Hernias

Question 1

What is a hernia.

Answer 1

The protrusion of a viscus or part of a viscus through a defect of the wall of its containing cavity into an abnormal position.

Question 2

What is an irreducible hernia.

Answer 2

Hernias involving the bowel are said to be irreducible if they cannot be pushed back into their right place.

Question 3

What is an incarcerated hernia.

Answer 3

It implies that the contents of the hernial sac are stuck inside by adhesions.

Question 4

What is an obstructed hernia.

Answer 4

GI hernias are obstructed if bowel contents cannot pass through them.

Question 5

What set of signs and symptoms do you see with an obstructed GI hernia.

Answer 5

The classical features of intestinal obstruction.

Question 6

What is a strangulated hernia.

Answer 6

A hernia is strangulated if the blood supply is cut off and ischaemia occurs.

Question 7

What is the best course of action when presented with a strangulated hernia.

Answer 7

Surgery.

Question 8

What are the typical hernias that can occur. (14)

Answer 8

Inguinal hernias. 
Femoral hernias. 
Paraumbilical hernias. 
Epigastric hernias. 
Incisional hernias. 
Spigelian hernias. 
Lumbar hernias. 
Richter's hernias. 
Maydl's hernias. 
Littre's hernias. 
Obturator hernias. 
Sciatic hernias. 
Sliding hernias. 
Other...

Question 9

What is the typical presentation of a femoral hernia. (2)

Answer 9

Bowel enters the femoral canal, presenting as a mass in the upper medial thigh or above the inguinal ligament (it points down the leg).

Question 10

Who do femoral hernias occur most in. (2)

Answer 10

Women.

Especially middle aged and elderly.

Question 11

What complication can occur with a femoral hernia. (2)

Answer 11

They can become strangulated.

They tend to be irreducible due to the rigidity of the canal borders.

Question 12

What is the anatomy of a femoral hernia. (5)

Answer 12

The neck: it is felt inferior and lateral to the pubic tubercle.
The boundaries of the femoral canal are-
Anteriorly: the inguinal ligament.
Medially: the lacunar ligament (and pubic bone).
Laterally: femoral vein (and iliopsoas).
Posteriorly: the pectineal ligament and pectineus.

Question 13

What is contained within the femoral canal. (2)

Answer 13

Fat.

Cloquet’s node.

Question 14

What is the differential diagnosis for a femoral hernia. (6)

Answer 14

Inguinal hernia. 
Saphena varix. 
Enlarged Cloquet's node. 
Lipoma. 
Femoral aneurysm. 
Psoas abscess.

Question 15

Where do paraumbilical hernias occur.

Answer 15

Just above or below the umbilicus.

Question 16

What are some risk factors for paraumbilical hernias. (2)

Answer 16

Obesity.

Ascites.

Question 17

What is within a paraumbilical hernia. (2)

Answer 17

Omentum or bowel.

Question 18

Where do epigastric hernias occur.

Answer 18

They pass through the lineal alba above the umbilicus.

Question 19

Where do incisional hernias occur.

Answer 19

They follow breakdown of muscle closure after surgery (11-20%).

Question 20

What complicates an incisional hernia repair.

Answer 20

Obesity.

Question 21

What is associated with mesh repair of incisional hernias. (2)

Answer 21

Lower recurrence rate.

Increased infection rate over sutures.

Question 22

Where do spigelian hernias occur.

Answer 22

They occur through the linea semilunaris at the lateral edge of the rectus sheath, below and lateral to the umbilicus.

Question 23

Where do lumbar hernias occur.

Answer 23

They occur through the inferior or superior lumbar triangles in the posterior abdominal wall.

Question 24

What is the characteristic of Richter’s hernias.

Answer 24

They involve bowel wall only, not the whole lumen.

Question 25

What do Maydl's hernias involve. (2)

Answer 25

They involve herniating 'double loop' of bowel. | The strangulated portion may reside as a single loop INSIDE the abdominal cavity.

Question 26

What are Littre's hernias.

Answer 26

They are hernial sacs containing strangulated Meckel's diverticulum.

Question 27

Where do obturator hernias occur.

Answer 27

They occur through the obturator canal.

Question 28

What is a typical symptom of an obturator hernia in a thin woman.

Answer 28

Pain along the medial side of the thigh.

Question 29

What is a sciatic hernia.

Answer 29

They pass through the lesser sciatic foramen.

Question 30

What suggests a sciatic hernia. (2)

Answer 30

A gluteal mass. | GI obstruction.

Question 31

What do sliding hernias contain.

Answer 31

A partially extraperitoneal structure.

Question 32

What is a characteristic of sliding hernias.

Answer 32

The sac does not completely surround the contents.

Question 33

Name a few other causes of hernias. (4)

Answer 33

Slipped disc. Arnold-Chiari hernia. Hiatus hernia. Tentorial hernia.

Question 34

What percentage of male infants suffer from indirect inguinal hernias.

Answer 34

4%.

Question 35

What is the cause of an indirect inguinal hernia in an infant male.

Answer 35

Patent procesus vaginalis.

Question 36

What is a risk factor for a male infant to develop an inguinal hernia.

Answer 36

Prematurity.

Question 37

What does it mean if you see a patent process vaginalis filled with fluid.

Answer 37

There is a communicating hydrocele.

Question 38

What percentage of live births have true umbilical hernias.

Answer 38

3%.

Question 39

What is the cause of a true umbilical hernia.

Answer 39

Persistent defect in the tranversalis fascia 9(the umbilical ring).

Question 40

What are the risk factors for a true umbilical hernia. (3)

Answer 40

African-Caribbeans. Trisomy 21. Congenital hypothyroidism.

Question 41

What is the route of an indirect inguinal hernia. (2)

Answer 41

They pass through the internal inguinal ring. | If they are large, the pass out through the external ring.

Question 42

What is the route of a direct inguinal hernia.

Answer 42

They push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal wall.

Question 43

What is Hesselach's triangle. (3)

Answer 43

Medial to the inferior epigastric vessels. Lateral to the rectus abdominus. Where most direct inguinal hernias emerge.

Question 44

What are some predisposing conditions to develop an inguinal hernia. (7)

Answer 44

``` Male. Chronic cough. Constipation. Urinary obstruction. Heavy lifting. Ascites. Past abdominal surgery. ```

Question 45

What is the ratio of males:females who get inguinal hernias.

Answer 45

8:1.

Question 46

What are the two important landmarks to identify. (2)

Answer 46

The deep inguinal ring. | The superficial inguinal ring.

Question 47

What is the landmark for the deep inguinal ring.

Answer 47

The mid-point of the inguinal ligament.

Question 48

What is the landmark for the superficial inguinal ring.

Answer 48

A split in the external aponeurosis just superior and medial to the pubic tubercle.

Question 49

What is the floor of the inguinal canal. (2)

Answer 49

Inguinal ligament. | Medially it is the lacunar ligament.

Question 50

What is the roof of the inguinal canal. (2)

Answer 50

Fibres of transversalis. | Internal oblique.

Question 51

What is the anterior wall of the inguinal canal. (2)

Answer 51

External oblique aponeurosis. | Internal oblique for the lateral third.

Question 52

What is the posterior wall of the inguinal canal. (2)

Answer 52

Laterally: transversalis fascia. Medialy: conjoint tendon.

Question 53

What side are inguinal hernias most common.

Answer 53

Right side.

Question 54

How do you distinguish a direct from an indirect inguinal hernia on clinical exam. (5)

Answer 54

``` Reduce the hernia. Occlude the deep ring with two fingers. Ask the patient to cough or stand up. If the hernia is restrained = indirect. If the hernia appears = direct. ```

Question 55

Where do direct inguinal hernias occur.

Answer 55

Medial to the inferior epigastric vessels.

Question 56

Where do indirect inguinal hernias occur.

Answer 56

Lateral to the inferior epigastric vessels.

Question 57

What are most inguinal hernias.

Answer 57

Indirect (80%).

Question 58

What kind of inguinal hernia more commonly strangulate.

Answer 58

Indirect.

Question 59

What two types of hernias frequently strangulate. (2)

Answer 59

Indirect inguinal hernias. | Femoral hernias.