Hernias Flashcards
Define ‘hernia’
Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position
Define reducible hernia
Sac can return to the abdominal cavity either spontaneously or with manipulation
Define irreducible
Sac cannot be reduced despite pressure or manipulation
Define strangulated
Blood supply of contents is compromised due to pressure at the neck of the hernia
Define sliding hernia
Part of the sac is formed by bowel (e.g. caecum or sigmoid): take care when excising the sac
Define Mayday’s hernia
Herniating double loop of bowel - strangulated portion may reside as a single loop inside the abdomen
Define Littre’s hernia
Hernial sac containing strangulated Meckel’s diverticulum
Define Amyand’s hernia
Inguinal hernia containing strangulated appendix
Define Richter’s hernia
Only part of circumference of bowel is within sack - most commonly seen with femoral hernias and can strangulate without obstructing
Define a pantaloon hernia
Simultaneous direct and indirect hernia
Define herniotomy
Excision of hernial sac
Define herniorrhaphy
Suture repair of hernial defect
Define hernioplasty
Mesh repair of hernial defect
What is the epidemiology of inguinal hernias?
- 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
Which side is more common for inguinal hernias?
Commoner on R (?damage to ilioinguinal nerve at appendicectomy leading to muscle weakness) but 5% are bilateral
How commonly do inguinal hernias present as an obstruction/strangulation?
8-15%
What are the aetiological factors in inguinal hernia?
- 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
What are the defining features of direct and indirect inguinal hernias?
- 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
What investigations should be done for an inguinal hernia?
Just an ultrasound, if in doubt
What are the clinical features of inguinal hernias in children?
- Lump in groin which may descend into scrotum
- Exacerbated by crying
- Commonly obstruct
What are the clinical features of inguinal hernias in adults?
- 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
What are the non surgical management options for inguinal hernias?
- Reduce risk factors e.g. cough, constipation
- Lose weight
- Truss
What are the surgical management options for inguinal hernias?
- 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)
What are the complications of an inguinal hernia repair?
- 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%
What are the contents of the inguinal canal?
Males: spermatic vessels and vas deferens
Females: round ligament
What are the borders of the inguinal canal?
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
Define femoral hernia
Protrusion of viscus through the femoral canal
What is the epidemiology of femoral hernias?
- F>M
- Middle aged and elderly
What is the aetiology of femoral hernias?
Acquired: raised intraabdominal pressure
Why are femoral hernias more common in women?
Femoral canal is larger in females due to the shape of the pelvis and changes in its configuration due to childbirth
What are the clinical features of femoral hernias?
- 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
How are femoral hernias managed?
- 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
How common are incisional hernias?
6% of surgical incisions
What are the risk factors for incisional hernias?
- 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
- Surgical technique/skill (major factor
- Post operative
- Increased intra abdominal pressure (chronic cough, straining, post op ileus)
- Infection
- Haematoma
How do you manage incisional hernias?
- 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
- Pre op
What are the features of umbilical hernias?
- Congenital
- 3% of LBs
- Defect in the umbilical scar
What are the risk factors for umbilical hernias?
- Afro-Caribbean
- Trisomy 21
- Congenital hypothyroidism
How do you manage umbilical hernias?
- Usually resolves by 2-3 years
- Mesh repair if no closure
- Can recur in adults: pregnancy or gross ascites
What are the features of paraumbilical hernias?
- Acquired: middle aged obese men
- Defect through the linea alba just above or below the umbilicus
- Small defect means they can strangulate (often omentum)
What are the risk factors for paraumbilical hernias?
Chronic cough, straining
How should you manage paraumbilical hernias?
Mayo (double breast linea alba with sutures)/mesh repair
What are the features of epigastric hernias?
- Young, M>F
- Pea sized swelling caused by defect in linea alba above the umbilicus
- Usually contains omentum: can strangulate
How should you manage epigastric hernias?
Mesh repair
What are the features of Spigelian hernias?
- HErnia through linea semilunaris
- Hernia lies between layers of abdo wall
- Palpable mass more likely to be colon ca
What are the features of obturator hernias?
- Old aged F>M
- Sac protrudes through the obturator foramen
- Pain on inner aspect of thigh or knee
- Frequently present obstructed/strangulated
What are the features of lumbar hernias?
- Middle aged M>F
- Typically follow loin incisions
- Hernias through superior/inferior lunbar triangles
What are the features of sciatic hernias?
- Hernia through lesser sciatic foramen
- Usually presents as SBO + gluteal mass
What are the features of gluteal hernias?
- Hernia through greater sciatic foramen
- USually presents as SBO + gluteal mass
