Hernias

Question 0

Indirect inguinal hernia

Answer 0

(80% of all inguinal hernias)
Common in young/middle aged patients
May extend to scrotum
Reduces upwards and laterally
Controlled by pressure over deep ring
Moves downwards and medially on release

Question 1

Layers of spermatic cord

Answer 1

External spermatic fascia (from external oblique)
Cremaster (from internal oblique)
Internal spermatic fascia (from transversalis)
Vas deferens

Question 2

Direct inguinal hernias

Answer 2

More common in elderly patients
Due to weakness in transversalis fascia
Emerges in Hesselbachs triangle
Does not extend to scrotum
Not controlled by pressure at midpoint of inguinal ligament

Question 3

Hesselbach’s triangle

Answer 3

Inferior epigastric artery (superolateral border)
Lateral margin of Rectus sheath (medial border)
Inguinal ligament (inferior border)

Question 4

Femoral hernia

Answer 4

Much less common than inguinal
More common in women
Often missed as small
Firm olive or grape just below ligament
More likely to obstruct: should always be repaired
Usually irreducible and no cough impulse
Can induce vomiting

Question 5

Complications of hernias

Answer 5

Incarceration: irreducibility, sometimes with loss of cough impulse
Obstruction: constriction of loops of bowel
Strangulation: arterial occlusion, infarction, peritonitis, groin abscess

Question 6

Richter’s hernia

Answer 6

Only part of the wall of the bowel herniates
Allows strangulation without obstruction
Commoner with femoral hernia (very narrow orifice of femoral canal)

Question 7

Why no surgery for inguinal hernia?

Answer 7

If it’s easily reducible
Low risk of strangulation
Patient choice

Question 8

Location of deep ring

Answer 8

Midpoint of inguinal ligament between anterior superior iliac spine and pubic tubercle

Question 9

Location of femoral artery

Answer 9

At mid-inguinal point, medial to deep ring, between anterior superior iliac spine and symphysis pubis

Question 10

Incisional hernias

Answer 10

Often appear months after surgery
Complicate 10% of abdominal wounds, particularly hernia repairs and stomas
Exaggerated by asking patient to lift head off the pillow (tenses Rectus muscles)
Often large with broad neck, cosmetic disability more than obstruction/strangulation
Poor muscle tone, obesity, post op wound infections, haematomas predisposes
Inadequate closure occassionally contributes

Question 11

Hernia repair: 2 components

Answer 11

Herniotomy: excision of sac and tying of neck
Herniorrhaphy: strengthening or repair procedure to prevent recurrence

Question 12

Mesh repair

Answer 12

Lichtensteins tension free hernia repair
Polypropylene mesh encourages in-growth of fibrous tissue
Sutured to inguinal ligament below and conjoint tendon above

Question 13

Inguinal canal components

Answer 13

Anterior wall - external oblique aponeurosis medially (plus internal oblique laterally)
Posterior wall - transversalis fascia
Roof - arching lower fibres of internal oblique
Floor - inguinal ligament

4cm long, passing from deep ring laterally to the superficial ring medially
Contains the spermatic cord in men and the round ligament in women
Plus the ilioinguinal nerve which supplies the skin of the scrotum and upper thigh (derived from L1 nerve root and responsible for the cremasteric reflex)
A