Hernias

Question 1

What is a hernia?

Answer 1

A protrusion of a viscus or part of a viscus through the wall which is designed to contain it.

Question 2

What are the 3 layers of a hernis?

Answer 2

The Covering of the sac (skin, fascia)
The sac- peritoneum
The contents.

Question 3

What is the most common groin hernia?

Answer 3

Inguinal

Question 4

What are the risk factors for inguinal hernias?

Answer 4

Male
Obesity,
Age,
open appendix surgery

Question 5

Which side is more common for inguinal hernias?

Answer 5

Right side

Question 6

What makes up the anterior, posterior and floor of the inguinal canal?

Answer 6

Anterior is the external oblique
Floor is the inguial ligament
Posterior wall is transverse fascia

Question 7

What is contained within the inguinal canal in men?

Anatomy (spermatic cord and ilio-inguinal nerve)

Answer 7

3 arteries: testicular artery, artery to vas deferans and cremasteric artery
3 nerves: ilioinguinal nerve, genital branch of genitofemoral nerve, Sympathetics (technically outside)
3 others: Panpiniform venous plexus, Vas deference, lymphatics

Question 8

Are most inguinal hernais direct or indirect?

Answer 8

Indirect

Question 9

Anatomically what is the difference between direct and indirect hernias?

Answer 9

Indirect: Enters the deep ring laterally and emerges through the superficially medially. Originates lateral to inferior epigastric artery
Direct: Emerges through the transverse facia of the posterior wall. Originals medial to inferior epigastric artery

Question 10

How can you clinically determine the difference between direct and indirect hernias?

Answer 10

Reduce hernia
Cover the deep inguinal ring and ask patient to cough.
Returns => direct
Remains reduced => indirect

Question 11

Do all inguinal hernias need to be fixed?

Answer 11

No if small and asymptomatic you can watchfully wait incase they grow or become symptomatic.

Question 12

Is incarceration of inguinal hernias common?

Answer 12

No- low risk

Question 13

25-75% of patients chose to get inguinal hernias repaired. How is this done?

Answer 13

1) Open lichtenstein method. GA, spinal or local. Mesh inserted near cord
2) Laproscopic: less pain, faster recovery, needs GA. More difficult op and takes longer. Reduced risk of infection or chronic pain

Question 14

What are the complications of inguinal hernia repair?

Answer 14

4% recure
Urinary retention
Bleeding/haematoma
Chronic pain-30% of patients get chronic groin pain
Numbness in groin
Testicular atrophy due to damage to testicular artery
Wound infection- infected mesh must be removed.

Question 15

What are the emergency presentations of any hernia?

Answer 15

Incarcerated hernia-stuck hernia (irreducible) => strangulation, obstruction

Question 16

How is an incarcerated hernia treated?

Answer 16

Try to reduce it under anasthetic- easier to operate if reduced
Operative repair after resuscitation.

Question 17

Which group of people get femoral hernias?

Answer 17

Older women

Multi-parous (children)

Question 18

How commonly do these present as emergency?

Answer 18

40%

Question 19

What surrounds the femoral canal?

Answer 19

Superior = inguinal ligament
Inferior = Pectoneal ligament
Medial = Lacunar ligament
Lateral is the femoral Vein
(Femoral artery and nerve are more lateral)

Question 20

How is a femoral hernia repaired in an emergency or elective?

Answer 20

Emergency = high approach
Elective = low approach (laproscopic)

Question 21

How should you assess a hernia?

Answer 21

Assess both standing and sitting. Get the patient to cough.
Is it reducible?
Yes- elective
No- Emergency

Question 22

How can you tell the difference between inguinal and femoral hernias?

Answer 22

Femoral = below and lateral to pubic tubercle
Inguinal = above and medial to pubic tubercle

Question 23

Why do epigastric hernias occur?

Answer 23

Men usually due to a defect in the linea alba

Question 24

What are the risk factors for paraumbilical hernias in adults?

Answer 24

Obesity, pregnancy, ascites

Question 25

How are para umbilical hernias repaired?

Answer 25

Reduction and inserting mesh behind abdominal wall to reinforce it.

Question 26

How commonly do incisional hernias occur and what are the risk factors?

Answer 26

10-15% of abdominal incisions

Risk factors: Obease, chest infection, smoking, old, steroid, malnutrition

Question 27

What are the 2 common paediatric hernias?

Answer 27

Umbilical

Inguinal

Question 28

How are paediatric umbilical hernias treated?

Answer 28

Usually resolve spontaneously by aged 4. If not operated to reduce- no mesh used.

Question 29

How are paediatric inguinal hernias treated and what are the risk factors?

Answer 29

Mostly indirect and in boys. More common in pre term.
Silk skin sign, crying and groin swelling- difficult to see.
Needs surgical repair- no mesh used