Hernias Flashcards
What is a hernia?
Protrusion of a viscus/ part of a viscus through the wall of its containing cavity.
What is a sliding hernia?
Part of the sac is formed by the bowel = careful with excision
What is Maydl’s hernia?
Herniated double loop of bowel
Amyands hernia?
Inguinal hernia containing strangulated appendix.
Richter’s hernia?
Only part of the circumference of the bowel is within the sac.
Most commonly seen with femorals .
Pantaloon hernia?
Simultaneous indirect and direct hernia
Mid-point of the inguinal ligament and what lies here?
Halfway between ASIS to the pubic tubercle.
Deep ring
Relevance of deep ring?
Occlude this to distinguish types of inguinal hernias.
If indirect it will not come back down.
Where is the mid-inguinal point and what is its relevance?
Mid inguinal point is half way between ASIS and pubic symphysis .
Femoral artery is here.
Boundaries of the inguinal canal?
Anterior = aponeurosis of external oblique
Posterior = transversalis fascia
Roof = internal oblique and transversus abdominus
Floor = inguinal ligament
Contents of inguinal canal in woman?
Round ligament
Genital branch of genitofemoral nerve
Ilio-inguinal nerve
Contents of inguinal canal in men?
Spermatic cord
Ilio-inguinal nerve
What are the three layers of the spermatic cord ?
External spermatic fascia
Internal oblique = cremasteric muscle
Transversalis fascia = internal spermatic fascia
What’s in the spermatic cord?
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.
Which gender does inguinal hernia’s mainly affect?
Male
Mechanism of indirect inguinal hernias?
Due to failure of processus vaginalis to close.
Protrusion through the deep ring = lateral to inferior epigastric artery.
Clinical features of indirect inguinal?
Descend into the scrotum, have a narrow neck and younger patients.
Direct inguinal hernia mechanism?
Protrusion through weakness in Hesslebach’s triangle.
Passes medially to the epigastric artery.
What are the borders of Hesslebach’s triangle.
Inferior epigastric artery, inguinal ligament and lateral border of rectus abdominus.
Clinical features of direct inguinal hernia?
Rarely descends int the scrotum, has a broad neck and old patients.
Conservative management of inguinal hernias?
RF’s = cough and constipation
Weight loss
Truss
Surgical management of inguinal hernias?
If primary / unilateral = open mesh approach
If bilateral / recurrent = laparoscopic mesh
Strangulated = Fluids, NBM and if dead bowel = resection.
Hernia repair complications?
Immediate = neuromuscular damage Early = bruising, pain, DVT, infection. Late = Recurrence, testicular artery damage = testicular atrophy.
Mechanism of femoral hernia?
Hernia through the femoral ring, and into the potential space of the femoral canal.
Femoral canal boundaries?
Lateral = Femoral vein Medial = Lacunar ligament Anterior = Inguinal ligament Posterior = Pectineal ligament
Clinical features if femoral hernia?
Often irreducible lump, with cough impulse.
Usually below inguinal ligament, but can migrate superiorly.
Medial to femoral pulse.
Risk factors for femoral hernia?
Female
Age
Pregnancy
Increased pressure = lifting, coughing, constipation.
Management of femoral hernia?
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.
Incisional hernia risk factors?
Pre-op = increasing age, obesity/malnutrition, co-morbidities.
Intra-op = Technique e.g. too small suture bites. Midline incision and placing drain through wounds.
Management of incisional hernia’s?
Manage risk factors.
Optimise patient pre-op
Nylon mesh repair.
Features of umbilical hernia?
M=F
Afro-caribbean
Asymptomatic
Most resolve by age of 2, if recur = mesh repair.
Para-umbilical hernia mechanism?
Defect in the linea alba superior / inferior to the umbilicus.
Which hernia’s risk strangulation?
Femoral
Para-umbilical
Spigelian
Para-umbilical management?
Mayo’s technique:
- Vertical overlap of adjacent aponeurotic structures.
- defect >4cm = mesh repair.
Spigelian hernia mechanism?
Hernia between the rectus abdominus and semi-lunar line
Spigelian hernia features and management?
Often penetrate abdominal muscles = not noticeable
Mesh repair
Obturator hernia mechanism?
Hernia via the obturator canal and through the foramen.
Clinical features of obturator hernia?
Elderly females
PC = small bowel obstruction.
Howship-Romberg sign
What is the Howsip-Romberg sign?
Obturator hernias compresses the obturator nerve = pain and parasthesia along the inner aspect of the thigh, down to the knee.
Mechanism of lumbar herniation?
Herniates through the lumbar triangle.
What are the borders of the lumbar triangle?
Crest of ileum
External oblique
Lattisimus dorsi.
Management of obturator hernia?
Often require laparotomy and bowel resection.
