Hernias Flashcards
Hernia
Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position.
Reducible
Sac can return to the abdominal cavity either spontaneously or w manipulation.
Irreducible
Sac cannot be reduced despite pressure or manipulation
Strangulated
Blood supply of contents is compromised due to pressure at the neck of the hernia.
Sliding hernia
Part of the sac is formed by bowel (e.g. caecum or sigmoid): take care when excising the sac.
Maydl’s
Herniating double loop of bowel. Strangulated portion may reside as a single loop inside the abdomen
Littre’s Hernia
Hernial Sac containing strangulated Meckel’s Diverticulum
Amyand’s hernia
Inguinal hernia containing stangulated appendix
Richter’s hernia
only part of circumference of bowel is within sac - commonly seen w femoral hernias
can stangulate w/o obstructing
pantaloon
simultaneous direct + indirect hernia
Herniotomy
excision of hernial sac
herniorrhaphy
suture repair or hernial defect
hernioplasty
mesh repair of hernial defect
Inguinal Hernia
M>F 50s
More common on R (?post-appendicectomy)
8-15% present as emergency - strangulation/ obstruction
Inguinal hernia Aetiology
Congenital patent processur vaginalis
- processus vaginalis should obliterate after descent of testes
- if stays patent - may fill with: fluid > hydrocele
> bowel/omentum > indirect hernia
Acquired - mainly ^IAP Chronic cough: COPD, asthma Prostatism Constipation Severe muscular effort: e.g. heavy lifting Previous incision/repair Ascites / obesity Appendicectomy
Inguinal Hernia Classification
Indirect - 80% younger
- congenital patnet processus vaginalis
- emerge through deep ring
- same 3 coverings as cord and descned into scrotum
- can strangulate
Direct - 20% elderly
- acquired
- emergen through Hesselbach’s triangle
- can acquire internal + external spermatic fascia
- rarely descend into scrotum
- rarely strangulate
Ix
- US if in doubt
Clinical Features of inguinal hernia
Children - lump in groin which may descend into scrotum
- exacerbated by crying
- commonly obstruct
Adults - lump in groin exacerbated by straining/coughing
- may be clear ppting event - heavy lifting
- dragging pain radiating to groin
- may present w obstruction _ strangulation
Questions
Reducible?
Ever episodes of obstruction / strangulation?
Predisposing factors: cough, straining, lifting?
Occupation and social circumstances?
Inguinal Hernia Mx
Non-surgical
- Rx RFs - coughs, constipation
- wt loss
Truss
Surgical
- Tension free mesh (lichtenstein repair) better than suture repair (shuoldice)
> 2% recurrence vs 10%
open approach can be done under LA or GA
Lap approach allows bilateral repair > improved cosmesis
- preferred for recurrent hernias
Primary unilateral repairs should be open (NICE)
Children only require Sac excision (herniotomy)
Inguinal Hernia Complications
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%
Femoral Hernia
definition, EP, Aetiology
Protrusion of viscus through femoral canal
F>M middle aged + elderly
Acquired - ^IAP. Femoral canal larger in females due to shape of pelvis + changes in configuration due to birth
Femoral Hernia Clinical Features
Painless groin lump
- neck inferior + lateral to pubic tubercle
- cough impulse
- often irreducible (tight borders)
Commonly w obstruction or strangulation
- tender, red and hot
- abdo pain, distension, vomiting, constipation
Femoral Hernia Mx
50% risk of strangulation w/i 1mo
Urgent surgery
Elective: Lockwood Approach
Low incision over hernia c¯ herniotomy and herniorrhaphy (suture ing. ligt. to pectineal ligt.)
Emergency: McEvedy Approach
High approach in inguinal region to allow inspection and resection of non-viable bowel.
Then herniotomy and herniorrhaphy
Incisional Hernia
Hernia arising through previously acquired defect
6% of incisions
RF Pre-operative ↑ age Obesity or malnutrition Comorbidities: 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
↑ IAP: chronic cough, straining, post-op ileus
Infection
Haematoma
Incisional Hernia Mx
Surgery is not appropriate for all patients.
risk of operation and recurrence w risk of obstruction/strangulation and pt. choice.
Usually broad-necked > low risk of strangulation
Conservative
Manage RFs: e.g. constipation, cough
Weight loss
Elasticated corset or truss
Surgical Pre-Op Optimise cardiorespiratory function Encourage wt. loss Nylon mesh repair: open or lap
Umbilical Hernia
Features - Congenital, 3% of LBs, defect in umbilical scar
RF - afrocaribbean, Down’s, Congen hypothyroidism
Mx
- usually resolves 2-3 years
- Mesh repair if no closure
- can recur in adults - pregn or gross ascites
Paraumbilical Hernia
Features
- acquired - middle aged obese men
- defect through linea alba (just above/below umbilicus)
- small defect > strangulation (often omentum)
RF - chronic cough
- straining
Mx -
- Mayo (double breasted liena alba sutures)
- mesh repair
Epigastric Hernia
Features M>F
- pea-sized swelling caused by defect in linea alba above the umbilicus
- usually contains omentum - can strangulate
Mx - mesh repair
Spigelian Hernia
Hernia through linea semilunaris
Hernia lies between layers of abdo wall
Palpable mass more likely to be colon Ca
Obturator Hernia
F>M old age
Sac protrudes through obturator foramen
PAin on inner aspect of thigh or knee
Frequently present obstructed/strangualted
Lumbar hernia
Middle aged M>F
typically following loin incisions
Hernias through sup/inf lumbar triangles
Sciatic hernia
hernia through lesser sciatic foramen
usually presents as small bowel obstruction + gluteal mass
Gluteal Hernia
Hernia through greater sciatic foramen
Usually persents SBO + gluteal mass
