posterior inguinal canal wall with synthetic mesh ie Lichtenstein tension free mesh repair
- laparoscopic Tapp (trans-abdominal pre-peritoneal) repair
- laparoscopic totally extra-peritoneal repair tep
Always open , laparoscopic only if recurrent or bilateral.
Name 5 immediate post op complications of surgical treatment of inguinal hernia
• Bruise
• wound haematoma
• scrotal haematoma
• acute retention of urine,
• pain
Name 4 late post op complications of surgical treatment of inguinal hernia
• Mesh infection
• recurrence 10% in 10 years
• nerve injury
• ischaemic orchitis
Approach to examination inguinal hernia? (7)
• Patient standing
• patient squatting:
Inspect - lump above or below inguinal lig, scrotal lump, estimate dimensions, skin changes, previous scars, other side, abdominal distension or mass
Palpate - tender, can get above lump, can palpate testes, consistency, fluctuant, size, tender, landmark for pubic tubercle to show its above and medial, deep inguinal ring, palpable cough impulse, try to reduce, describe point of reduction
• supine: reduce, locate deep inguinal. ring and hold, then ask patient to sit, swing over bed and stand
• standing; do cough impulse. If remains reduced, indirect. If not, direct. Not very accurate
Remove pressure and watch if comes out oblique (indirect) or forward (direct)
Percuss and auscultale for bowel sounds
Name 5 differences between inguinal and femoral hernia
• Appear through superficial ring vs femoral canal
• superior and medial to pubic tubercle vs inferior and lateral
• usually reducible vs not
• expansive cough impulse usually present vs absent
• low risk strangulation vs high
Name 10 risk factors incisional hernia
Pre-operation
• elderly
• malnutrition
• diabetes
• morbid obesity
• increased abdominal pressure secondary to chronic bronchitis, Ascites
• chronic disease (ESRF, CLD, malignancy) ; steroids
Intra-op
• wrong suture material
• wrong technique
Post-op
• wound breakdown/haematoma
• ischaemic wound due to excessive tension
• complications: anastomotic leaks, infection, post-op alelectasis and chest infection
Treatment umbilical hernia?
Mayo’s “vest over pants” operation
