Hernias Flashcards
Definition of hernias?
An abnormal protrusion of a viscous outwith its normal body cavity
4 of the most common hernias?
Inguinal
Umbilical
Incisional
Femoral
Causes of abdominal wall hernias?
May arise from natural openings OR weak areas, caused by stretching or surgical incisions
5 natural abdominal wall hernias?
Inguinal Femoral Umbilical Oesophageal hiatus hernia Obturator
4 weak area hernias?
Incisional
Parastomal (around a stoma)
Epigastric
Paraumbilical
6 factors that predispose to abdominal hernias?
Increase in intra-abdominal pressure: Heavy lifting Coughing Constipation Prostatism Pregnancy Obesity
Classification of hernias?
Reducible
Irreducible:
Obstructed (can progress to strangulation)
Incarcerated
What does strangulation mean, in relation to hernias?
Compromise of blood supply of the contents of the hernia; strangulation increases morbidity and mortality
Initially, the low pressure venous system is occluded and then the arterial supply; this leads to ischaemia and then gangrene (coagulative necrosis)
What are incisional hernias?
Incompletely-healed surgical wound can cause a hernia
Aetiology of incisional hernias?
Age and general debility, e.g: malignancy
Steroids
Obesity
Post-operative wound infection or haematoma
Raised intra-abdominal pressure, e.g: ileus
Type of incision; vertical incisions have greater incidence of hernia than transverse
Prevention of incisional hernia?
In predisposed patients, use tension sutures + “mass closure” of the linea alba
What is a para-umbilical hernia?
Around the umbilicus and occur in ADULTS, usually in obese individuals
Causes of epigastric hernias?
Arise from a CONGENITAL weakness of the linea alba, between the umbilicus and xiphisternum
They usually contain extra-peritoneal fat
Occurrence of epigastric hernias?
More common in males, usually in late teens or early adulthood
Symptoms of epigastric hernia?
Usually asymptomatic or there are local symptoms
Treatment of epigastric hernia?
Repair with sutures or mesh
Cause of umbilical hernias?
Congenital problem; occurs in CHILDREN, within 1st year of life or when they are born
They can occur alongside pediatric inguinal hernias
Treatment of umbilical hernias?
Usually resolve by the age of 3; if >3 years of age, operate
What is the processus vaginalis?
Tunica vaginalis is the embryological remnant of the processus vaginalis; in males, the processus vaginalis proceeds down the gubernaculum and forms a small pouch next to the testes and the neck closes off, called fusion, to form the tunica vaginalis
What problems can occur with fusion?
If fusion does not occur completely and the neck remains open, a scrotal or inguinal hernia can form
Also, hydroceles can form, as fluid enters the processus vaginalis from the peritoneal cavity
Occurrence of pediatric inguinal hernia?
30% present before the age of 1; they are far more common in males and also in premature and low birth weight infants
Right-sided hernias are more common and there is a risk of developing a contralateral hernia
When does the risk of strangulation, with a pediatric inguinal hernial, occur?
Increased risk of strangulation if aged less than 1; urgent surgery required
What are femoral hernias?
Form due to a defect in the femoral canal
Boundaries of the inguinal canal?
Anterior - inguinal ligament
Medial - lacunar ligament
Lateral - femoral vein
Posterior - pectinate ligament
Location and features of femoral hernias?
Below and lateral to the PUBIC TUBERCLE and usually flatten/cause a loss of the groin crease; they are 10 x more common in females, particular in thin, elderly females with no previous surgery
Half present as a surgical emergency and, of those, 50% require small bowel resection
Location and features of inguinal hernias?
Above pubic tubercle and increase the groin crease
How to examine scrotal swellings?
Can you get above it? - if yes, it is likely a scrotal swelling and perhaps a hydrocele; if not, it is likely an inguino-scrotal hernia
Can you feel the testes separate? - if you can separate from the testes, it is an epididymal cyst
Causes of scrotal swellings?
Inguino-scrotal hernia (indirect)
Hydrocele
Epididymal cyst
Testicular swelling in young males; be wary of testicular cancer
Signs of inguinal hernia?
Hernia to scrotum, probably an indirect hernia
Find the pubic tubercle:
If above and medial - inguinal
If below and lateral - femoral
Ask patient to cough
How to clinically differentiate between direct or indirect hernias?
Not clinically useful:
Reduce hernia and place pressure over the deep inguinal ring and get patient to cough
Place little finger in the canal (behind the cord)
It is best to differentiate at surgery:
If medial to inferior epigastric vessels - direct
If lateral to inferior epigastric vessels - indirect
Types of inguinal hernias?
Indirect inguinal hernias are lateral to the inferior epigastric vessels and with the cord; they may reach the scrotum and are more common in males
All congenital hernias are indirect
Direct inguinal hernia - posterior bulge through transversalis fascia and they are medial to the inferior epigastric vessels; they are often bilateral
What is Hesselbach’s triangle?
Inguinal ligament inferiorly
Inferior epigastric vessels laterally
Lateral border of the rectus sheath medially
When to operate on hernias?
Hernia at risk of complications even if no symptoms, e.g: femoral
Hernia with previous symptoms of obstruction
Hernia interfering with lifestyle
Complications of inguinal hernias?
Haematoma (wound or scrotum)
Acute urinary retention
Wound infection
Chronic neurogenic pain
Hernia Recurrence
Testicular pain and atrophy
