Hernias Flashcards
1
Q
What is a hernia?
A
A hernia is an abnormal protrusion of an organ or tissue through a defect in surrounding tissue structures
2
Q
What is a hernia sac?
A
While there is a defect in muscle and fascia, the peritoneum covers the hernia, forming a sac around the herniated contents
3
Q
Indirect ingunal hernia?
A
A congenital form of inguinal hernia in which the hernia contents enter the inguinal canal through the deep or internal inguinal ring
4
Q
Direct inguinal hernia?
A
An acquired form of inguinal hernia in which the hernia contents enter the inguinal canal “directly” through an area of weakness in the posterior wall of the canal
5
Q
Amyands hernia?
A
a rare form of an inguinal hernia which occurs when the appendix is included in the hernial sac
6
Q
Pantaloons hernia?
A
hernia with both direct and indirect components
7
Q
Richters hernia?
A
when the antimesenteric wall of the intestine protrudes through a defect in the abdominal wall
8
Q
Abdominal hernias?
A
an abnormal protrusion of intra-abdominal contents through congenital/acquired areas of weakness in the abdominal wall.
9
Q
Four categories of anatomically classified abdominal wall hernias?
A
- ventral
- groin
- pelvic
- flank
10
Q
Types of ventral hernias?
A
- epigastric
- umbilical
- incisional
- Spigelian
- parastomal
11
Q
Epigastric hernia?
A
herniation through the linea alba, between the xiphoid process and the umbilicus
12
Q
What is an umbilical hernia?
A
occurs at the umbilicus when a loop of intestine pushes through the umbilical ring
13
Q
Incisional hernia?
A
Herniation of intra-abdominal contents through an abdominal wall defect created during a previous abdominal surgery
14
Q
Spigelian hernia?
A
a rare type of hernia that can occur anywhere along the semilunar line; most commonly below the arcuate line (i.e., below the umbilicus)
15
Q
Parastomal hernia?
A
herniation through a surgically created abdominal wall defect (i.e., a stoma)
16
Q
Types of groin hernias?
A
- Inguinal hernia (direct/indirect)
- Femoral hernia
17
Q
Types of pelvic hernias?
A
- obturator
- sciatic
- perineal
18
Q
Obturator hernia?
A
herniation through the obturator foramen, especially the right side
(since the sigmoid colon blocks the obturator canal on the left)
19
Q
Sciatic hernia?
A
herniation through greater or lesser sciatic foramen
20
Q
Perineal hernia?
A
herniation through the pelvic floor
21
Q
Types of flank hernias?
A
- incisional
- superior lumbar
- inferior lumbar
22
Q
Incisional hernias?
A
Herniation of intra-abdominal contents through an abdominal wall defect created during a previous abdominal surgery
23
Q
Superior lumbar hernia?
A
herniation through the superior lumbar triangle
24
Q
Inferior lumbar hernia?
A
herniation through the inferior lumbar triangle
25
What is a reducible hernia?
Hernial contents completely return to the abdominal cavity through the abdominal wall defect on lying down or upon application of mild external pressure
26
Clinical features of reducible hernia?
1. manifest as an asymptomatic nontender mass.
2. Increases on straining (e.g., sitting up from a recumbent position)
3. Decreases completely on lying down
4. Visible cough impulse present: expansion of the hernia when the patient is asked to cough
5. Edges of the fascial defect are palpable
6. Bowel sounds may be heard over the mass (if the hernial content is bowel)
27
What is an irreducible/incarcerated hernia?
Hernial contents become adhered to the hernial sac and cannot be reduced into the abdominal cavity
28
Clinical features of irreducible/incarcerated hernia?
1. Irreducible nontender mass
2. Visible cough impulse present
3. May decrease partially on lying down
4. Increased risk of obstruction and strangulation
29
What is an obstructed hernia?
The abdominal wall defect acts as a tourniquet around the hernial contents, causing edema and distension of the hernial contents.
30
Clinical features of obstructed hernia?
1. Acute pain at the site of the hernia
2. Features of closed-loop bowel obstruction (if the hernial content is bowel)
3. Absent cough impulse
4. Ischemia and necrosis of the hernial contents due to compromised vascular supply
5. Signs of strangulation
6. A tender, irreducible hernia
7. Absent cough impulse
8. Edematous, erythematous, warm overlying skin
9. Toxic appearance, fever, signs of sepsis
10. May lead to intestinal gangrene
11. Fatal if left untreated The smaller the hernial orifice, the higher the risk of incarceration
31
Diagnostics for hernias?
Usually a clinical diagnosis
- Imaging: indicated if the diagnosis is unclear and/or to identify contents of the hernial sac (e.g., loops of bowel)
32
What kind of imaging is used in diagnosing hernias?
1. ultrasound
2. IV and oral contrast enhanced CT scan
3. abdominal x-ray
33
Indication and findings of an ultrasound?
Indication: especially useful to identify ventral hernias
e.g., epigastric, Spigelian, incisional, or umbilical hernia
Findings: abdominal wall defect with/without protrusion of intra-abdominal contents through it
34
Indication and findings of an IV and oral contrast enhanced CT scan?
Indications: useful for suspected hernias that may be difficult to identify on physical examination
e.g., lumbar, obturator, perineal or sciatic hernia
Findings: abdominal wall defect with/without protrusion of intra-abdominal contents through it
35
Indications and findings of an abdominal x-ray?
Indicated if an obstructed and/or strangulated hernia is suspected
Findings: features of bowel obstruction
- Dilated bowel loops proximal to obstruction
- Collapsed bowel loops distal to obstruction
- Multiple air-fluid levels within dilated bowel loops
36
Differential diagnosis of a ventral hernia?
1. Diastasis recti: a > 2 cm separation of the right and left rectus abdominis muscle with resultant protrusion of abdominal organs on straining
2. In newborns: omphalocele, gastroschisis
3. Abdominal wall tumor (e.g., desmoid tumor)
4. Lipoma
5. Rectus sheath hematoma
37
Differential diagnosis of pelvic and groin hernias?
1. Inguinal lymphadenopathy
2. Cryptorchid testes
3. Lipoma
4. Femoral artery aneurysm
38
Differential diagnosis of a strangulated hernia?
1. Abscess
2. Hematoma
3. Lymphadenitis (strangulated groin hernias)
39
Surgical treatment of hernias?
Surgical hernia repair is recommended for the management of most abdominal hernias.
1. Surgery: open or laparoscopic tension-free closure of the abdominal wall defect with/ without a mesh
2. Elective surgery is indicated in reducible and incarcerated hernias.
3. Emergency surgery is indicated in obstructed or strangulated hernias.
40
Conservative management (observation) is indicated in?
1. Congenital umbilical hernia in children < 5 years of age
2. Asymptomatic wide-necked hernias in patients with high operative risk
- A truss or corset may be considered in these patients to decrease the risk of obstruction and strangulation.
41
Incisional hernia?
Herniation of intra-abdominal contents through an abdominal wall defect created during a previous abdominal surgery
Incidence: 15% of patients who have undergone abdominal surgery develop incisional ∼ hernias
42
Risk factors of incisional hernias?
1. Upper midline laparotomy incisions (highest risk)
2. Wound dehiscence
3. Postoperative wound infection
4. Poor wound healing
5. Emergency abdominal surgeries
43
Clinical features of incisional hernias?
1. Most ( 75%) incisional hernias occur within 3 years of surgery
2. Mass/protrusion at the site of the incisional scar which increases with coughing/straining
3. Edges of the hernial defect can be palpated on reducing the hernia
44
Conservative management in incisional hernias is indicated in?
1. Asymptomatic incisional hernias, with a wide neck;
2. Patients who are at a high anesthetic risk (advanced age, multiple comorbidities)
45
Surgery in incisional hernia is indicated in?
1. symptomatic/complicated hernias or those with a narrow neck.
2. Small incisional hernias (< 3 cm defect): primary repair
3. Larger incisional hernias: hernioplasty (mesh repair)
46
Types of umbilical hernias?
1. Congenital umbilical hernia
- Site of hernial defect, Umbilical orifice
2. Acquired umbilical hernia (Paraumbilical hernia)
- Adjacent to the umbilical orifice (superior/inferior/lateral)
47
Epidemiology of umbilical hernias?
Present in ∼ 15% of infants
Accounts for ∼ 5% of all adult abdominal hernias
Site of hernial defect , Umbilical orifice
48
Etiology of umbilical hernias?
Failed spontaneous closure of the umbilical ring → patent umbilical orifice
- Acquired abdominal wall defect
49
Risk factors for umbilical hernias?
1. Persistently raised intra-abdominal pressure
2. Other congenital anomalies (e.g., Down syndrome, trisomy 18, congenital hypothyroidism)
3. Persistently raised intraabdominal pressure
50
Clinical features of umbilical hernias?
1. Mass protruding through the umbilicus
2. Mass increases on crying/coughing/straining; reduced in size on lying down
3. Hernia can be completely reduced (unless incarcerated)
4. Mass protruding adjacent to the umbilical orifice pushing the umbilicus into a crescent shape
5. Fascial defect is small
51
Risk of developing complications (Incarceration/ obstruction/ strangulation) ?
1. Low , High Treatment
2. Conservative: 90% will spontaneously close by 5 years of age ∼
3. Surgery (rarely necessary)
4. Large umbilical hernias (defect > 2 cm or protuberant hernias)
5. No evidence of spontaneous closure by 5 years of age
6. Incarcerated, obstructed, or strangulated umbilical hernias
7. Surgery (primary repair/mesh plasty): all paraumbilical hernias
52
Differential diagnoses of umbilical hernias?
1. Omphalocele
2. Gastroschisis
3. Supraumbilical hernia
4. Epigastric hernia
5. Spigelian hernia
53
What is an inguinal hernia?
An inguinal hernia is an abnormal protrusion of intra-abdominal contents through the inguinal canal
54
Direct hernia?
protrusion of abdominal and/or pelvic contents directly through the weakened posterior wall of the inguinal canal
- medial to the inferior epigastric artery
> herniates through the superficial (external) ring
Note: within Hasselbach Triangle
55
Indirect hernia?
protrusion of abdominal and/or pelvic contents into the inguinal canal through the deep inguinal ring
- lateral to the inferior epigastric artery
> runs from the deep inguinal ring through the inguinal canal to the superficial (external) inguinal ring
Note: outside the Hasselbach triangle
56
Presentation of inguinal hernias?
- asymptomatic, presenting as a painless swelling in the groin.
Note:
Pain and features of intestinal obstruction are signs of a complicated inguinal hernia
i.e. obstructed/strangulated hernia
57
Surgical repair of an inguinal hernia?
Surgical repair is the definitive treatment.
1. Elective open/laparoscopic mesh repair of the inguinal hernia is the standard of care for uncomplicated inguinal hernias.
2. Emergency surgery which may include resection of gangrenous bowel is indicated in patients with complicated inguinal hernias.
58
Epidemiology of inguinal hernias?
1. 5–10% In the US
2. Inguinal hernias are the most common type of hernias (75% of all cases)
3. Indirect inguinal hernia > direct inguinal hernia
4. Responsible for one of the most common general surgical procedures in the United States
5. Sex: ♂ > ♀
6. Age
> Indirect inguinal hernia - most commonly seen in male infants and older men
> Direct inguinal hernia - most commonly seen in older men
59
Classification of risk factors?
1. congenital
2. genetic
3. demographic
4. age
5. factors that increase intra-abdominal pressure
6. acquired factors that weaken tissue
60
Congenital risk factors?
1. Congenital weaknesses of the abdominal wall musculature
- increased amount of type III collagen (thinner) relative to type I collagen (thicker) increases the risk of inguinal hernias
2. Presence of patent processus vaginalis (PPV).
61
Genetic risk factors?
Family history
- Family history seems a strong risk factor for developing an inguinal hernia, increasing risk eight times.
62
Demographic risk factors?
Male sex
- Recall that males have a 27% lifetime risk of developing an inguinal hernia compared to the lifetime risk of 3% for females
63
Age as a risk factor for herniation?
Increasing age
- As we age, tissues weaken, predisposing individuals to the development of all types of hernias
64
Factors that increase intra-abdominal pressure that put you at risk for herniation?
1. Strenuous physical activity and hard labor
2. Chronic cough
- related to COPD, chronic bronchitis, or asthma.
3. Chronic constipation
4. Prostatism or lower urinary tract obstruction with increased urinary straining
5. Pregnancy
6. Ascites
65
Acquired factors that weaken tissue and put you at risk for herniation?
Smoking and uncontrolled diabetes are factors that impair collagen synthesis and degrade existing collagen.
66
Boundaries of the inguinal canal?
Extends between the deep (internal) and superficial (external) ring
1. Roof (superior): internal oblique and transversus abdominis muscles
2. Anterior wall: external oblique aponeurosis and internal oblique muscle laterally
3. Floor (inferior): inguinal ligament (shelving edge of external oblique) and lacunar ligament (medially)
4. Posterior wall: transversalis fascia laterally; conjoint tendon medially
67
Hasselbach triangle borders?
Medially: rectus abdominis muscle
Laterally: inferior epigastric vessels
Inferiorly: inguinal ligament
68
Pathophysiology of direct inguinal hernia?
Acquired condition
1. Caused by weakening of the transversalis fascia
2. Commonly secondary to conditions resulting in increased intraabdominal pressure
e.g., chronic obstructive pulmonary disease with chronic coughing, constipation
3. May be associated with long-term glucocorticoid use
69
Where are direct inguinal hernias located?
- Medial to the inferior epigastric blood vessels (within Hesselbach triangle) and lateral to the rectus abdominis
- Hernial sac protrudes directly through the posterior wall of the inguinal canal (without involvement of the spermatic cord or round ligament of the uterus)
- Only hernias through the superficial (external) ring Only surrounded by the external spermatic fascia
70
Pathophysiology of indirect inguinal hernia?
- Most commonly results from incomplete obliteration of processus vaginalis during fetal development (but can also be acquired).
Note: May not become apparent until adulthood despite being present since birth
71
Where are indirect inguinal hernias located?
- Runs from the deep inguinal ring through the inguinal canal to the superficial (external) inguinal ring (in men, along with the spermatic cord)
- Surrounded by the external spermatic fascia, cremasteric muscle fibers, and internal spermatic fascia
72
Clinical features of an inguinal hernia?
1. Visible, palpable groin protrusion or bulge
2. Inguinal pain (does not have to correlate with the size of the hernia)
3. Increase of symptoms during physical activity (walking or standing, coughing, sneezing, abdominal pressure)
4. Indirect inguinal hernia may be associated with a communicating hydrocele
73
Describe how you palpate the inguinal hernia?
1. With the patient standing, palpate from the scrotal skin towards the superficial (external) inguinal ring.
2. Ask the patient to cough or strain and bear down (Valsalva maneuver).
- Bulging can be felt with a fingertip (expansile cough impulse).
74
Diagnosing an inguinal hernia?
Inguinal hernia diagnosis is typically established based on medical history and physical exam findings
Note: CT/MRT: to distinguish from differential diagnoses in ambiguous cases
75
Differential diagnoses?
1. Varicocele, hydrocele, and spermatocele
2. Femoral hernia
3. (Testicular) tumor
4. Abscess
5. Lymphoma
6. Testicular torsion
7. Inguinal lymphadenitis
8. Femoral artery aneurysm
76
Treatment of inguinal hernias?
1. Emergent repair of a hernia is indicated when strangulation is suspected or confirmed.
2. You should suspect strangulation in a patient with an incarcerated hernia who presents with or develops fever, leukocytosis, hemodynamic instability, or erythema of the overlying skin.
3. Incarceration with intestinal obstruction should be repaired urgently.
4. Patients with incarceration or strangulation are more likely to need IV Fluids, NGT.
5. If a perforation from strangulation is suspected or confirmed, antibiotic coverage should be part of the resuscitation efforts.
77
What is taxis of an incarcerated hernia? Importance?
manual reduction of an incarcerated hernia
- may convert an urgent case to an elective or semi-elective case and reduce the morbidity associated with more urgent repairs.
- Therefore, you should attempt reduction of any incarcerated hernia that is not strangulated
78
When should you attempt to reduce an incarcerated hernia?
when patient with an incarcerated hernia does not have any signs or symptoms of strangulation
Note:
Because there is a possibility that an unrecognized portion of ischemic or necrotic bowel could be reduced into the abdomen, it is wise to observe patients following manual reduction for any change in clinical condition that might indicate this situation
79
Describe manual reduction in an incarcerated hernia?
Reduction is best with good pain control and often some light sedation.
The patient should be placed in reverse Trendelenburg, which allows gravity to help reduce the hernia.
In children flexing and externally rotating the ipsilateral hip (frog-leg position) can facilitate reduction as it straightens the inguinal canal.
A cold pack may be applied to the groin to reduce swellin
80
Indications for treatment in inguinal hernia repair?
1. Uncomplicated hernia + moderate symptoms
- Inguinal pain associated with exertion
2. Daily activities are limited due to pain
3. Manual reduction is not possible
4. Uncomplicated hernia + mild symptoms
- elective hernia repair
81
What is open hernia repair?
reinforcement of the posterior wall of the inguinal canal with synthetic mesh or primary tissue approximation
82
Open tissue repair procedures?
1. Bassini repair
- repairs direct and indirect inguinal hernias
2. Shouldice repair
- repairs direct and indirect inguinal hernias, and
3. McVay repair
- repairs both inguinal and femoral hernias.
83
Tension free repair?
Lichtenstein repair
- mesh repair
84
Laparoscopic repair?
1. Transabdominal preperitoneal repair (TAPP)
2. Total extraperitoneal repair (TEP)
85
Indications for open hernia repair?
1. Complicated hernias
2. Previous preperitoneal surgeries
e.g., hysterectomy, cesarean section
3. Presence of ascites
4. Inability to undergo surgery under general anesthesia
5. Recurrent hernia (if the patient initially had a laparoscopic hernia repair)
86
What is laparoscopic hernia repair?
1. Bilateral hernia
2. Recurrent hernia (if the patient initially had an open hernia repair)
87
Mesh vs non mesh surgical repair?
Mesh is preferred because of decreased recurrence rates and postoperative pain. It is contraindicated in the case of inguinal infection or contamination
88
Conventional (open) surgical procedures?
1. Lichtenstein repair:
reinforcement by implementation of a synthetic mesh between the abdominal internal oblique muscle and the aponeurosis of the abdominal external oblique muscle
2. Shouldice repair
doubling of the transverse fascia and fixation of the abdominal internal oblique muscle and transverse muscle at the inguinal ligament by suture (a non mesh repair)
89
Laparoscopic surgical procedures?
1. Transabdominal preperitoneal repair (TAPP)
- laparoscopic, preperitoneal mesh implementation between the parietal peritoneum and transverse fascia
2. Total extraperitoneal repair (TEP)
- laparoscopic, extraperitoneal mesh implementation between parietal peritoneum and transverse fascia
90
Choice of which repair to do is based on?
The choice of which repair to perform depends on the type of hernia and patient's risk factors.
Note: Recurrence after surgical intervention is 0.5–15% depending on the surgical procedure
91
Patient risk factors for hernias?
92
Risks of surgery?
1. Vas deferens injury
2. Spermatic vessels injury, dissection, or constriction, which may lead to testicular necrosis
3. Injury to femoral nerve, artery, or vein
4. Chronic inguinal pain
5. Bladder injury
93
Complications of hernias?
1. Incarcerated hernia
2. Strangulated hernia
3. Symptoms of bowel obstruction
4. Symptoms of intestinal necrosis: pain and erythema in the lower abdomen and scrotum
5. Possible intestinal perforation and/or peritonitis
6. Possible systemic inflammatory response syndrome (SIRS)
94
What is an incarcerated hernia?
inability to reduce the hernia back into abdominal cavity; fixation of contents in the hernial sac
Note: Surgical emergency in case of concurrent bowel obstruction
95
What is a strangulated hernia?
tight constriction of hernial contents leading to constriction of blood vessels, bowel ischemia, and necrosis
Note: Patients must undergo surgery within 4–6 hours to avoid possible bowel loss.
96
Epidemiology of inguinal hernia in infants?
Incidence: 1–5% of all children ∼ * ♂ > ♀ ( 4:1) ∼
Occurs more often on the right side
97
Etiology and risk factors of inguinal hernia in infants?
Due to patent processus vaginalis
Premature birth
Urogenital dysplasia syndromes
Increased intraabdominal pressure (e.g., gastroschisis, ascites, omphalocele)
Weakness of the connective tissue (e.g., Ehlers-Danlos syndrome)
98
Therapy for inguinal hernias in infants?
Premature infants with uncomplicated inguinal hernia: Surgery should be performed after discharge from the neonatal intensive care unit (NICU).
If hernia can be reduced manually: Wait 24–48 hours before performing surgery to allow enough time for edema to decrease.
If hernia cannot be reduced manually: immediate surgery
Asymptomatic inguinal hernia: within 14 days of diagnosis
99
What is a femoral hernia?
A femoral hernia is an uncommon type of inguinal hernia, in which intra-abdominal contents (e.g., intraperitoneal fat, mesentery, bowels) herniate into the femoral canal through the femoral ring.
100
Risk factors for femoral hernia?
1. old age,
2. female gender,
3. obesity,
4. previous hernia repair.
101
Presentation of femoral hernia?
present with a global swelling inferior to the inguinal ligament and medial to the femoral vein that worsens with coughing or straining.
102
Femoral hernia is diagnosed by?
is primarily clinical with ultrasonography being indicated if the diagnosis is inconclusive.
103
Complications of femoral hernias?
associated with a high risk of incarceration and strangulation
- therefore, be surgically treated as early as possible.
104
Treatment for femoral hernias?
1. non-complicated femoral hernias = mesh hernioplasty
2. complicated femoral hernias = repair without a mesh is used for
105
Epidemiology of femoral hernia?
Uncommon hernia ( 5% of all hernias)
Sex: ♀ > ♂ (3:1)
Peak incidence: 40–70 years
106
Etiology of femoral hernias?
Advancing age and female gender
Increased intra-abdominal pressure
Obesity
Chronic constipation
Chronic cough (e.g., due to COPD)
Straining during micturition (e.g., due to prostatic hypertrophy)
Multiparity
Previous abdominal surgeries (especially those involving the inguinal region)
In contrast to indirect inguinal hernias, which may occur congenitally, femoral hernias are almost always acquired
