Hernias

Question 1

What is a hernia?

Answer 1

A hernia is defined as the protrusion of an organ or fascia through the wall of a cavity that normally contains it.

Question 2

What are the two types of hernias?

Answer 2

Direct hernias and Indirect hernias

Question 3

In the case of a direct hernia, what happens?

Answer 3

In a direct inguinal hernia, bowel herniates through a weakness in the inguinal triangle, and enters the inguinal canal.

Question 4

In the case of an indirect hernia, what happens?

Answer 4

indirect inguinal hernia – where bowel enters the inguinal canal via the deep inguinal ring.

Question 5

Indirect hernias are also called…

Answer 5

Oblique hernias

Question 6

1. How do femoral hernias appear on examination?

Answer 6

Femoral hernias tend to be irreducible, and hot and painful if they are strangulated

They can be distinguished from inguinal hernias because they appear below and lateral to the pubic tubercle

Question 7

Describe the inguinal region

Answer 7

It is the Junction between the anterior abdominal wall and the thigh.

This area is between the ASIS and the pubic tubercle

It is clinically important because it is a potential site where most of the abdominal hernias occur.

It is anatomically important because structures exit and enter the abdominal cavity (e.g. spermatic cord, round ligament, vessels

Question 8

3. What causes the inherent weakness in the abdominal wall in the groin?

Answer 8

It is caused by changes that occur in the development of the gonads.
Before the descent of the testes and the ovaries from their original position high in the anterior abdominal wall, a peritoneal outpouching (the processus vaginalis) forms, protruding through layers of the anterior abdominal wall

Question 9

What is the Inguinal canal vulnerable to?

Answer 9

This canal remains vulnerable throughout life for potential herniation of the abdominal viscera to occur.

Question 10

Outline the anatomy of a hernia

Answer 10

Weakness/defect/hole on the wall through which the hernia protrudes

Hernial Sac – e.g. peritoneum with neck, body and fundus

Contents of the hernial sac - e.g. bowel, bladder

Hernial coverings - skin

Question 11

Summarise the clinical features of hernias

Answer 11

A lump or protrusion in the groin

Appears intermittently or present all the time

Painless/painful and uncomfortable

Hernia may be reducible or irreducible

May be strangulated with tissue death- and associated with vomiting, constipation, intestinal obstruction – this is an emergency situation

Question 12

7. List some facts about hernias in the groin

Answer 12

In both sexes most of the groin lumps or swellings are hernias.

Inguinal hernias > femoral

Inguinal hernia is 8 times greater in males than in females
Femoral hernias are rare in males -accounts for 2.5% of the groin swellings

Femoral hernias are higher in women and increases with age and number of pregnancies

Question 13

List the different types of hernias

Answer 13

1. Inguinal Hernias:
   a. Indirect inguinal hernia
   b. Direct inguinal hernia
2. Femoral Hernias

Question 14

Describe the key difference between direct and indirect inguinal hernias

Answer 14

A direct hernial defect tends to go through Hesselbach’s Triangle (inguinal traingle) which is always MEDIAL to the inferior epigastric vessels- through deep inguinal ring

An Indirect hernial defect is always the internal ring which is always LATERAL to the inferior epigastric vessels- through posterior wall of canal

Question 15

Summarise direct inguinal hernias

Answer 15

Older age group

Associated with chronic straining

Associated with weak musculature

The hernia’s path is straight through the posterior wall of the inguinal canal

Defect is in the posterior wall of the inguinal canal medial to the Inferior epigastric vessels

Question 16

Describe the other features of direct inguinal hernias

Answer 16

Acquired as it develops when abdominal musculature has been weakened- commonly seen in mature men

Internally, a thickening of the transversalis fascia follows the course of the inguinal ligament

This type does not traverse the entire length of the inguinal canal but may exit through the superficial inguinal ring- when this occurs the peritoneal sac acquires a layer of external spermatic fascia and can extend, like an indirect hernia into the scrotum.

Question 17

Summarise indirect inguinal hernias

Answer 17

It is the most common type of inguinal hernia.
It tends to be in younger adults and children
The hernia takes an indirect path through the abdominal wall

The defect is a dilated deep ring

The hernia enters the deep ring then passes through the inguinal canal, external inguinal ring and into the scrotum

Question 18

Describe the features of indirect inguinal hernias

Answer 18

More common in men

Part or all of the embryonic processus vaginalis remains open or patent- it is therefore congenital

Extent of excursion down the canal depends on the amount of processus vaginalis that remains patent.

If all of it is patent- the peritoneal sac may traverse the entire length, exit the superficial ring and continue into the scrotum in men or the labia majus in women

In this case, the protruding peritoneal sac acquires the same three coverings associated with the spermatic cord in men or the round ligament of the uterus in women.

Question 19

Summarise femoral hernias

Answer 19

They are hernias that pass through the femoral canal

Not as common as inguinal hernias

Commoner in elderly and females

Have a high incidence of obstruction and strangulation

Question 20

How do femoral hernias appear on examination

Answer 20

Femoral hernias tend to be irreducible, and hot and painful if they are strangulated

They can be distinguished from inguinal hernias because they appear below and lateral to the pubic tubercle

Inguinal hernias are above and medial to the pubic tubercle