Hernias Flashcards
What type of pain do you get from visceral stretching, inflammation or ischameia?
Where is it normally experienced?
Diffuse poorly defined
But often felt in the midline
Normally get nausea, vomiting and sweating
What are the 3 areas of viscera of the GI tract?
Foregut viscera
Midgut viscera
Hindgut viscera
Where is pain experienced if theres issue with the foregut viscera?
Epigastric area
Where is pain experienced if theres issue with the midgut viscera?
Peri-umbilical area
Where is pain experienced if theres issue with the hindgut viscera?
Supra-pubic area
Imagine the abdominal as a 3 by 3 grid, what are all the areas of the squares called?
(Look at end of lecture)
Top right = right hyperchondrium
Top middle = Epigastric
Top left = left hyperchondrium
Middle right = right flank
Middle = peri-umbilical
Middle left = left flank
Bottom right = right iliac fossa
Bottoms middle = suprapubic
Bottom left = left iliac
What Dermatomes is pain from the foregut experienced in?
T5-T9
What Dermatomes is pain from the midgut experienced in?
T10-T11
What Dermatomes is pain from the hindgut experienced in?
T12 - L2
What nerve is pain in the foregut associated with?
What spinal nerve roots form this nerve?
Greater splanchnic nerve
T5 - T9
What nerve is pain in the midgut associated with?
What spinal nerve roots form this nerve?
Lesser splanchnic nerve
T10 - T11
What nerve is pain in the hindgut associated with?
What spinal nerve roots form this nerve?
Least splanchnic nerve
T12 - L2
How do the visceral afferent nerves (sensory nerves leading from the organs) relate to the sympathetic nerves supplying the organs?
Follow the same path
Describe the sympathetic outflow of the abdomen:
The preganglionic fibres of T5 - L2 come out of spine, pass through the sympathetic chain, combine to form splanchnic nerves then synapse with pre-vertebral ganglia then lead out to postganglionic fibres ending up at viscera
Describe how the visceral sensory afferent nerves of the viscera run:
Run from organ back to the splanchnic nerves where they then spread across the spinal nerve roots that supply that splanchnic nerves ( that’s why pain from the viscera affects a broad area)
What is a Hernia?
A protrusion of an organ or contents of a cavity extending beyond the normal confines of that cavity through a weakness
What is an abdominal hernia?
Protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall
What is an incarcerated hernia?
Hernia that is stuck (non reducible
What is a reducible hernia?
Hernias that are not stuck and can be pushed back into place
What are the signs and symptoms of a reducible hernia?
Fullness or swelling
Gets larger when intraabdominal pressure increases
Aches
What are the signs and symptoms of incarcerated hernias?
Pain
Non reducible
Nausea and vomiting
Systemic problems if bowel becomes ischaemc
What causes hernias?
Weakness in cavity (congenital, post surgery, normal areas of weakness)
Anything increasing Intra-abdominal pressure (obesity, weightlifting, chronic constipation coughing)
What are the 3 parts to a hernia?
The coverings of the sac
The sac (visceral peritoneum)
Contents of sac (viscera)
What are some weaknesses in the abdominal wall that can lad to hernias?
Inguinal canal
Femoral canal
Umbilicus
Previous incisions (surgery)
What is the main type of hernia?
What side of the body does this happen on the most?
Inguinal hernia
Common on the right hand side
What are the 2 types of Inguinal hernia?
Direct Inguinal hernia
Indirect Inguinal hernia
What is the Inguinal canal?
Oblique passage through lower part of abdominal wall with the entrance deep in the peritoneal cavity
Where does the Inguinal canal run through in males?
Where does the Inguinal canal run through in females?
Males = abdomen -> testis
Females = uterus -> labium majus
What sex are Inguinal hernias most common in?
Males
When do the testis descend in males?
7th - 8th month
What is the processus vaginalis?
Pouch of peritoneal cavity that descends in front of/before the testis arrives in the scrotum
When the processus vaginalis obliterates what does it form?
Tunica vaginalis forming enveloping part of the testis
What is the gubernaculum?
Connective tissue which condenses can guides the testis into the scrotum
It becomes the ligament holding the testis in the scrotum
What can happen if the Processus vaginalis doesn’t obliterate at all?
There would be a connection between the peritoneal cavity and the scrotum which can lead to a scotral hernia
What can happen if the processus vaginalis only partially obliterates?
Inguinal hernias can form
What are the borders of the Inguinal canal?
Look at the last slide for an image
Anterior = external oblique
Floor = Inguinal ligament which is formed by the external oblique
Roof = aponeurosis of internal oblique (reinforced by aponeurosis of transverse abdominis
Posterior wall = transversalis fascia
What is the O and I of the inguinal ligament?
O = ASIS
I = Pubic tubercle
What 2 muscles forming borders of the inguinal canal form the conjoint tendon?
Internal oblique (aponeurosis)
Transverse aponeurosis
Where is the superfical ring located?
Where is the deep ring located?
Superficial = defect in aponeurosis in external oblique (anterior wall)
Deep = transversalis fascia (posterior wall)
What is the most common type of inguinal hernia?
Indirect hernia
What is a key landmark for determining whether an Inguinal hernia is direct or indirect?
Inferior Epigastric vessels
What direction do the inferior Epigastric vessels run??
Oblique angle outwards
What is meant by the location of a hernia?
Where the hernia first leaves its cavity
What is an indirect inguinal hernia?
Where does it come out with respect to the inferior Epigastric vessels?
When a bit of bowel or omentum pass through the deep ring of the inguinal canal up to the point where the processus vaginalis obliterates
Comes out lateral to inferior Epigastric vessels
What is a direct inguinal hernia?
When the hernia pushes through the anterior abdominal wall (usually through the Hesselbachs triangle) through the superfical ring down into the scrotum
DOES NOT TRAVEL THROUGH THE INGUINAL CANAL
Comes out medial to the inferior Epigastric vessels
What forms the borders of Hesselbachs triangle?
Look at the last slide and look at the triangle
Medial border = Rectus abdominis (lateral border)
Inguinal ligament
Lateral border = inferior Epigastric vessels
Floor = inguinal ligament
What is significant about Hesselbachs triangle?
Weakness in abdominal wall where direct inguinal hernias normally occur
When can indirect inguinal ligaments enter the scrotum?
When processus vaginalis gets obliterated quite far along
Where do indirect inguinal hernias emerge w.r.t the inferior Epigastric vessels?
What about direct inguinal hernias?
Indirect inguinal hernias = lateral to
Direct inguinal hernias = medial to
Why are femoral hernias more common in females?
They have a wider bony pelvis/larger femoral angle (femoral canal therefore larger)
What does NAVEL (NAVY) represent in terms of the femoral triangle?
Structures from lateral to medial
Femoral nerve
Femoral artery
Femoral Vein
Empty space (femoral canal)
Lymphatics
Why is the femoral canal important?
The empty space allows the femoral vein to expand as it fills with blood
How does an Umbilical hernia normally present?
Infants
Bulge at umbilicus
Not usually painful
Usually resolves itself
What is a paraumbilical hernia?
Umbilical hernia in adults
Where the hernia goes through the linea alba in the region of the umbilicus
How frequent are paraumbilical hernias?
Don’t often form since canal is small but if it does form likely to become incarcerated acted since canal is small
What is meant by a hernia being strangulated?
The blood supply is disrupted which can lead to tissue necrosis
What are the symptoms of hernias dependant on?
Name some symptoms:
Based on what happens if loops of bowel get trapped
What is diverticulitis?
Inflammation of diverticular in the large intestine (descending colon)
Where would pain be experienced with diverticulitis?
On LHS (L flank and left iliac fossa)
What is cholecystitis?
Inflammation of the gall bladder
How is the pain experienced in cholecystitis and why?
Experienced in waves
The release of cholecystokinin leads to the gall bladder contracting causing the pain waves
Where is the pain for appendicitis experienced?
Always starts in suprapubic area and spreads to the right (right iliac fossa) due to the visceral afferent as
