hernias

Question 1

what is the difference between a direct and indirect hernia? which is more common?

Answer 1

indirect – peritoneal sac enters the inguinal canal through the deep inguinal ring - more common
direct – peritoneal sac enters the inguinal canal though the posterior wall of the inguinal canal

direct - occurs medially to the inferior epigastric vessels (through the inguinal (hesselbach’s) triangle
indirect hernia - laterally to these vessels

Question 2

what happens in indirect inguinal hernias? what about in severe cases?

Answer 2

the peritoneal sac (± loops of bowel) enters the inguinal canal via the deep inguinal ring

severe - peritoneal sac and its contents traverse the entire inguinal canal, emerge through the superficial inguinal ring, and reach the scrotum

Question 3

what causes indirect hernias? how does this affect the severity of presentation?

Answer 3

failure of the processus vaginalis to regress

the degree of herniation depends on the amount of processus vaginalis still present

Question 4

what causes direct hernias?

Answer 4

weakening of abdo muscles - acquired

Question 5

what happens in direct hernias?

Answer 5

peritoneal sac bulges into inguinal canal via the posterior wall medial + can enter the superficial inguinal ring

Question 6

what happens in direct hernias?

Answer 6

peritoneal sac bulges into inguinal canal via the posterior wall medial + can enter the superficial inguinal ring

Question 7

indirect inguinal hernia - where do you see them?

Answer 7

just above + medial to pubic tubercle; may extend to scrotum

Question 8

indirect inguinal hernia - common pt demographic

Answer 8

young or middle-aged men

Question 9

distinguishing indirect and direct hernias OE

Answer 9

indirect - can reduce hernia over (ie into) the deep inguinal ring (above midpoint of inguinal ligament). get them to cough, release pressure but keep fingers on skin + feel for it move down + medial

Question 10

distinguishing indirect and direct hernias OE

Answer 10

indirect - can reduce hernia over (ie into) the deep inguinal ring (midpoint of ASIS + pubic tubercle). get them to cough, release pressure but keep fingers on skin + feel for it move down + medial

Question 11

direct inguinal hernia - patient demographic

Answer 11

commoner in elderly

Question 12

inguinal hernias - complications

Answer 12

incarceration - irreductibility ± loss of cough impulse
obstruction - constriction of bowel loops
strangulation - arterial occlusion, infarction, peritonitis, groin abscess

Question 13

inguinal hernias - complications

Answer 13

incarceration - irreductibility ± loss of cough impulse
obstruction - constriction of bowel loops
strangulation - arterial occlusion, infarction, peritonitis, groin abscess

Question 14

femoral hernia - epidemiology

Answer 14

much less common than inguinal

commoner in females

Question 15

femoral hernia - prognosis

Answer 15

more likely to obstruct - should always be repaired

Question 16

femoral hernia - prognosis

Answer 16

more likely to obstruct - should always be repaired

Question 17

which 2 main structures pass through the inguinal canal?

Answer 17

spermatic cord - men
round ligament - women

ilioinguinal nerve - supplies skin of scrotum + upper thigh / mons pubis + labia majora

Question 18

inguinal canal - start and end?

Answer 18

start - deep ring (lateral)

end - superficial ring (medial)

Question 19

how do you find 1) the midinguinal point? what is there? what about 2) the midpoint of inguinal ligament? what is there?

Answer 19

1) midpoint of ASIS + pubic symphysis - femoral pulse

2) midpoint of ASIS + pubic tubercle - deep ring is above this point

Question 20

how do you find 1) the midinguinal point? what is there? what about 2) the midpoint of inguinal ligament? what is there?

Answer 20

1) midpoint of ASIS + pubic tubercle - femoral pulse

2) deep ring

Question 21

hernia - management

Answer 21

mesh surgery most common, after excision of sac + tying of neck