Hernias Flashcards
What is a hernia?
A protrusion of a viscus or part of a viscus through the wall which is designed to contain it
What is a viscus?
Internal organ of the body
What do hernias consist of?
Sac, coverings of the sac, contents
What does the hernia sac consist of?
Peritoneum
What are coverings of the hernia sac?
Skin, fat and fascia
What are common contents of a hernia?
Small bowel or omentum
What are the two most common hernias?
Femoral and inguinal
What is an inguinal hernia?
Bulge through the inguinal canal
What is a femoral hernia?
Bulge through the femoral canal
What is the most common groin hernia?
Inguinal
Why are inguinal hernias more common in men?
Passage of the testes through the inguinal canal during development makes it wider and more susceptible
Who are femoral hernias more common in?
Women with lots of children
Which type of hernia is more commonly an emergency presentation?
Femoral
What is the purpose of the inguinal canal?
None in females but allows the passage of the testes in males
What allows the passage of the spermatic cord through the inguinal canal?
Oblique intermuscular slit
What forms the roof of the inguinal canal?
Transversalis fascia, internal oblique, transversus abdominus
What makes up the posterior wall of the inguinal canal?
Transversalis fascia
What makes up the floor of the inguinal canal?
Inguinal ligament, lacunar ligament
What makes up the anterior wall of the inguinal canal?
Aponeurosis of the external oblique, internal oblique
Where does the inferior epigastric artery arise from?
External iliac artery
What supplies the muscles of the abdominal wall?
Inferior epigastric artery
Where does the inguinal ligament run from?
ASIS to pubic tubercle
What does the deep inguinal ring do?
Allows entry of the vas deferens, arteries, veins and nerves
Where is the deep inguinal ligament found?
2cm up from the midpoint of the inguinal ligament
What does the superficial ring do?
Allows exit of its contents into the scrotum
What is the rule associated with the spermatic cord?
3 arteries, 3 nerves, 3 other things
What are the 3 arteries of the spermatic cord?
Testicular artery, artery to vas deferens, (deferential artery), cremasteric artery (to cremasteric artery)
What are the 3 nerves of the spermatic cord?
Nerve to cremaster (genital branch of genitofemoral nerve), testicular nerve (sympathetic), ilioinguinal nerve (technically outside cord)
What are the 3 other things on the spermatic cord?
Vas (ductus) deferens, pampiniform plexus, lymphatic vessels
What are the risk factors for an inguinal hernia?
Male, increased age, obesity, chronic cough, previous hernia, heavy lifting, constipation, pregnancy
When is the peak incidence of inguinal hernias?
6th decade
Which side and type of inguinal hernias are more common?
Right side, indirect
Where are direct hernias in relation to the inferior epigastric vessels?
Medial
What happens in a direct hernia?
Abdominal contents herniate through a weak spot in the fascia of the posterior wall of the inguinal canal
Which type of hernia is more common in older men?
Direct
Where are indirect hernias in relation to the inferior epigastric vessels?
Lateral
What happens in an indirect hernia?
Abdominal contents protrude through the deep inguinal ring
What can be a cause of an indirect hernia?
Failure of embryonic closure of the processus vaginalis
What type of hernia can pass into the scrotum and how?
Indirect- through the inguinal canal
What is the process for differentiating between direct and indirect hernias?
Ask patient to stand up, press on hernia and cover deep ring, ask patient to cough
If the hernia does not bulge out on a cough, what is it?
Indirect
If a hernia does bulge out on a cough, what is it?
Direct
What is a risk of hernia (uncommon though)?
Incarceration (something getting stuck and causing loss of blood supply)
Do hernias always need to be treated?
No
What happens in terms of treatment in incarceration?
The hernia cannot be pushed back in manually
What is open hernia surgery (Lichtenstein method)?
Inserting mesh over the site of the hernia once it has been pushed back in
What type of anaesthetic is required for an open hernia repair?
Local or spinal
What are the advantages of laparoscopic surgery?
Less pain, shorter recovery and less chance of infection
What are the disadvantages of laparoscopic surgery?
Harder procedure to do/learn and cannot be done in emergencies
What type of anaesthetic is needed for laparoscopic surgery?
General
What is a major complication of the Lichtenstein method?
Damage to the ilioinguinal nerve which can cause chronic pain for a few years
What are other complications of surgery?
Recurrence, urinary retention, bleeding.haematoma, numbness, testicular atrophy, wound infection
What are types of emergency hernia?
Irreducible, strangulating or causing obstruction
What is the first step to treating an emergency hernia?
Give patient analgesia and try to force it back in
What is the second step (if the fist doesn’t work) in treating an emergency hernia?
surgery
What type of hernias often have an acute emergency presentation?
Femoral
What is the femoral canal in relation to the inguinal ligament?
Inferior border
What is the anterior border of the femoral canal?
Inguinal ligament
What is the posterior border of the femoral canal?
Pectineal line and ligament
What is the medial border of the femoral canal?
Lacunar ligament
What is the lateral border of the femoral canal?
Femoral vein
Which of the four borders of the femoral canal is not firm?
Femoral vein
What does the femoral canal contain?
Fat and lymph nodes
What is the low/Lockwood approach to treating femoral hernias?
Used for elective surgery, incision below the medial portion of the inguinal ligament
What is the high/McEvedy approach to treating femoral hernias?
Used for emergency surgey, incision transversely 2cm above the pubic tubercle and extending laterally
What is done to eliminate the weak structure during surgery for femoral hernias?
Inguinal ligament is sutured to the pectineal ligament
A hernia is a clinical diagnosis, but what tests can be done if need be?
Ultrasound or CT
What should happen when a patient with a hernia lies down?
It should go away
Where do inguinal hernias originate in relation to the pubic tubercle?
Above and medial
Where do femoral hernias originate in relation to the pubic tubercle?
Below and lateral
What is the difference in the urgency or treatment for inguinal and femoral hernias?
Inguinal- waiting list
Femoral- ASAP
What causes an epigastric hernia?
A congenital defect in the linea alba between the xiphoid process of the sternum and the umbilicus
Where are paraumbilical hernias found?
Usually above the umbilicus
What are the risk factors for a paraumbilical hernia?
Obesity, pregnancy, ascites
What are incisional hernias?
Acquired rather than congenital and usually occur in the site of a previous abdominal incision
Who are incisional hernias more common in?
Older and frail people
An obturator hernia is a hernia through where?
Obturator foramen
What and who is an obturator hernia common in?
Cause of small bowel obstruction in elderly females
What type of pain will people with an obturator hernia experience and why?
Thigh pain due to obturator nerve disruption
What are common paediatric hernias and when do they usually resolve?
Umbilical hernias- by the age of 4
What happens if umbilical hernias persist past the age of 4?
They must be repaired
What hernias may baby boys also get?
Indirect inguinal hernias
When are indirect inguinal hernias more common in baby boys and when do they show up?
More common in premature baby boys and show up when they cry
What is a test for an indirect inguinal hernia in boys and how does this work?
Silk test- rubbing hand over groin will make a noise like bits of silk rubbing together
Do indirect inguinal hernias in baby boys always need repaired?
Yes as they have a high rate of incarceration
What technique is used to remove an indirect inguinal hernia from babies?
Herniotomy- hernia sac is ligated without any repair of the inguinal canal and no mesh is required
Where is the superficial ring in relation to the pubic tubercle?
Above and medial
What makes up Hesselbach’s triangle?
- Inguinal ligament inferiorly
- Inferior epigastric vessels laterally
- Lateral border of the rectus sheath medially
Which type of hernia is a ‘posterior bulge through the transversalis fascia’?
Direct inguinal
Which type of hernia can often be bilateral?
Direct inguinal
Which type of hernia is more common in younger men?
Indirect inguinal
Which type of hernia is more common in older men?
Direct inguinal
Which type of hernia can give scrotal swelling?
Indirect inguinal
Is a hernia the only cause for scrotal swelling?
No
Which type of inguinal hernia has a slightly higher risk of strangulation?
Indirect
Should you treat an asymptomatic hernia, which is at risk for complications?
Yes
What does strangulation of a hernia lead to?
Occlusion of the venous system, then the arterial system which leads to gangrene
What 2 things should patients not do after surgery and for how long?
No driving for a week
No heavy lifting for a month
Which type of hernia increases the groin crease and which loses it?
Inguinal- increases
Groin- loses
A thin old lady presents with a hernia. She has 4 children. What type is it most likely to be?
Femoral
What is another factor which makes a femoral hernia more likely, apart from being female with children?
Previous small bowel obstruction with no repair surgery
A female presents with a hernia. What type is it most likely to be?
Inguinal (although it is more common for femoral hernias to occur in women, it is still more likely that a woman will have an inguinal hernia)
What do epigastric hernias normally contain?
Extraperitoneal fat
Who are epigastric hernias most common in?
Males, late teens or young adults
What type of hernias are usually asymptomatic but may have local symptoms?
Epigastric
How can epigastric hernias be repaired?
Sutures or mesh
What is the main difference between umbilical and paraumbilical hernias?
Umbilical- children
Paraumbilical- adults
Who is most likely to present with a paraumbilical hernia?
An obese adult (or pregnancy/ascites)
As well as old, frail people, who is more at risk for an incisional hernia?
Someone who has had a wound infection post-op
What is changed about the surgery in people at risk of incisional hernias?
Tension sutures are used and there is a mass closure of the linea alba
Which side is an inguinal hernia in babies most likely to be on?
The right
