Hernias Flashcards
What is an inguinal hernia?
A protrusion of all or part of a viscus through the wall of the abdominal or pelvic cavity in which is normally contained, causing a visible or easily palpable bulge.
Where do inguinal hernias lie in relation to the pubic tubercle?
Superior & medial
What side inguinal hernias are more common? Why?
R sided inguinal hernias are more common
Due to descend of the testis or previous appendectomy
Risk factors for inguinal hernias?
1) male sex
2) FH –> this is common in collagen defect medical conditions such as Ehlers-Danlos syndrome, Marfan’s syndrome
3) Previous RLQ incisions e.g. appendectomy and prostatectomy
4) Premature babies
What type of genetic conditions can predispose to inguinal hernias?
Collagen defect conditions e.g. Ehlers-Danlos syndrome & Marfan’s syndrome
Why can collagen defect conditions predispose to inguinal hernias?
1) Patients with inguinal hernias have demonstrated to have decreased collagen levels and abnormal collagen metabolism
2) This results in progressive degeneration of elastin-related fibres in transversalis fascia of abdomen and groin area
3) Leads to the protrusion of abdominal and/or pelvic contents occur in the inguinal area, creating a visible bulge.
What happens in Richter’s hernia?
A rare type of abdominal hernia that occurs when only part of the bowel wall protrudes through a defect in the abdominal wall.
Mx of strangulated Richter’s hernia?
Emergency surgery
What is Maydl’s hernia?
Two small bowel loops are contained within the same hernia.
What is the inguinal ligament?
Runs from the pubic tubercle to the ASIS.
Just above this ligament runs a structure known as the inguinal canal.
Function of the inguinal canal?
Passage between peritoneal cavity & external genitalia
What does the inguinal canal contain in men only?
Spermatic cord to testis
What does the inguinal canal contain in women only?
Round ligament
What does the inguinal canal contain in men and women?
Ilioinguinal nerve & genital branch of genitofemoral nerve.
Entry & exit point of the inguinal canal?
Entry - deep inguinal ring
Exit - superficial inguinal ring
Location of the deep inguinal ring?
Just above midpoint of inguinal canal
Location of the superficial inguinal ring?
Just above and lateral to pubic tubercle
What is a DIRECT inguinal hernia caused by?
Weakness in the POSTERIOR wall of the inguinal canal (Hesselbach’s triangle).
Where does a DIRECT hernia enter & exit the inguinal canal?
Enters medial to the deep inguinal ring.
Exits via superficial inguinal ring.
What happens in an INDIRECT inguinal hernia?
The abdo contents enter the DEEP ring, pass along the length of the inguinal canal and exit via the superficial ring.
Is it more common for a direct or indirect inguinal hernia to enter the scrotum?
Indirect (as the path through both anatomical inguinal rings offers less resistance).
What exam finding can help you differentiate between indirect and direct inguinal hernias?
Place your finger over the deep inguinal ring (just above the mid-point of the inguinal ligament).
You will be able to control an indirect inguinal hernia which has been reduced.
If when you press the deep ring, the hernia still protrudes, then the hernia is emerging via a defect in the posterior wall medial to this point and is, therefore, a direct hernia.
What structure allows the testes to descend from the abdo cavity, through the inguinal canal and into the scrotum in development?
Processus vaginalis (a pouch of peritoneum that extends from the abdo cavity through the inguinal canal).
What happens to the processes vaginalis after the testes descend through the inguinal canal?
Normally, the deep inguinal ring closes and the processus vaginalis is obliterated.
However, in some patients, the inguinal ring remains patent, and the processus vaginalis remains intact.
This leaves a tract or tunnel from the abdominal contents, through the inguinal canal and into the scrotum.
The bowel can herniate along this tract, creating an indirect inguinal hernia.
How to locate the deep inguinal ring?
Mid way between ASIS & pubic tubercle (i.e. halfway point of inguinal ligament)
What is the gold standard management for inguinal hernias?
Mesh repair.
How does mx of inguinal hernia differ for bilateral vs unilateral?
Unilateral –> open approach
Bilateral/recurrent –> laparoscopic approach
What is a femoral hernia?
When a section of the bowel or any other part of the abdominal viscera pass into the femoral canal into the medial upper thigh.
How do femoral hernias frequently present?
Bowel obstruction
Where is the femoral canal located?
Just medial to the femoral vein
Purpose of the femoral canal?
To allow expansion of the femoral vein to increase venous return from the lower limb.
What are femoral hernias at high risk of?
Strangulation
Are femoral hernias more common in men or women?
Women (think litte old ladies)
Is a low or high BMI a risk factor for a femoral hernia?
Low BMI
Location of femoral vs inguinal hernia?
Femoral –> located below and lateral to the pubic tubercle.
Inguinal –> situated above and medial to the pubic tubercle.
What investigation can be used to diagnose a femoral hernia?
US
Mx of femoral hernia?
Due to high risk of strangulation, femoral hernias should ALWAYS be repaired.
Mx –> laparoscopic mesh repair.
What are the clinical features of a strangulated hernia?
1) Episodes of pain in a hernia that was previously asymptomatic
2) Irreducible hernias
3) Pain
4) Fever
5) Increase in the size of a hernia or erythema of the overlying skin
6) Peritonitic features such as guarding and localised tenderness
7) Bowel obstruction e.g. distension, nausea, vomiting
8) Bowel ischemia e.g. bloody stools
What is an incisional hernia?
Occurs at the site of an incision from previous surgery.
What are umbilical hernias?
Umbilical hernias occur around the umbilicus due to a defect in the muscle around the umbilicus.
Who are umbilical hernias more common in?
Neonates
