Hernias

Question 1

Hernia

Answer 1

weakness/discontinuity in a cavity wall (muscle/fascia) which allows a body organ (e.g. bowel) to pass through that cavity wall where it normally would be contained

Question 2

Richter’s hernia

Answer 2

protrusion and/or strangulation of part of the intestine’s antimesenteric border through a rigid small defect in the abdominal wall. only the antimesenteric wall of the bowel herniates without compromising the entire lumen.

Question 3

Richter’s hernia clinical presentation

Answer 3

present with strangulation without symptoms of obstruction
progress more rapidly to gangrene
the terminal ileum is most frequently involved

Question 4

Richter’s hernia Mx

Answer 4

should be operated on immediately

Question 5

Congenital hernias

Answer 5

typically close spontaneously by 5 years of age
surgical intervention is rarely necessary.
Congenital indirect inguinal hernias are Usually due to patent processus vaginalis. More common in younger males

Question 6

Reducible hernia

Answer 6

Can be flattened out with changes in position e.g. lying down, or by applying pressure

Question 7

Irreducible hernia

Answer 7

Cannot be replaced into its position when pressed. Usually suggests incarceration/strangulation

Question 8

Hernia risk factors

Answer 8

Persistently raised intra-abdominal pressure
Obesity
Ascites
pregnancy
Age
Surgical wounds
Weight lifting
COPD ( due to coughing)
intrabdominal tumours
chronic cough

Question 9

Hernia clinical presentation

Answer 9

A soft lump
may protrude on coughing or standing
Aching or dragging sensation

Question 10

Hernia clinical examination

Answer 10

Inspection
Scars, distension ( obstruction as result of hernia?)
Ask patient to cough
lift head off the pillow to contract abdominal muscles can help see an incisional hernia
Palpation
Tender? Skin changes?
Reducible?
Pulsatile?
Extend into scrotum? If due to a hernia- cannot get above. Will not transilluminate ( a hydrocele would)

Question 11

Hernia Ix

Answer 11

Typically a clinical diagnosis

Ultrasound - to confirm

CT - usually reserved for patients presenting with complications

Question 12

Incarceration

Answer 12

the hernia cannot be reduced back- irreducible

Question 13

Strangulation

Answer 13

hernia is non-reducible
blood supply to hernia tissue is cut off - bowel becomes ischaemic

Question 14

Signs of strangulation

Answer 14

tenderness at site, severe pain out of proportion to signs, may be gangrenous
painful irreducible bulge
N&V
mechanical obstruction will lead to a tender distended abdomen with absent bowel sounds
Edematous, erythematous, warm overlying skin
Potentially fever

Question 15

Femoral hernia epidemiology

Answer 15

slender, often older females , multiparous women
and are more prone to strangulation

Question 16

Femoral hernia location

Answer 16

below the inguinal ligament
lateral and inferior to the pubic tubercle
Medial to femoral pulse (which is 1/3 way from ASIS to pubic symphysis)

Question 17

differentials to exclude for femoral hernias:

Answer 17

Lymphadenopathy/lymphadenitis
Abscess
Femoral artery aneurysm
Hydrocoele or varicocele in males
Lipoma
Inguinal hernia

Question 18

Inguinal hernia

Answer 18

Protrusion of abdominal or pelvic contents through a dilated internal ring or attenuated inguinal floor in the inguinal canal. An inguinal hernia bulge lies in the line of the inguinal ligament between the anterior iliac spine and pubis.

Question 19

inguinal triangle

Answer 19

The inguinal triangle is an area of potential weakness in the abdominal wall, where herniation can occur

Question 20

borders of hesselbach’s/inguinal triangle

Answer 20

Recus abdominis (medial boarder)
Inferior epigastric vessels (superior/lateral boarder)
Poupart’s ligament (AKA inguinal ligament) (inferior border)

Question 21

Direct inguinal hernia

Answer 21

Occurs medially to inferior epigastric vessels
Can exit the canal via superficial inguinal ring and form a lump in the scrotum or labia majora.

Question 22

Indirect inguinal hernia

Answer 22

Occurs laterally to inferior epigastric vessels
passes through superficial and deep rings
Indirect hernia has no reappearance on coughing when covering the deep inguinal ring
more common than direct
more at risk of strangulation than direct

Question 23

Differentials inguinal hernia

Answer 23

Femoral hernia
Lymph node
Saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
Femoral aneurysm
Abscess
Undescended/ectopic testes
Kidney transplant

Question 24

Inguinal hernia Mx

Answer 24

Small asymptomatic - referral for open repair with mesh
Large/symptomatic -
Open mesh repair
laparoscopic repair ( bilateral and recurrent hernias)

A truss (or a wearable device that compresses the tissues over the inguinal canal) used for pts where surgical intervention represents a very significant risk, w life expectancy is limited, or refuse repair

Question 25

Hiatus hernia

Answer 25

herniation of the stomach through the diaphragm

Question 26

Sliding hiatal hernia

Answer 26

(80%) The gastro-oesophageal junction slides up into the chest. A less competent sphincter results in acid reflux. Treatment is similar as for GORD.

Question 27

Rolling hiatal hernia

Answer 27

(20%) The gastro-oesophageal junction remains in the abdomen but part of the stomach protrude into the chest alongside the oesophagus. This type needs more urgent treatment as volvulus can result in ischemia and necrosis.

Question 28

Symptoms of hiatus hernia

Answer 28

Painful burning feeling in chest, often after eating ( heartburn)
Bring up small amount of food or acid
Bad breath
N +V
Difficulty when swallowing
Pain when swallowing
Haematemesis
shortness of breath
chronic cough

Question 29

Hiatus hernia Ix

Answer 29

diagnosed using barium swallows (upper GI series)
CXR- retrocardiac air bubble or normal
OGD
CT/MRI - when diagnosis not clear
Esophageal manometry/pH monitoring - additional confirmation

Question 30

Hiatus hernia conservative Mx

Answer 30

Lifestyle- losing weight, elevating the head of the bed, avoid large meals, meals just before bedtime, alcohol, and acidic foods.
Substances suspected to inhibit the lower esophageal sphincter should be avoided (nicotine, chocolate, peppermint, caffeine, fatty foods, and medications such as calcium-channel blockers, nitrates, and beta-blockers)

Patients with symptoms of GORD:PPI use for 4-8 weeks before assessing response

Question 31

Hiatus hernia surgical Mx

Answer 31

A loose Nissen’s fundoplication
hiatus herniorrhaphy
Gastric resection is reserved for patients with irreversible ischaemia or necrosis

Question 32

Epigastric hernia

Answer 32

Hernia through linea alba above umbilicus
younger pts

Question 33

Paraumbilical hernia

Answer 33

Herniation occurring through the linea alba around the umbilical region

Question 34

Obturator hernia

Answer 34

The abdominal/ pelvic contents hernia through the obturator foramen due to a defect in the pelvic floor

Question 35

Obturator hernia epidemiology

Answer 35

women and elderly

Question 36

Obturator hernia clinical presentation

Answer 36

asymptomatic
irritation to the obturator nerve
paraesthesia along the medial thigh
Howship–Romberg sign: Pain extending from the inner thigh to the knee when the hip is internally rotated due to compression of the obturator nerve

Question 37

Incisional hernia

Answer 37

Occur at sites of previous operations due to inadequate closure of the muscle and tissues after the incision
difficult to repair, often left alone

Question 38

Spigelian hernia

Answer 38

hernia through abdominal wall between lateral border of rectus abdominis and linea semilunari

Question 39

congenital inguinal hernia

Answer 39

indirect hernias resulting form a patent processus vaginalis
premature baby boys its most common and 60% right sided
should be surgically repaired asap

Question 40

infantile umbilical hernia

Answer 40

Symmetrical bulge under the umbilicus
more common in premature and Afro-Carribean babies
vast majority resolve without intervention before 4-5 years