Hernias Flashcards
A hernia consists of 3 layers
1. A sac (of peritoneum) o The bulge people get o Skin, fat and fascia o More interested in the hole, the defect allowing the hernia to happen o Omentum, small bowel, or just fat
- Coverings of the sac
- Contents
Common adult hernias
> Inguinal > Femoral > Para-umbilical > Epigastric > Incisional
Inguinal hernias
> Very common in men
can be “direct” or “indirect”
> right commoner than left
Indirect is more common.
Spermatic Cord consists of?
> 3 arteries
3 nerves
3 other things
arteries//
- testicular artery, deferential artery, cremasteric muscle artery
Nerves//
- genital branch of the genitofemoral, cremasteric nerve, sympathetic nerve fibers
3 other things//
- ductus deferens, pampiniform plexus, lymphatic vessels
Femoral hernias
commoner in females - elderly, several children
emergency procedure
easily missed
40% present acutely
Risk factors for groin hernias
> Male > age > Obesity > Chronic cough > Prev hernia > Collagen disorder > AAA > Appendicectomy
Indirect hernia?
Bulges straight through the deep inguinal ring.
Traverses inguinal canal
Lateral to inferior epigastric vessels
Can go into scrotum.
Direct hernia?
Bulge through weakened transversals fascia
directly behind superficial inguinal ring
medial to inferior epigastric vessels
NEVER/rarely go into the scrotum
Where is there transversals fascia?
Roof of the inguinal canal
Posterior wall
Repair of inguinal hernias
> Watchful waiting - elderly and frail with asymptomatic hernia
> Beware of groin pain hernia
> OPERATION
Incarcerated hernia
Something (like the small bowel) has become trapped within the hernia and is losing blood supply due to strangulation.
Open Hernia surgery
Lichtenstein method
- Mesh repair
- does not put tension on muscles
- lowers rate of recurrence
- uses glue
- patients are able to walk only a few hours after surgery
Laparoscopic surgery
- less pain and faster recovery
- needs general anaesthetic
- longer learning curve
Post-surgery complciations
> Recurrence > Urinary retention > Bleeding/haematoma > Chronic pain > numbness > Testicular atrophy > Wound infection
Hernias - emergency presentation
> Irreducible
Strangulate
Obstruct
- if reducible, push it back in under anaesthetic
- If not –> operative repair after rests
Femoral canal (structures)
NAV Y fronts
Nerve –> Artery –> Vein (laterally to medially)
Femoral or inguinal - which is more prone to incarceration?
Femoral - lots of tight, firm tissue.
Groin lump assessment
What should you ask the patient to do?
> Hernia is usually a clinical diagnosis
Assess standing and sitting
> Ask patient to COUGH
Is the lump reducible?
Position
What is meant by reducible?
Can the hernia be pushed back inside
Where does neck of inguinal hernia originate?
Above and medial to pubic tubercle
Where do femoral hernias originate?
Below and lateral to the pubic tubercle
Which hernias are more urgent?
Femoral hernias
Epigastric Hernia
> Defect in the linea alba between the xiphisternumand umbilicus
Congenital
More common in females
obesity and pregnancy
Paraumbilical Hernias
Defect around the umbilicus
Obesity, pregnancy, ascites
Almost always repaired
suture
open mesh
laparoscopic
Incisional Hernia
> Hernia at site of prev abode incision
Occur in 10-15% of abode incisions
Risk factors//
obesity smoking age surgical site infection post chest infection
Whole wound might give way
Often quite large
Paediatric hernias
Common
usually resolve by age 4
If they persist - repair them.
Paediatric inguinal hernia
- presentation
- more common in
- specific sign (soft material)
3-5% of Boys at term
Almost always INDIRECT.
Commoner in prem babies
Groin swelling on crying
Maybe difficult to elicit on exam
“SILK” sign - when palpating child’s groin, you can feel the hernial sac which feels like rubbing silk together.
ALWAYS REPAIRED
Obturator hernia (rare)
- Cause of small bowel obstruction in elderly females
- Medial thigh pain - obturator nerve compression
- small bowel passes through obturator canal
more common females
