Hernias

Question 1

anatomy of the groin

Answer 1

-During fetal development the testes descend from the abdomen through the inguinal canal and into the scrotum

-The inguinal canal is made up of:
-Internal abdominal oblique and transversus abdominis muscle (roof)
-Inguinal ligament and lacunar ligament (floor)
-External and internal abdominal oblique aponeurosis (anterior wall)
-Transversalis fascia, conjoint tendon (posterior wall)

-Internal ring: entrance to canal
-External ring: exit of canal

-Contains the:
-Spermatic cord (males)
-Round ligament (females)
-Ilioinguinal nerve

Question 2

causes of hernias

Answer 2

-Any condition that increases the pressure in the abdominal cavity can contribute to the formation/worsening of a hernia
-Obesity
-Heavy Lifting
-Coughing
-Straining during a bowel movement/urination
-COPD
-Fluid in the abdominal cavity (ascites)
-Peritoneal dialysis
-Family History

-May be present at birth, or develop later in life
-Some involve pathways formed during fetal development, existing openings in the abdominal cavity, or areas of abdominal wall weakness

Question 3

hernia symptoms

Answer 3

-Are generally asymptomatic, but all have risk of becoming strangulated, and having their blood supply cut off
-Strangulation can be a medical/surgical emergency

Question 4

hernia physical exam

Answer 4

-Should be performed with the patient in the supine and standing position, with and without the Valsalva maneuver
-Hernia sac as well as the fascial defect should be identified
-Should examine for evidence of obstruction/strangulation

Question 5

reducible hernia

Answer 5

-Ability to return the contents of the hernia into the abdominal cavity, either spontaneously or manually
-New lump in the groin/other abdominal wall area
-May ache but is not tender when touched
-Sometimes pain precedes the discovery of the bulge
-Bulge increases in size when standing or with increased intra-abdominal pressure (coughing, Valsalva maneuver)

Question 6

irreducible hernia

Answer 6

-Also known as incarcerated hernia
-Vascular supply is not compromised
-Occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity spontaneously or by reduction attempt
-May exist for long time without the presence of pain/discomfort
-Can lead to strangulation

Question 7

strangulated hernia

Answer 7

-Vascular supply of the bowel is compromised due to incarceration of hernia contents
-Initially presents as pain followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea/vomiting)
-Patient may appear ill, could have fever
-Surgical emergency

-Strangulated hernias physical exam:
-Pain out of proportion to exam findings
-Fever/toxic appearance
-Pain that persists after reduction of hernia

Question 8

inguinal hernia

Answer 8

-Makes up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women.
-2 types of inguinal hernias: indirect inguinal hernia and direct inguinal hernia.

-Indirect inguinal hernia
-direct inguinal hernia

Question 9

Indirect inguinal hernia

Answer 9

-Follows pathway that testicles made during pre-birth development.
-This pathway normally closes before birth but remains a possible place for a hernia
-Sometimes the hernia sac may protrude into the scrotum.
-This type of hernia may occur at any age but becomes more common as people age.

Question 10

direct inguinal hernia

Answer 10

-This occurs slightly to the inside of the site of the indirect hernia, in a place where the abdominal wall is naturally slightly thinner.
-It rarely will protrude into the scrotum.
-The direct hernia almost always occurs in the middle-aged and elderly because their abdominal walls weaken as they age.

Question 11

hiatal hernia

Answer 11

-A hiatal hernia occurs when the upper part of the stomach, which is joined to the esophagus moves up into the chest through the diaphragm.
-It is common and occurs in about 10% of pts

-SX:
-heartburn
-sudden regurgitation
-belching
-pain on swallowing hot fluids
-feeling a food sticking in the esophagus

-MC in overweight middle-aged women and elderly people.
-It can occur during pregnancy.
-dx confirmed by barium swallow, radiographs or endoscopy.

Question 12

Answer 12

hiatal hernia

Question 13

Answer 13

hiatal hernia

Question 14

hiatal hernia tx

Answer 14

-Weight loss.
-Eating small meals each day instead of 2 or 3 large ones helps.
-Avoid smoking.
-Antacids.
-Avoidance of spicy food.
-Avoidance of hot drinks.
-Avoidance of gassy drinks.

Question 15

femoral hernia

Answer 15

-femoral canal is the way that the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh.
-Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) into the canal.
-This hernia causes a bulge below the inguinal crease in roughly the middle of the thigh.
-Rare and usually occurring in women, these hernias are particularly at risk of becoming irreducible and strangulated.

Question 16

umbilical hernia

Answer 16

-10-30% rare often noted at birth as a protrusion at the the umbilicus.
-Caused when an opening in the abdominal wall, which normally closes before birth, doesn’t close completely.
-Even if the area is closed at birth, these hernias can appear later in life because this spot remains a weaker place in the abdominal wall.
-They most often appear later in elderly people and middle-aged women who have had children

Question 17

incisional hernia

Answer 17

-Abdominal surgery causes a flaw in the abdominal wall that must heal on its own.
-This flaw can create an area of weakness where a hernia may develop.
-This occurs after 2-10% of all abdominal surgeries, although some people are more at risk.
-After surgical repair, these hernias have a high rate of returning (20-45%)

-RISK:
-Technical
-Wound infection
-Smoking
-Hypoxia/ ischemia
-Tension
-Obesity
-Malnutrition

Question 18

spigelian hernia

Answer 18

This rare hernia occurs along the edge of the rectus abdominus muscle

Question 19

types of wounds

Answer 19

-seroma- formation of fluid collection under the skin -> no systemic signs (seen in flap surgery)
-wound infection- purulent
-wound dehiscence- opening on incision under the skin -> fluid under the skin -> systemic symptoms
-evisceration - you can see the bowel

Question 20

obturator hernia

Answer 20

-This extremely rare abdominal hernia happens mostly in women.
-This hernia protrudes from the pelvic cavity through an opening in the obturator foramen.
-This will not show any bulge but can act like a bowel obstruction and cause nausea and vomiting.

Question 21

Answer 21

obturator hernia

Question 22

epigastric hernia

Answer 22

-Occurring between the umbilicus and the lower part of the rib cage in the midline of the abdomen, these hernias are composed usually of fatty tissue and rarely contain intestine.
-Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered

Question 23

common vs rare hernia

Answer 23

Question 24

diff dx

Answer 24

-Hydrocele
-Varicocele
-Epididymoorchitis
-Torsion of testis
-Undescended testis
-Ectopic testis
-Testicular tumor
-Femoral artery aneurysm
-Lipoma
-Lymphadenopathy

Question 25

treatment of hernias

Answer 25

-depends on whether it is reducible or irreducible and possibly strangulated.
-Reducible -> Can be treated with surgery but does not have to be.

-Irreducible:
-All acutely irreducible hernias need emergency treatment because of the risk of strangulation.
-An attempt to push the hernia back can be made

-Strangulation -> Operation

-Prevention:
-You can do little to prevent areas of the abdominal wall from being or becoming weak, which can potentially become a site for a hernia.