Hernias Flashcards
Where do hiatus hernias occur?
At the gastro-oesophageal junction (part of the gastric cardia) above the diaphragm
What causes hiatus hernias?
Diaphragmatic weakness an increased intra-abdominal pressure
What is the major risk factor for hiatus hernias?
obestiy
What happens during a hiatus hernia?
Proximal stomach perforates through the diaphragm
What are the two types of hiatus hernias?
Sliding
Rolling (para-oesophageal)
What is the difference between a sliding and rolling hiatus hernia?
Sliding - LOS moves superiorly
Rolling - LOS stays in same position
How do hiatus hernias present?
Reflux, reflux oesophagitis
How can you investigate a possible hiatus hernia?
CXR
Barium swallow
Endoscopy
How do you manage a hiatus hernia?
Avoid triggers Elevate head of bed to reduce reflux at night Weight loss Smaller peals PPIs Surgery for specific patients
What is a hernia?
Abnormal protrusion of a viscus (internal body organ) outwit its normal body cavity (very common)
What does a hernia consist of?
A sac (peritoneum)
Cover of the sac
Contents (bowel, momentum, fat)
What are natural abdominal wall hernias?
Inguinal Femoral Umbilical Oesophageal Hiatus Obturator
What are weak areas where hernias develop?
Incisional
Para-stomal
Epigastric
Para-umbilical
What is the main risk factor for hernias?
Increased intra-abdominal pressure
What are sources of increased intra-abdominal pressure?
Heavy lifting Coughing Constipation Prostation (BPH) Pregnancy Obesity
What happens during a hernia?
Section of bowel passes through a weak point
What are the two types of hernias?
Reducible
iressducible
Irreducible hernias can become obstructed leading to?
Strangulation or incarceration
What is strangulation?
Compromise of blood supply; venous then arterial –> gangrene
What are risk factors for incisional hernias?
Age Obesity Debility Post-op wound infection or haematoma Increased abdominal pressure Steroids Type of infeciton
What are predisposing factors for epigastric hernias?
Congenital weakness in linea alba
Male > female (usually late teens/early adult)
What are symptoms/features of epigastric hernias?
Usually asymptomatic or local symptoms
How do you treat epigastric hernias?
Suture/mesh
Congenital umbilical hernias are meant to resolve before the age of _____ otherwise operate
3-4
Paediatric hernias are more common in?
Males, preterm/LBW infants
Paediatric hernias occur most common on the _____ side
right
Paediatric hernias are almost alway _____
indirect
How do paediatric hernias typically present
Groin swelling on crying - may be difficult to elicit on examination
What is the silk sign of paediatric hernias?
Rubbing two layers against each other feels like 2 pieces of silk
How do you treat paediatric hernias?
Urgent surgical repair - increased strangulation risk < 1 year old
What is the anterior border of the femoral canal?
Inguinal ligament
What is the posterior border of the femoral canal?
Pectinate ligament
What is the lateral border of the femoral canal?
Femoral vein
What is the medial border of the femoral canal?
Lancunar ligament
Where are femoral hernias usually located?
Below and lateral to the pubic tubercle
What usually happens to the groin crease when there is a femoral hernia?
Usually fall tens
Femoral hernias occur more in?
Women
What % of femoral hernias are surgical emergencies?
50
What makes a femoral hernia a surgical emergency; if it is..?
Irreducible
Strangualtion
Obstruction
How do you treat femoral hernias?
Gentle reduction under analgesia
Operative repair under resus (inguinal ligament is sutured to pectineal ligament)
To find inguinal hernias you need to examine the patient..?
Upright
If the hernia extends to the scrotum it is probably?
Indirect
An inguinal hernia is usually above and medial to the?
Pubic tubercle
An indirect inguinal hernia is a bulge straight through the?
Deep inguinal rign
An indirect inguinal hernia is lateral to`
Inferior epigastric vessels and outwith the cord
An indirect inguinal hernia may reach the?
Scrotum
Indirect inguinal hernias are more common in?
Men
What is the diagnostic feature differentiating direct and indirect inguinal hernias?
Indirect - can be controlled by digital pressure over inguinal ring (press and ask to cough - should stay in)
Direct - can’t
Congenital inguinal hernias are always?
Indirect
Direct inguinal hernias go straight through the?
Transversalis fascia in the posterior wall
The posterior bulge through the transversals fascia is medial to the _____ and is often?
Inferior epigastric
Bilateral
Direct inguinal hernias are more common in?
Older men
Direct inguinal hernias never go through to the?
Scrotum
What is the processus vaginalis?
Outpouching of peritoneum attached to testicel left behind as it descends
If the obliteratetion of the processus vaginalis fails an _____ hernia occurs
Inguinal
How do you treat a hernia?
Operate if risk of complications, previous symptoms of obstruction, interfering with lifestyle
What are complications of inguinal hernias?
Haematoma Acute urinary retention Wound infection Chronic neurogenic pain Recurrence Numbness Testicular atrophy/ischaemic orchitis
What is a herniotomy?
Excise peritoneal sac - congenital hernias
What is a herniorrhaphy?
Wall defect reapir
The Liechtenstein method/open hernia repair can be done under?
Spinal or local
Open hernia repairs have a higher rate of?
Infection
Laprascopic hernia repairs have the advantages of? Disadvantages?
Less pain
Faster recovery
Needs GA
Longer learning curve for surgeons
The inguinal canal is between the?
Deep and superficial ring
The deep ring is at the?
Mid-inguinal point
The superficial ring is where?
Above and medial to the pubic tubercle
What is anterior to the inguinal canal?
External oblique aponeurosis
What makes up the floor of the inguinal canal?
Inguinal and Lacunar ligament
What makes up the roof of the inguinal ligament?
Conjoint tendon coming over
What is posterior to the inguinal ligament?
Transversalis fascia and conjoint tendon (med)
What makes up Hasselbach’s triangle?
Inguinal ligament inferiorly
Inferior epigastric vessels laterally
Lateral border of rectus sheath medially
How do you investigate a hernia?
Assess standing and sitting
Ask them to cough
Is lump reducible?
What is the position of inguinal hernias?
Originate above and lateral to pubic tubercle
What is the position of a femoral hernia?
Originate below and lateral to the pubic tubercle
What is incarceration of a hernia?
Contents of the hernia become trapped in the weak point in the abdominal wall which can obstruct the bowel leading to severe pain, nausea, vomiting, and the inability to pass bowels or gas
An incarcerated hernia can cut off blood flow to part of the bowel; this is known as?
Strangulation
How does a hernia usually present?
As a lump which is worst on coughing, disappears on lying down and can be pushed back in
