Hernias

Question 1

What are the risk factors for hernias?

Answer 1

High: Gender, Age, Obesity, Prostatectomy, Inheritance
Moderate: Ehlers Danlos
Low: Smoking, Chronic Constipation, Occupational
Very Low: COPD and Cough

Question 2

What is the clinical presentation of inguinal hernia (5)

Answer 2

1. Intermittent bulge in groin associated with exertion or standing
2. Pain in groin without bulge
3. Lying flat relieves symptoms
4. Valsalva manoevere reproduces symptoms
5. Incarcerated results in Abdo Distention + Pain + N/V

Question 3

Radiological Imaging to evaluate Inguinal hernias?

Answer 3

1. Dynamic US
2. AXR
3. CT AP

Question 4

What are the complications of an inguinal hernia?

Answer 4

1. Incarcerated
2. Obstructed
3. Strangulated

Question 5

What should be done in a strangulated hernia (steps)?

Answer 5

1. NBM
2. IV Drip
3. NG Tube with low-intermittent suction
4. IV Abx
5. Pre-op investigations
6. Emergent Surgery

Question 6

Can you have ischemic bowel due to hernia but without IO?

Answer 6

Yes. Richter’s Hernia

Question 7

What are the clinical differences between an indirect or direct inguinal hernia?

Answer 7

1. Indirect lies lateral to the inferior epigastric vessel; direct lies medial
2. Indirect is reduced back, out and up; direct is reduced back
3. Indirect risk of strangulation at superficial ring; direct low risk
4. Indirect can descend into scrotum
5. Indirect not reduced on lying down
6. Indirect controlled by pressure over deep ring; direct over superficial

Question 8

Management of Inguinal Hernias?

Answer 8

Watchful waiting
Hernia Truss

Open:
- Herniotomy
- Herniorrhaphy*
- Hernioplasty
*Shouldice (Layered closure (1) TF to IO and TA; (2) EO to IO fascia; Bassini: Suture conjoint tendon to inguinal ligament from pubic tubercle to deep ring; McVay repair: conjoint tendon to pectineal ligament to inguinal ligament

Laparoscopic
- TEP
- TAPP
–myopectineal orifice approached posteriorly and allows for inguinal, femoral and obturator hernia repairs to be performed simultaneously

Question 9

What are the boundaries of the myopectineal orifice?

Answer 9

Medially: Lateral border of the rectus abdominis
Laterally: Iliopsoas
Inferiorly: Bony margin of Pelvis
Superior: TF and IO

Question 10

Complications of Hernia Surgery?

Answer 10

Early
- ARU
- Hematoma
- Seroma
- nerve damage (ilioinguinal, lateral femoral cutaneous)
- wound infection

Late
- Chronic pain
- Injury to vas deferens
- Recurrence
- Ischemic Orchitis (thrombosis of pampiniform plexus)
- Testicular Atrophy (testicular artery damage)
- Meshoma (folding of mesh)

Question 11

What are the differentials for a groin swelling?

Answer 11

Hernias: Femoral/Inguinal
Vascular: Hematoma, Saphena Varix, Femoral Artery Aneurysm
Soft Tissue/Bone: Tumours,
Others: Hydrocele, Varicocele, Undescended Testes, Cord Lipoma
Nerve: Femoral Nerve Neuroma
Lymphatics: Inguinal Nerve Lymphadenopathy, Lymphoma

Question 12

Tell me about femoral hernias

Answer 12

1. Uncommon
2. 70% women (pelvis wider so femoral canal wider)
3. 25% strangulated/incarcerated
4. Femoral Canal’s opening is the femoral ring (anterior: inguinal ligament; posterior: pectineal ligament; medially: lacunar ligament; laterally: femoral vein
5. the canal’s original function is a dead space for expansion of the femoral vein
6. 5 features that make it different from inguinal hernias: in the femoral canal, easily strangulated, no cough impulse, not reducible, inferior and lateral to PT
7. Investigate using CT AP
8. Management: Infra-inguinal (for femoral hernia only), Trans-inguinal (covers both inguinal and femoral hernia), Supra-inguinal (for strangulated)
9. Complications of Surgery: Same as inguinal hernia + damage to femoral vein

Question 13

What is an umbilical hernia

Answer 13

Hernia with the primary defect being in the middle in the centre of the umbilical ring

Question 14

What is the classifications of umbilical hernias

Answer 14

Small (<1cm)
Moderate (1-4cm)
Large (>4cm)

Question 15

Types of umbilical hernias

Answer 15

True
Para

Question 16

For the different types of umbilical hernia, what are the causes?

Answer 16

Pregnancy, Obesity and Liver Ascites

Question 17

Management of umbilical hernia?

Answer 17

SMall: Primary Surgical Repair
Moderate: Open Repair with Mesh (3cm overlap) + sublay mesh repair
Large: Lap Intra-peritoneal Onlay Mesh + Closure of Defect (aim for 5cm overlap)

Question 18

Complications of Surgery of Umbilical Hernia

Answer 18

1. Same
2. Injury to viscera

Question 19

What is an incisional hernia

Answer 19

Extrusion of the peritoneum & abdominal contents through a weak scar or accidental wound on the abdominal wall.

Question 20

Management of incisional hernia?

Answer 20

Primary Repair with Mesh
- Onlay
-Sublay
- Underlay
- Open vs Lap

Question 21

Complications of umbilical hernia?

Answer 21

1. Usual
2. Enterocutaneous Fistula

Question 22

Distinguishing between the differentials of hernias

Answer 22

1. Femoral Artery Aneurysm (Pulsatile mass at mid inguinal pt)/Saphena Varix (cough impulse over saphena varix)/Hematoma(history of trauma, ecchymoses)
2. Tumors – Constitutional Symptoms
3. Inguinal Lymphadenopathy – Constitutional Symptoms, Fever
4. Abscess - Fever, Chills, Rigors
5. Lymphoma/Mets – Hard Firm Inguinal Nodes
6. Hidradenitis – Abscess at intertriginous regions
7. Varicocele – Dull Ache, Unilateral Bag of Worms, no transillumination
8. Hydrocele – Mass in scrotum that transilluminates

Question 23

History and PE for Hernias

Answer 23

1

Question 24

Relevant Embryology of the Reproductive System (until descent of testis)

Answer 24

1. Indifferent gonads develop from the intermediate mesoderm along the posterior wall of the abdominal cavity
   - Urogenital Ridge gives rise to embryonic kidneys
   - Gonadal ridge is where the future gonads develop
2. Primordial germ cells appear along the endoderm cells in the wall of the yolk sac close to the allantois
   - migrate along the dorsal mesentery of hindgut
   - arrive at primitive gonads at 5th week; invade gonadal ridge in 6th week
3. Epithelium of gonadal ridges penetrates mesenchyme to form primitive sex cords; sex cords connected to surface epithelium
4. In presence of SRY gene, sex cords proliferate and penetrate into medulla to form testis
5. Become horseshoe shaped in 4th month comprising primitive germ cells & sertoli cells from gonadal surface epithelium; cords near testis hilum break up to form rete testis
   6, At puberty, sex cords acquire lumen and form seminiferous tubules
6. Leydig cells are derived from mesenchyme of gonadal ridge, lie between testis cords. develop shortly after onset of testis cord differentiation; produce testosterone from 8w onwards

Question 25

Relevant Embryology of Reproductive System (From descent of testis)

Answer 25

1. The testis is located in the upper lumbar region and the gubernaculum extends from its pole down to the inguinal region and then to the future scrotum
2. It pulls, passing through the depe inguinal ring and emerging through the superficial inguinal ring, shortening as it descends
   - the outpouching formed is called the processus vaginalis
3. Later, this outpuching is obliterated - no communication between processus vaginalis & peritoneum –> tunica vaginalis

• TF = Internal Spermatic Fascia
• IO = Cremasteric Fascia
• EO = External Spermatic Fascia
• Processus Vaginalis = Parietal & Visceral layer of tunicavaginalis