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Surgery Finals > Hernias > Flashcards

Hernias Flashcards

1
Q

Define ‘hernia’

A

Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position

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2
Q

Define reducible hernia

A

Sac can return to the abdominal cavity either spontaneously or with manipulation

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3
Q

Define irreducible

A

Sac cannot be reduced despite pressure or manipulation

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4
Q

Define strangulated

A

Blood supply of contents is compromised due to pressure at the neck of the hernia

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5
Q

Define sliding hernia

A

Part of the sac is formed by bowel (e.g. caecum or sigmoid): take care when excising the sac

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6
Q

Define Mayday’s hernia

A

Herniating double loop of bowel - strangulated portion may reside as a single loop inside the abdomen

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7
Q

Define Littre’s hernia

A

Hernial sac containing strangulated Meckel’s diverticulum

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8
Q

Define Amyand’s hernia

A

Inguinal hernia containing strangulated appendix

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9
Q

Define Richter’s hernia

A

Only part of circumference of bowel is within sack - most commonly seen with femoral hernias and can strangulate without obstructing

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10
Q

Define a pantaloon hernia

A

Simultaneous direct and indirect hernia

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11
Q

Define herniotomy

A

Excision of hernial sac

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12
Q

Define herniorrhaphy

A

Suture repair of hernial defect

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13
Q

Define hernioplasty

A

Mesh repair of hernial defect

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14
Q

What is the epidemiology of inguinal hernias?

A
  • 3% adults will need hernioplasty
  • ~4% male neonates have hernia (increased in prems)
  • M>F 9:1 (due to descent of testes)
  • Majority present in 50s
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15
Q

Which side is more common for inguinal hernias?

A

Commoner on R (?damage to ilioinguinal nerve at appendicectomy leading to muscle weakness) but 5% are bilateral

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16
Q

How commonly do inguinal hernias present as an obstruction/strangulation?

A

8-15%

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17
Q

What are the aetiological factors in inguinal hernia?

A
  • Congenital: patent processus vaginalis
    • Should obliterate after descent of the testes
    • If it doesn’t can fill with fluid (hydrocele) or bowel/omentum (indirect hernia)
  • Acquired: things which increased IAP:
    • Chronic cough: COPD, asthma
    • Prostatism
    • Constipation
    • Severe muscular effort e.g. heavy lifting
    • Previous incision/reapir
    • Ascites/obesity
    • Appendicectomy
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18
Q

What are the defining features of direct and indirect inguinal hernias?

A
  • Indirect
    • 80% - commoner in the young
    • Congenital patent processus vaginalis
    • Emerge through the deep ring
    • Same 3 coverings as cord and descend into the scrotum
    • Can strangulate
  • Direct
    • 20% - commoner in the elderly
    • Acquired
    • Emerge through Hesselbach’s triangle
    • Can acquire internal and external spermatic fascia
    • Rarely descend into scrotum
    • Rarely strangulate
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19
Q

What investigations should be done for an inguinal hernia?

A

Just an ultrasound, if in doubt

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20
Q

What are the clinical features of inguinal hernias in children?

A
  • Lump in groin which may descend into scrotum
  • Exacerbated by crying
  • Commonly obstruct
21
Q

What are the clinical features of inguinal hernias in adults?

A
  • Lump in groin, exacerbated by straining/coughing
  • May be clear precipitating event e.g. heavy lifting
  • Dragging pain radiating to groin
  • May present with obstruction/strangulation
22
Q

What are the non surgical management options for inguinal hernias?

A
  • Reduce risk factors e.g. cough, constipation
  • Lose weight
  • Truss
23
Q

What are the surgical management options for inguinal hernias?

A
  • Tension free mesh (e.g. Lichtenstein repair) between than suture repair (e.g. Shouldice repair)
    • Recurrence <2% vs 10%
  • Open approach can be under LA or GA
  • Lap approach allows bilateral repair and improved cosmesis - also preferred if recurrent
  • Primary unilateral repairs should be open (NICE)
  • Children only require sac excision (herniotomy)
24
Q

What are the complications of an inguinal hernia repair?

A
  • Early
    • Haematoma/seroma formation (10%)
    • Intra-abdominal injury (lap)
    • Infection: 1%
    • Urinary retention
  • Late
    • Recurrence (<2%)
    • Ischaemic orchitis: 0.5%
    • Chronic groin pain/paraesthesia 5%
25
Q

What are the contents of the inguinal canal?

A

Males: spermatic vessels and vas deferens

Females: round ligament

26
Q

What are the borders of the inguinal canal?

A

MALT (2M, 2A, 2L, 2T)

  • Superior: 2 muscles
    • Internal oblique
    • Transverse abdominus
  • Anterior: 2 aponeuroses
    • Of external oblique
    • Of internal oblique
  • Lower wall/inferior: 2 ligaments
    • Inguinal
    • Lacunar
  • Posterior: 2 Ts
    • Transversalis fascia
    • Conjoint tendon
27
Q

Define femoral hernia

A

Protrusion of viscus through the femoral canal

28
Q

What is the epidemiology of femoral hernias?

A
  • F>M
  • Middle aged and elderly
29
Q

What is the aetiology of femoral hernias?

A

Acquired: raised intraabdominal pressure

30
Q

Why are femoral hernias more common in women?

A

Femoral canal is larger in females due to the shape of the pelvis and changes in its configuration due to childbirth

31
Q

What are the clinical features of femoral hernias?

A
  • Painless groin lump
    • Neck inferior (and lateral) to the pubic tubercle
    • Cough impulse
    • Often irreducible (tight borders)
  • Commonly present with obstruction or strangulation
    • Tender, red, and hot
    • Abdo pain, distension, vomiting, constipation
32
Q

How are femoral hernias managed?

A
  • 50% risk of strangulation within 1 month so urgent surgery
  • Elective: Lockwood approach
    • Low incision over hernia with herniotomy and herniorrhaphy (suture inguinal ligament to pectineal ligament)
  • Emergency: McEvedy approach
    • High approach in inguinal region to allow inspection and resection of non viable bowel
    • Then herniotomy and herniorrphaphy
33
Q

How common are incisional hernias?

A

6% of surgical incisions

34
Q

What are the risk factors for incisional hernias?

A
  • Pre operative
    • Old
    • Obesity or malnutrition
    • Cormorbidities: DM, renal failure, malignancy
    • Drugs: steroids, chemo, radio
  • Intra operative
    • Surgical technique/skill (major factor
      • Too small suture bites
      • Inappropriate suture material
    • Incision type e.g. midline
    • Placing drains through wounds
  • Post operative
    • Increased intra abdominal pressure (chronic cough, straining, post op ileus)
    • Infection
    • Haematoma
35
Q

How do you manage incisional hernias?

A
  • Surgery not appropriate for all - need to balance risks/benefits/risk of recurrence
  • Usually broad necked so low risk of strangulation
  • Conservative
    • Manage risk factors: constipation, cough
    • Weight loss
    • Elasticated corset or truss
  • Surgical
    • Pre op
      • Optimise cardioresp function
      • Encourage weight loss
    • Nylon mesh repair: open or lap
36
Q

What are the features of umbilical hernias?

A
  • Congenital
  • 3% of LBs
  • Defect in the umbilical scar
37
Q

What are the risk factors for umbilical hernias?

A
  • Afro-Caribbean
  • Trisomy 21
  • Congenital hypothyroidism
38
Q

How do you manage umbilical hernias?

A
  • Usually resolves by 2-3 years
  • Mesh repair if no closure
  • Can recur in adults: pregnancy or gross ascites
39
Q

What are the features of paraumbilical hernias?

A
  • Acquired: middle aged obese men
  • Defect through the linea alba just above or below the umbilicus
  • Small defect means they can strangulate (often omentum)
40
Q

What are the risk factors for paraumbilical hernias?

A

Chronic cough, straining

41
Q

How should you manage paraumbilical hernias?

A

Mayo (double breast linea alba with sutures)/mesh repair

42
Q

What are the features of epigastric hernias?

A
  • Young, M>F
  • Pea sized swelling caused by defect in linea alba above the umbilicus
  • Usually contains omentum: can strangulate
43
Q

How should you manage epigastric hernias?

A

Mesh repair

44
Q

What are the features of Spigelian hernias?

A
  • HErnia through linea semilunaris
  • Hernia lies between layers of abdo wall
  • Palpable mass more likely to be colon ca
45
Q

What are the features of obturator hernias?

A
  • Old aged F>M
  • Sac protrudes through the obturator foramen
  • Pain on inner aspect of thigh or knee
  • Frequently present obstructed/strangulated
46
Q

What are the features of lumbar hernias?

A
  • Middle aged M>F
  • Typically follow loin incisions
  • Hernias through superior/inferior lunbar triangles
47
Q

What are the features of sciatic hernias?

A
  • Hernia through lesser sciatic foramen
  • Usually presents as SBO + gluteal mass
48
Q

What are the features of gluteal hernias?

A
  • Hernia through greater sciatic foramen
  • USually presents as SBO + gluteal mass

Surgery Finals (12 decks)

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