Hernias Flashcards
Which type of hernia is surgical emergency?
strangulated- vascular compromise of hernia contents
Hernias more common in males
Groin and epigrastric
Most common location of hernias
Inguinal region in men and women
Hernias more commonly seen in women
Femoral, umbilical, incisional. Inguinal most common
Which hernias are more common on the R
Inguinal and femoral hernias
Why doesn’t femoral hernia occur on L, and mostly seen just on R?
Because sigmoid colon on L inhibits femoral hernia
Fixing a hernia=
Herniorrhaphy/Herniaplasty
Types of mesh used in hernia repair
Polyester, polypropylene, and biologic
Caution with polyester and polypropylene mesh
Are non-absorbable, so if they get infected have to be taken out
Which type of mesh is preferred?
regular- polyester and polypropylene
Hesselbach’s triangle bordered by
epigastric vessels, rectus sheath, and inguinal ligament
Landmark for differentiating direct from indirect hernias
Inferior epigastric vessels
Inguinal hernia external vs. internal ring
External ring- external oblique aponeurosis. Internal ring- Internal oblique muscle and transversus abdominis muscle
Direct inguinal hernias occur…
through Hesselbach’s triangle (rupture)- failure of the floor musculature
Indirect inguinal hernias occur…
lateral to the epigastric vessels- dilation of something that is already there
Which inguinal hernia is congenital?
Indirect
Which nerves lie deep to the external oblique aponeurosis?
Iliohypogastric nerve and ilioinguinal nerve
Injury of iliohypograstric and ilioinguinal nerves result in…
numbness or chronic pain of skin of groin, base of penis, and ipsilateral upper medial thigh (supplied by these nerves). No effect on erectile function
Indirect + direct hernia=
combined hernia aka pantaloon hernia, or saddle-bag hernia
Pantaloon hernia gets its name from…
hernia sacs of direct and indirect hernias being separated by the inferior epigastric vessels
Patient presents with bulge in groin, especially with activity. There is also severe pain and paresthsias in groin region. You suspect…
Inguinal hernia. severe pain is sign of incarceration or strangulation. Paresthsia results form compression of or irritation of ilioinguinal or iliohypogastric nerves.
Neuralgia paresthesia often present in
overweight ppl that lean on tables a lot
How to diagnose inguinal hernia on male or female
Patient standing. male- “turn head and cough” . Valsalva in females
Patient with inguinal hernia - during PE what do you check for?
Do supine and standing. Check if mass is reducible or not, firm or soft, fixed or mobile. Note location in relation to inguinal ligament. have patient turn and cough or valsalva if female. If cannot be reproduced, ask patient to walk around and lift something heavy. Come back, or get an US
US is good to check for which type of hernias?
Direct, indirect, and femoral, and excluding recurrent hernias
US to check for hernia must be done in which position
While patient is coughing or during valsalva
If groin pain, cause might be…
hernia or consider inguinal nerve injury or entrapment
If find hernia- do surgery unless small, asymptomatic. what does non-operative tx include?
Truss or binder to hold the hernia contents in place
complications of non-opertative management of surgery
testicular atrophy, progression of hernia to incarceration/strangulation, or inguinal neuritis
Operant management is elective vs. emergent for…
elective for reducible or incarcerated hernias. Emergent for strangulated hernias.
What are the signs of strangulated hernia in patient?
N/V, Change in skin color over the hernia, increasing pain
Most common anterior repair with decreased recurrence rate
Tension free repair using prosthetic mesh
“anterior hernia repair” - what surgery technique is used
Open inguinal herniorrhaphy- incision made directly over the hernia
Type of surgery for inguinal or femoral hernia
Open inguinal herniorrhaphy and laparoscopic posterior repair
Where does laparoscopic repair for inguinal hernias occur?
from the peritoneal surface or from within the preperitoneal space
clear benefit of doing laparoscopic repair over open repair
If patient has bilateral inguinal hernia or recurrent hernias
You think patient has inguinal hernia. Patient is very obese so it is hard to tell.. what else could it be?
Femoral hernia in obese patient or large femoral hernia often confused with inguinal hernia
Open repair in femoral hernia involves…
removal of hernia sac and Cooper’s ligament repair or mesh repair of the femoral canal
When do you repair an umbilical hernia in babies?
at 5 years of age, earlier only if strangulation hernia
Where do umbilical hernias occur?
Occurs at the site where the umbilical vein entered the abdomen during gestation
Tx in umbilical hernia
repair either with open or laparoscopically. Mesh placed for any defect larger than 3cm.
Avoid mesh in what population for umbilical hernias
avoided in women of childbearing age
Epigastric hernia involves…
herniation of the falciform ligament through the linea alba
No hernia sac in which hernia type?
Epigastric hernia
Diastesis recti
NOT a hernia. Patulence of the linea alba following stretching and parting of the rectus abdominus muscle bellies.
Patient presents with palpable bulge at site of previous incision. Has difficulty sitting up and climbing stairs, indicating loss of abdominal strength
Incisional/ventral hernia
Risk factors for incisional/ventral hernia
Infection after sugery, increased tension on abdominal wall, COPD, diabetes, steroid use
How does loss of domain occur in incisional/ventral hernias
over time, hernia can become very large and recuts muscles can separate, causing loss of domain
What to do to fix loss of domain problem
Component separation- cut external oblique muscles to make room, reconstructs linea alba
Where does spigelian hernia develop?
arises where the arcuate line intersects with the lateral border of the rectus abdominis , usually at or below arcuate line
Spigelian hernias are often “interparietal” meaning…
they don’t go through all the muscle layers
50 year old woman presents with localized pain near arcuate line. NO palpable bulge. US or CT might show…
spigelian hernia
OBturator hernia
Union of pubic bone and ischium. Canal covered by thin membrane- weakening of membrane-enlargement of canal- hernia sac formation
Howhsip-Romberg sign
compression of the obturator nerve causing pain in medial thigh- might see this in obturator hernia
Lumbar hernia can occur through…
superior lumbar triangle (Grynfeltt’s) or inferior lumbar triangle (Petit’s)
superior triangle bounded by…
12th rib, paraspinal muscles, and internal oblique muscle
Inferior triangle bounded by…
iliac crest, latissimus dorsi, and external oblique
What might come through lumbar hernia?
perirenal fat
Mesh or suture repair in lumbar hernias?
Mesh repair
Patient presents with enlarging mass in gluteal or intragluteal area. ..
Sciatic hernia. Sciatic nerve pain may also occur..
Mesh or suture repair in sciatic hernia
Mesh
Small hernias can be closed with…, while large ones require…
sutures, mesh- larger
which hernia might occur after APR or perineal prostatectomy
Perineal hernia-hernia sac protruding through pelvic diaphragm
When to internal hernias happen
When the viscera herniate through an opening inside of the peritoneal cavity
Developmental types of internal hernias
Mesocolic or mesenteric hernias
Acquired internal hernias
due to defects in the mesentery left by surgeons or from adhesions that form following surgery
Diaphragmatic hernias
Congenital. Bockdalek-posterior and Morgagni- anterior
Complications of hernia repair
Wound infection, ischemic orchitis, neuralgia/inguinodynia, hematoma/seroma, PE, hemorrhage, testicular atrophy, recurrence
What increases risk of wound infection after hernia repair?
infection at a distant site, like bladder infection
Ischemic orchitis results from
thrombosis of the small veins of the pampiniform plexus leading to venous congestion, testicular atrophy
Orchiectomy
taking out testicles, rarely a consequence of ischemic orchitis
How can neuralgia occur after hernia repair?
d/t traction, cautery, entrapment by suture or mesh
hernia recurrence most common technical causes
excessive tension, missed hernias first time around, improper mesh size, failure to suture the mesh to enough tissue or to close the internal ring
