Hernias Flashcards
Define a hernia. What are the different types?
Protrusion of an organ through its containing wall.
- epigastric
- umbilical
- incisional
- inguinal
- femoral
- Spigelian
Describe the anatomy of an indirect inguinal hernia.
Herniates LATERAL to inferior epigastric artery.
Moves within spermatic cord and enters inguinal canal via deep inguinal ring.
Describe the anatomy of a direct inguinal hernia.
Herniates MEDIAL to inferior epigastric artery.
Moves outside the spermatic cord and enters the inguinal canal by pushing through Hesselbach’s triangle.
Contrast inguinal and femoral hernias.
Inguinal hernias are above and medial to the pubic tubercle.
Femoral hernias are below and lateral to the pubic tubercle.
Femoral hernias are more likely to strangulate (against lacunar ligament at the medial border of the femoral canal).
Femoral hernias are more common in women (childbirth stretches ligaments and widens femoral canal) BUT inguinal hernias are still more common overall in women and men.
What is a Richter’s hernia?
Only a small segment of bowel is strangulated so the lumen remains patent.
Therefore no signs of intestinal obstruction.
More common in femoral hernias (narrower neck)
Risk of missing during hernia repair —> necrosis —> peritonitis
What is the aetiology and signs and symptoms for paraumbilical hernias?
Middle-old age, females>males, obesity, parity
- swelling
- discomfort
- sometimes pain/tenderness around umbilicus
- made worse by standing/exercise
note: strangulation of hernia common, but contents are omentum/extraperitoneal fat (so no bowel obstruction)
What are the examination findings in paraumbilical hernias?
Hernia lateral to umbilical scar which is pushed to one side and becomes crescent-shaped.
Expansile cough impulse.
If it is difficult to clean it can discharge or an ompholith can form.
Reminder: what are the borders of the femoral triangle?
Base = inguinal ligament Lateral = medial margin of sartorius Medial = medial margin of adductor longus Apex = adductor canal Floor = iliopsoas, pectineus, adductor longus Roof = skin and fascia
Reminder: what is the mid-point of the inguinal ligament?
Mid-point between ASIS and pubic tubercle
deep inguinal ring
Reminder: what is the mid-inguinal point?
Mid-point between ASIS and pubic symphysis
femoral artery
Where is the superficial inguinal ring located?
Just superior and medial to the pubic tubercle
What layers does the inguinal canal travel through?
Peritoneum —> Transversalis fascia —> Deep inguinal ring —> Transversalis abdominis —> internal oblique —> external oblique aponeurosis —> Superficial inguinal ring
Reminder: what are the borders of the inguinal canal?
MALT = muscle (internal oblique - roof), aponeurosis (external oblique - anterior), ligament (inguinal ligament - floor), tendon (transversalis fascia - posterior)
Reminder: what are the contents of the inguinal canal?
Male
- spermatic cord (vas deferens, testicular artery, testicular nerves, pampiniform plexus, lymphatics)
- ilioinguinal nerve
Female:
- round ligament of uterus
- ilioinguinal nerve
Outline the examination of hernias.
SSS CCC TTT
Site
Size
Shape
Consistency
Contours
Colour
Tenderness
Temperature
Transillumination
Contrast the positions of different hernias.
Inguinal = visible in all but obese
- direct: superomedial to pubic tubercle
- indirect: anwhere between deep inguinal ring (midpoint of inguinal ligament) and scrotum/labia majora; reduces obliquely
Femoral = inferolateral to pubic tubercle
Umbilical = beside umbilicus (which is pushed to one side and stretched into crescent shape)
Epigastric = in midline between xiphisternum and umbilicus through linea alba
Spigelian = edge of rectus sheath, inferior to umbilicus, above inguinal area
Obturator = obturator foramen, usually concealed within adductor muscles, medial thigh
Lumbar/gluteal = near site of previous surgery
Contrast an epigastric hernia and divarication of the recti.
Epigastric hernia = in midline between xiphisternum and umbilicus through linea alba
Divarication of recti = sepearation of rectus abdominis muscles with extenuation of linea alba from xiphisternum to umbilicus (and occasionally below)
note: cosmetic, wide defect does not cause strangulation
Contrast the colour of inguinal and femoral hernias.
Inguinal = normal unless strangulated (red)
Femoral = always normal, even if strangulated
What is the temperature of hernias?
Same as surrounding skin except sometimes is warmer when strangulated
Contrast the tenderness of inguinal and femoral hernias.
Inguinal: normal pressure uncomfortable, strangulated hernias very tender
Femoral: not tender unless strangulated
Contrast the shape of inguinal and femoral hernias.
Inguinal:
- direct: round
- indirect: sausage-shaped (in inguinal canal) or pear-shaped (beyond superficial ring)
Femoral: spherical, neck cannot be clearly defined
Contrast the size of inguinal and femoral hernias.
Inguinal: small and barely detectable —> large masses descending to knee level
Femoral: small (enlargement limited by Scarper’s fascia —> spread upwards towards fold in groin)
Contrast the surface of different hernias.
Inguinal = usually smooth (but depends on contents), can sometimes palpate indentable faeces in incarcerated segment
Femoral = usually smooth and firm due to thick-walled fatty sac surrounding contents
Umbilical = soft, compressible, easily reduced
Epigastric = firm
What is incarceration of a hernia?
Contents are imprisoned in sac by hernia (usually due to adhesions) but still alive and functioning
