Hernias Flashcards
What is the most common type of Hiatus hernia?
Sliding - Gastro-oesophageal junction slides up into the chest. Often associated with GORD
What is the less common type of Hiatus hernia?
Rolling - Gastro-oesophageal junction remains in the abdomen, but a bulge of stomach rolls into the chest with the oesophagus. LOS intact so GORD uncommon
Which type of Hiatus hernia is more at risk of strangulation?
Rolling
What investigations can be done for a patient with suspected Hiatus hernia?
CXR - Gas bubble and fluid level in chest
Barium swallow
OGD - Assess for oesophagitis
Manometry (Pressure sensing tube placed in oesophagus) to rule out Achalasia or Dysmotility
What is the treatment of a Hiatus hernia?
Lifestyle adjustments - Lose weight
Treat any reflux - PPIs
Surgery if doesn’t respond to treatment or rolling as strangulation can occur
What is the aetiology of Inguinal hernias?
More common in males (due to descent of the testes)
Tends to be in older patients for acquired and younger patients for congenital
What are the two main causes of Inguinal hernias?
Congenital - Patent processus vaginalis (Should go after birth). Can fill with fluid (Hydrocele) or bowel (Indirect hernia)
Acquired - Mainly due to increased abdominal pressure eg chronic cough, constipation, severe muscular effort, obesity, ascites, appendectomy. Weakening of the muscle wall
What is the pathology of a congenital Inguinal hernia?
Indirect Patent processus vaginalis Emerge through deep inguinal ring Has the same 3 covering as the spermatic cord (Internal spermatic fascia, Cremasteric muscle, External spermatic fascia) Descends into the scrotum *Can strangulate*
What is the pathology of an acquired Inguinal hernia?
Direct
Emerge through weakened area called Hesselbach’s triangle - medial to the inferior epigastric vessels
Rarely descent into scrotum
Rarely strangulate!
What are the boundaries of Hesselbach’s triangle?
Superio-lateral - Inferior epigastric vessels
Medial - Linea semilunaris (lateral margin of the rectus sheath)
Inferior - Inguinal ligament
What investigations can be done in a patient with suspected Inguinal hernia?
USS
What are some of the clinical features of an Inguinal hernia in children?
Lump in groin which may descend into the scrotum
Exacerbated by crying or coughing
Commonly obstruct
What are some of the clinical features of an Inguinal hernia in adults?
Lump in groin
Exacerbated by straining or coughing
May be a clear event that caused it in Hx
Dragging type pain that radiates to the groin
may present with strangulation or obstruction
What questions are important to ask in a patient with a suspected hernia?
Is it reducible?
Is it painful?
Has there been any episodes of obstruction or strangulation?
Are there any predisposing factors? eg Straining, lifting, coughing
Occupation, lifestyle
What are some of the non surgical treatments for an Inguinal hernia?
Manage any risk factors eg cough, constipation
Lifestyle adjustments eg weight loss
Truss (similar to support brace, support the area effected and keep it in the correct position)
What are some of the surgical treatments for an Inguinal hernia?
Tension free mesh and suture repair
Open repair
Laparoscopic repair - better for recurrent hernias
Children may have herniotomy - sac excision
What are some of the early complications of an Inguinal hernia repair?
Haematoma/Seroma
Intra-abdominal injury (Laparoscopic)
Infection
Urinary retention
What are some of the late complications of an Inguinal hernia repair?
Recurrence
Chronic groin pain
Groin paraesthesia
Ischaemic orchitis (inflammation of testicles)
What are the borders of the Inguinal canal?
Anterior wall - Aponeurosis of external oblique
Posterior wall - Transversalis fascia
Roof - Transversalis fasica, Internal oblique, Transversus abdominis
Floor - Inguinal ligament, lacunar ligament medially
What are the borders of the Femoral canal
Anterior - Inguinal ligament
Posterior - Pectineal ligament, Pectineus muscle, Superior rami of the pubi
Medial - Lacunar ligament
Lateral - Femoral vein
What are the borders of the Femoral triangle
Superior - Inguinal ligament
Lateral - Medial border of the Sartorius muscle
Medial - Medial border of the Adductor longus muscle (Also forms floor of the triangle)
What is found at the mid inguinal point
Half way between ASIS and pubis symphysis
Femoral artery is found here
What is found at the mid point of the inguinal ligament
Half way along the inguinal ligament which runs from ASIS to pubic tubercle
Deep inguinal ring is found here
What are some of the risk factors for a Femoral hernia?
Female - due to wider shape of pelvis and changes during childbirth
Increasing age
Increased intra abdominal pressure
What are some of the clinical features of a Femoral hernia?
Painless lump in the groin that has a cough impulse and often cannot be reduced
Commonly presents with strangulation/obstruction
What are the symptoms of strangulation or obstruction of a hernia?
Tender Erythematous Hot Abdominal pain Distension Vomiting Constipation
What is the management of a Femoral hernia?
Urgent surgical repair as highly likely to strangulate
Define Incisional hernia
Hernia arises through a previously acquired defect
What are some of the pre operative risk factors for an Incisional hernia?
Increasing age Obesity Malnutrition Co morbidities eg DM, malignacy Drugs eg steroids, chemotherapy
What are some of the intra operative risk factors for an Incisional hernia?
Srugical technique/skill - too small sutures or wrong material used
Incision type/position eg midline
Drain placement through wounds
What are some of the post operative risk factors for an Incisional hernia?
Increased intra abdominal pressure eg cough, straining, post op ileus
Infection
Haematoma
What is the management for an Incisional hernia?
Mange risk factors eg cough Weight loss Truss/Corset Surgery if appropriate (Nylon mesh repair) *Low chance of strangulation*
What is the managment of Umbilical hernias?
Usually congenital
Tends to resolve when 2-3 y/o can recur in pregnancy or ascites
What are some of the features of a Periumbilical hernia?
Middle aged obese men
Defect through linea alba
Chronic cough/straining are risk factors
Mesh repair needed
What causes an Epigastric hernia?
Defect in linea alba, small pea sized hernia
Usually contains omentum
Mesh repair
What is a Spigelian hernia?
Hernia through linea semilunaris, lies between the layers of the abdominal wall
High risk of strangulation
Mesh repair
What can cause a persistent midline bulge when patients lie down/raise head?
Divarication of the abdominal wall (Diastasis recti)
Happens in obese or pregnant patients
Not a true hernia, weakening of the abdominal wall muscles
