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Surgery block > Hernias > Flashcards

Hernias Flashcards

1
Q

What is a hernia?

A

When an internal part of the body (often bowel) pushes through a weakness int he muscle or surrounding tissue wall.

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2
Q

What is the most common type of hernia?

A

Inguinal hernias

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3
Q

What are the different anatomical parts of a hernia?

A

Hernial defect (orfice) the hole/weakness in the muscle it protrudes through
Neck of hernia - the bit through the orifice
Sac of hernia - the bulging bit
Hernial contents - what is inside the hernia.

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4
Q

What is an epigastric hernia?

A

Hernia in the upper abdomen at the midline

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5
Q

What is an incisional hernia?

A

Hernia as the site of the previous surgical incision

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6
Q

What is an umbilical hernia?

A

Hernia as the navel/umbilicus

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7
Q

What do you call a hernia in the femoral canal?

A

A femoral hernia

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8
Q

What do you call a hernia near the opening of the inguinal canal?

A

Direct inguinal hernia

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9
Q

What do you call a hernia at the opening of the inguinal canal?

A

Indirect inguinal hernia

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10
Q

What is the inguinal canal?

A

A short passage that extends inferiorly and medially through the inferior part of the abdominal wall.
It is superior and parallel to the inguinal ligament.
Is a passage for structures to pass from the abdominal wall to the external genitalia.

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11
Q

What is the common content of the inguinal canal?

A

The spermatic cord in males
The round ligament of the uterus in females
Blood and lymphatic vessels
The ilioinguinal nerve.

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12
Q

What is the mid-inguinal point?
Why is this an important landmark?

A

Is half way between the ASIS and the pubic symphysis.
Is where the femoral artery can be palpated.

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13
Q

What is the midpoint of the inguinal ligament?
Why is this an important landmark?

A

Is half way along the inguinal ligament which runs between the ASIS and the pubic tubercle
Is a landmark for the femoral nerve, can be used in a nerve block.

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14
Q

What is the inguinal ligament?

A

A fibrous band extending from the ASIS to the pubic tubercle
Made from an extension of the aponeurosis of the external oblique muscle.

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15
Q

What are the key anatomical differences between an indirect and direct inguinal hernia?

A

Indirect - travels lateral to the inferior epigastric vein
Direct - travels medial to the inferior epigastric vein (this is within Hasselbach/inguinal triangle)

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16
Q

What are the key features of an indirect inguinal hernia?

A

Protrudes through deep inguinal ring to enter inguinal canal (can come out superficial inguinal ring)
Passess lateral to inferior epigastric artery
Low risk of strangulation
More common in males

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17
Q

What are the key features of a direct inguinal hernia?

A

Protrocudes through hasselback/inguinal triangle (NOT deep inguinal ring)
Passess medial to inferior epigastric artery
Low risk of strangulation
More common in males

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18
Q

What are the key features of a femoral hernia?

A

Protrudes below inguinal ligament, below pubic tubercle
High risk of strangulation
More common in females.

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19
Q

What are the borders of the inguinal/hesselbach triangle?

A

Medial - rectus abdominus muscle
Lateral - inferior epigastric vessels
Inferior - inguinal ligament

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20
Q

What is the key difference in how direct and indirect inguinal hernias present?

A

Indirect - can protrude into prostate, tend to be due to incomplete closer of deep inguinal ‘patent processes vaginalis’ ring infancy or old age
Direct - lump in groin, caused by weakness in abdominal wall due to age.

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21
Q

What is the processus vaginalis?

A

The peritoneal tunnel through which the testes migrate from the retroperitoneum towards the scrotum during embryological development.

22
Q

What is meant by a patent processus vaginalis?

A

THe the mbryological tunnel for passage of the testes from the retroperitoneum to the scrotum remains open
Creates a path from the abdominal cavity to the inguinal canal

23
Q

What is the deep inguinal ring in relation to hernias?

A

Serves as an entrance point for abdominal contents (typically intestines) to protrude into the inguinal canal.

24
Q

How does an indirect inguinal hernia occur?

A

When the hernia sac, formed by the processes vaginalis, passes through the deep inguinal ring into the canal, lateral to the inferior epigastric vessels, and potentially into the scrotum.

25
Q

What are the key parts of the abdominal wall anatomy in relation to formation of the inguinal canal?

A

TIE
Transversalis fascia - forms the deep inguinal ring.
Internal oblique muscle - forms the roof of the inguinal canal.
External oblique aponeurosis - forms the superficial inguinal ring.

26
Q

Define hiatus hernia

A

The protrusion of the stomach through the oesophageal hiatus in the diaphragm.

27
Q

What are the common signs and symptoms of a hiatus hernia?

A

Acid reflux
Bad breath
Burp and bloated
Nausea or vomiting
Difficulty or pain when swallowing.

28
Q

What are the risk factors for a hernia formation?

A

Age
Gender
Obesity
Chronic cough (COPD)
Constipation
Heavy lifting
Past abdominal surgery
Pregnancy (hiatus hernia)
Smoking + aging = acquired collagen deficiency
Basically, anything that increases intra-abdominal pressure.

29
Q

What are the typical features of an abdominal wall hernia?

A

Soft lump protruding from the abdominal wall
Reducible (pushed back in)
May protrude on coughing (inc intra-abdo pressure) or standing (pulled out by gravity)
Conserve should reduce when lying down
Feeling of an aching, pulling or dragging sensation in the groin region.

30
Q

What red flag symptoms indicate someone with a hernia should have an immediate surgical review?

A

Sudden, severe pain in the region of the hernia
Persistent vomiting
Difficultly pooing or passing wind
The hernia becomes acutely firm or tender
The hernia is non-reducible
This indicates strangulation, obstruction of bowel within hernia - these are both surgical emergencies.

31
Q

What are the common complications of a hernia?

A

Incarceration (stuck and irreducible)
Obstruction (can perforate)
Strangulation (if prolonged can lead to gangrene of the bowel)

32
Q

What is incarceration of a hernia?

A

Where the hernia cannot be reduced back into the proper position (non-reducible)
If contains bowel can lead to obstruction and strangulation.

33
Q

How does an obstructed hernia present?

A

When an irreducible hernia leads to intestinal lumen obstruction
Like a bowel obstruction
Vomiting, generalised abdominal pain and absolute consitipation

34
Q

What is strangulation of a hernia?
How does this present?

A

When the base of the hernia becomes so tight that it cuts off blood supply causing ischaemia.
This can present with significant pain and tenderness at the hernia site
Bowel can die within hour - requires surgery
Also causes a mechanical obstruction.

35
Q

Why is the width of the hernia neck significant?

A

Wider nick = wider hiatus/opening = allows more room for abdominal contents to pass through = lower risk of complications.
Contents easily out, also easily back in, so lower risk of incarceration, obstruction and strangulation.

36
Q

How do we diagnose hernias?

A

Clinical examination
Uncertain in non-acute context - refer for USS
Acute context - CT scan is advisable - also look for evidence of ischemia/obstruction.

37
Q

What features are important to note about a hernia during clinical examination?

A

Effect of cough impulse
Location/position
Reducible or not
Pain
Overlying skin changes
If involves the scrotum - are you able to separate it from the testis.

38
Q

When is conservative approach for a hernia repair used?

A

When the hernia has a wide neck (low risk of complications) and the patients are poor candidates for surgery due to co-morbidities

39
Q

What is the main surgical approach to repairing a hernia?

A

Mesh repair - placing a mesh over the defect in the abdominal wall
Mesh is sutured to the muscles and tissue on either side of the defect, covering it and preventing herniation of the cavity contents.
Over time tissues grows into the mesh and provide extra support.

40
Q

What factors are considered when deciding if surgery is an appropriate approach for a patient with a hernia?

A

The neck width of the hernia - aka the risk of complications
The type of hernia - femoral more likely to become obstructed or strangulated
Symptom severity - impact on daily life, severe or getting worse, ADL.
Fitness for surgery - general health of patient

41
Q

What type of inguinal hernia is most likely to be found in the scrotum ?

A

indirect

42
Q

Where does the inguinal canal start?

A

At the mid point of the inguinal ligament

43
Q

What are the two main areas of weakness in the inguinal canal?

A

The deep inguinal ring - hole in transversalis fascia.
The superficial inguinal ring - hole in external oblique aponeurosis.

44
Q

What are the different boundaries of the inguinal canal?

A

Floor - inguinal ligament
Anterior - external oblique aponeurosis (IO in lat 1/3)
Posterior - transversalis fascia and conjoint tendon
Lateral - internal oblique and transvers abdominus
THese combine together to form the roof, tends also join to give the conjoint tendon which form the medial/ posterior roof aspect of the canal.

45
Q

What type of inguinal hernia has a higher risk of complications?

A

The indirect inguinal hernia (tend to have a narrower neck)

46
Q

How should you examine the inguinal hernias?

A

Exposed from umbilicus to mid-thigh.
Examine standing
Examine supine
IPPA:
Inspect - swelling, skin changes, cough impulse, position of the penis, scars, erythema.
Palpate - temp, tenderness, extends into the scrotum, if in groin alone check is femoral hernia, above to get above swelling in scrotum (yes = hydrocele, no inguinal hernia), consistency, position relevant to testes

47
Q

How can you compare a direct and indirect inguinal hernia by appearance?

A

Direct = spherical (more lateral)
Indirect = pyriform (more medial)

48
Q

How do you differentiate between a inguinal and femoral hernia on palpation?

A

Inguinal - above and lateral to the pubic tubercle
Femoral - inferior and lateral to the pubic tubercle

49
Q

What is the Zieman technique or the modified cough impulse technique for identifying the anatomical location of inguinal hernias?

A

Index finger - over deep ring (mid point of the inguinal ligament) - indirect inguinal hernia
Middle finger - superficial ring - direct inguinal hernia
Ring finger - saphenous openining (4cm inferior and 4cm lateral to pubic tubercle) - femoral hernia.

50
Q

What complications are we concerned about if a hernia is irreducible?

A

Obstruction
Strangulation
Incarcerated

51
Q

What are the key surgical principles when treating a hernia with surgery?

A

Reduction of hernial contents
Remove infarcted content
Removal of sac or replacing it inside abdomen
Closing defect
Using mesh or sutures to reinforce the wall.

52
Q
A

Surgery block (23 decks)

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