Hernias Flashcards
What is a hernia
condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it
What is a reducible hernia?
a hernia that can be manually “reduced” or pushed back through the defect
what is an incarcinated hernia?
hernia which cannot be manually reduced (may NOT be painful) = surgery
What is a strangulated hernia
an incarcerated hernia with some degree of torsion leading to ischemic bowel
very painful
emergency surgery
how many sides foes the ingunial canal have?
Roof
Floor
Anterior wall
Posterior wall
Posterior wall is made of?
Transversalis fascia and conjoined tendon of the internal oblique and transversus abdominis muscles
What is the anterior muscle made of?
Primarily External Oblique muscle
What is the floor of the inguinal canal?
Inguinal Ligament and Lacunar ligament
What is the roof of the inguinal canal
External oblique & Transversus abdominis muscles
Contents of Inguinal Canal
Males – Ilioinguinal nerve & Spermatic Cord
Females – Ilioinguinal nerve and Round Ligament of the uterus
What does hesslebach’s triangle consist of?
Medial border – Rectus abdominis (sheath of muscle)
Lateral border – Inferior epigastric vessels
Inferior border – Inguinal ligament
What is the entrance and exit for hesslebachs triangle
Deep inguinal ring – entrance to the inguinal canal
Superficial inguinal ring – exit of the inguinal canal
What are 7 types of hernias?
inguinal Femoral Umbilical Spigelian Hiatal Hernia Incisional / Ventral Sports Hernia
Epidemiology for hernias
Occur in 5% of all men at some point in their lifetime
Men > Women
75 – 80% of all hernias are groin (inguinal or femoral) hernias
2 – 20% are incisional / ventral
3 – 10% are umbilical
What are the risk factors for Hernias
Increased intra-abdominal pressure Coughing Heavy lifting Constipation or straining at stool Pregnancy / ascites Obesity Advancing age Smoking Steroid use
What is a direct hernia
Usually acquired, herniation through defect in the posterior inguinal wall (through Hesselbach’s triangle) – occurs most commonly in older males
What is an indirect hernia
Usually congenital, through deep inguinal ring, lies within the spermatic cord, and the hernia sac is covered by the cremaster muscle – occurs most commonly in younger males and may be in scrotum
Clinical Presentation of hernias
unilateral groin pain especially w/exertion
Report of intermittent bulge in groin
What is the gold standard for hernias?
surgical repair – herniorraphy
what are 4 different techniques for hernias
Open
Laparoscopic
Mesh vs No mesh
Local anesthesia w/sedation / vs GA
What are some complications of hernias?
incarceration
strangulated hernia
pediatric hernias
Epidemiology of femoral hernias?
84% of femoral hernias occur in women
25% of femoral hernias become incarcerated or strangulated
Hernia protrudes through the femoral canal – so sac is seen or palpated in the upper thigh
Clinical Presentation of femoral hernias
May complain of intermittent groin mass/bulge or pain
Presenting feature may be small bowel obstruction due to incarceration / strangulation
Elderly pts may be asymptomatic EVEN in the face of incarceration
Bulge just BELOW the inguinal ligament
Tenderness if incarcerated
Treatment for femoral hernias?
Surgery
Umbilical hernia epidemiology?
Congenital defects
African Americans > Caucasians
Most newborn umbilical hernias close spontaneously by age 2
Patients w/ascites have a higher incidence of umbilical hernias
Have a generally low rate of incarceration
Clinical Presentation for umbilical hernias
Painless bulge around umbilicus
May present with gastric symptoms (pain)
In children under 2 – wait for spontaneous closure unless LARGE
In adults often associated w/obesity
Visible and palpable umbilical defect
Often easily reducible by just pushing on defect
Spigelian Hernias facts
Protrude through the Spigelian fascia – this structure is near the terminus of the transversus abdominis muscle along the lateral edge of rectus abdominis
Clinical presentation for spigelian hernias
Often pts present with obscure abdominal pain and no apparent cause
no bulge seen or palpated because it is obscured by abdominal wall
Diagnostic imaging for spigelian hernias
Ultrasound
CT scan
Diagnostic laparoscopy
Treatment for spigelian hernias
Surgical referral
Probable surgical intervention
Hiatal Hernia
Reflux barrier composed of two components working together prevent reflux
Lower esophageal sphincter
Crural diaphragm
Stomach can herniate up through diaphragm into thoracic compartment
What is the clinical presenation for hiatal hernia
May have some epigastric tenderness but physical findings may be lacking
Present w/symptoms similar to GERD – dyspepsia, reflux
Some types of HH can present w/postprandial pain, bloating, early satiety, SOB w/meals, dysphagia
How to make a diagnosis of hiatal hernia
Chest X-ray (CXR) – look for air fluid levels in mediastinum on lateral x-ray
Barium swallow – can confirm Dx also looks for strictures, ulcers, (this is the gold standard for Dx)
Esophagogastroduodenoscopy (EGD) – can help if pt has Barrett’s esophagus
Esophageal manometry
How to treat hiatal hernia
asymptomatic – no further Tx is indicated
If pt is symptomatic – trial of medical management – similar to Rxing GERD
Surgical management is a major surgical procedure
5 causes of Incisional or Ventral Hernia
Infection Malnutrition Obesity Flawed wound closure Conditions that increase abdominal pressure on a wound
Clinical Presentation of Incisional or Ventral Hernia
Presence of bulge at incision site
Reproducing intermittent bulge with Valsalva maneuver and that disappears with exhalation
Edge of fascial defect is usually palpable on exam
Prior Hx of surgical procedure
Presence of previously noted pre-disposing factors
Complaints of intermittent or persistent bulge at incision site
Treatment for incisional or ventral hernia
Definitive treatment is surgical repair
Sports hernia
Can often go unrecognized
Also called Athletic Pubalgia
Seen most frequently in high performance athletes
Painful musculotendinous injury to the medial inguinal floor
Clinical presentation for sports hernia
Tenderness over the pubic ramus
Usually high performance athlete with history of groin or lower abdominal pain aggravated by physical activity and relieved by rest
Treatment for sports hernia
Conservative Tx – activity modification, PT
If not helping consider surgical intervention
