Hernias

Question 1

What is a hernia?

Answer 1

Protrusion of a viscus/ part of a viscus through the wall of its containing cavity.

Question 2

What is a sliding hernia?

Answer 2

Part of the sac is formed by the bowel = careful with excision

Question 3

What is Maydl’s hernia?

Answer 3

Herniated double loop of bowel

Question 4

Amyands hernia?

Answer 4

Inguinal hernia containing strangulated appendix.

Question 5

Richter’s hernia?

Answer 5

Only part of the circumference of the bowel is within the sac.
Most commonly seen with femorals .

Question 6

Pantaloon hernia?

Answer 6

Simultaneous indirect and direct hernia

Question 7

Mid-point of the inguinal ligament and what lies here?

Answer 7

Halfway between ASIS to the pubic tubercle.

Deep ring

Question 8

Relevance of deep ring?

Answer 8

Occlude this to distinguish types of inguinal hernias.

If indirect it will not come back down.

Question 9

Where is the mid-inguinal point and what is its relevance?

Answer 9

Mid inguinal point is half way between ASIS and pubic symphysis .

Femoral artery is here.

Question 10

Boundaries of the inguinal canal?

Answer 10

Anterior = aponeurosis of external oblique

Posterior = transversalis fascia

Roof = internal oblique and transversus abdominus

Floor = inguinal ligament

Question 11

Contents of inguinal canal in woman?

Answer 11

Round ligament
Genital branch of genitofemoral nerve
Ilio-inguinal nerve

Question 12

Contents of inguinal canal in men?

Answer 12

Spermatic cord

Ilio-inguinal nerve

Question 13

What are the three layers of the spermatic cord ?

Answer 13

External spermatic fascia
Internal oblique = cremasteric muscle
Transversalis fascia = internal spermatic fascia

Question 14

What’s in the spermatic cord?

Answer 14

3 arteries = testicular, deferential and cremasteric

3 nerves = genital branch of genitofemoral nerve, sympathetic chain ( and ilio-inguinal nerve)

3 others = vas deferens, lymphatic and venous plexus.

Question 15

Which gender does inguinal hernia’s mainly affect?

Answer 15

Male

Question 16

Mechanism of indirect inguinal hernias?

Answer 16

Due to failure of processus vaginalis to close.

Protrusion through the deep ring = lateral to inferior epigastric artery.

Question 17

Clinical features of indirect inguinal?

Answer 17

Descend into the scrotum, have a narrow neck and younger patients.

Question 18

Direct inguinal hernia mechanism?

Answer 18

Protrusion through weakness in Hesslebach’s triangle.

Passes medially to the epigastric artery.

Question 19

What are the borders of Hesslebach’s triangle.

Answer 19

Inferior epigastric artery, inguinal ligament and lateral border of rectus abdominus.

Question 20

Clinical features of direct inguinal hernia?

Answer 20

Rarely descends int the scrotum, has a broad neck and old patients.

Question 21

Conservative management of inguinal hernias?

Answer 21

RF’s = cough and constipation
Weight loss
Truss

Question 22

Surgical management of inguinal hernias?

Answer 22

If primary / unilateral = open mesh approach
If bilateral / recurrent = laparoscopic mesh
Strangulated = Fluids, NBM and if dead bowel = resection.

Question 23

Hernia repair complications?

Answer 23

Immediate = neuromuscular damage
Early = bruising, pain, DVT, infection. 
Late = Recurrence, testicular artery damage = testicular atrophy.

Question 24

Mechanism of femoral hernia?

Answer 24

Hernia through the femoral ring, and into the potential space of the femoral canal.

Question 25

Femoral canal boundaries?

Answer 25

Lateral = Femoral vein
Medial = Lacunar ligament
Anterior = Inguinal ligament
Posterior = Pectineal ligament

Question 26

Clinical features if femoral hernia?

Answer 26

Often irreducible lump, with cough impulse.
Usually below inguinal ligament, but can migrate superiorly.
Medial to femoral pulse.

Question 27

Risk factors for femoral hernia?

Answer 27

Female
Age
Pregnancy
Increased pressure = lifting, coughing, constipation.

Question 28

Management of femoral hernia?

Answer 28

Low approach / Lockwood:

• Incision below inguinal ligament
• Won’t interfere with inguinal structures, but small space for removal of compromised bowl.

McEvedy’s / high approach:

• Above inguinal ligament, via posterior wall of inguinal canal.
• Easy access for bowel, but need to repair the inguinal canal = new weakness.

Question 29

Incisional hernia risk factors?

Answer 29

Pre-op = increasing age, obesity/malnutrition, co-morbidities.

Intra-op = Technique e.g. too small suture bites. Midline incision and placing drain through wounds.

Question 30

Management of incisional hernia’s?

Answer 30

Manage risk factors.
Optimise patient pre-op
Nylon mesh repair.

Question 31

Features of umbilical hernia?

Answer 31

M=F
Afro-caribbean
Asymptomatic
Most resolve by age of 2, if recur = mesh repair.

Question 32

Para-umbilical hernia mechanism?

Answer 32

Defect in the linea alba superior / inferior to the umbilicus.

Question 33

Which hernia’s risk strangulation?

Answer 33

Femoral
Para-umbilical
Spigelian

Question 34

Para-umbilical management?

Answer 34

Mayo’s technique:

• Vertical overlap of adjacent aponeurotic structures.
• defect >4cm = mesh repair.

Question 35

Spigelian hernia mechanism?

Answer 35

Hernia between the rectus abdominus and semi-lunar line

Question 36

Spigelian hernia features and management?

Answer 36

Often penetrate abdominal muscles = not noticeable

Mesh repair

Question 37

Obturator hernia mechanism?

Answer 37

Hernia via the obturator canal and through the foramen.

Question 38

Clinical features of obturator hernia?

Answer 38

Elderly females
PC = small bowel obstruction.
Howship-Romberg sign

Question 39

What is the Howsip-Romberg sign?

Answer 39

Obturator hernias compresses the obturator nerve = pain and parasthesia along the inner aspect of the thigh, down to the knee.

Question 40

Mechanism of lumbar herniation?

Answer 40

Herniates through the lumbar triangle.

Question 41

What are the borders of the lumbar triangle?

Answer 41

Crest of ileum
External oblique
Lattisimus dorsi.

Question 42

Management of obturator hernia?

Answer 42

Often require laparotomy and bowel resection.