Hernias Flashcards
What forms the walls of the inguinal canal? (anterior, posterior, superior, inferior)
- Anterior: external oblique aponeurosis +
internal oblique - Posterior: Fascia transversalis + Conjoint tendon
- Superior: Arching fibers of internal oblique + Transverse abdominis
- Inferior: Inguinal ligament + Lacunar ligament
In women it contains the ilioinguinal nerve, round ligament of uterus and lymphatics
What are the contents of the spermatic cord?
- vas deferens
- pampiniform plexus
- testicular and cremasteric arteries/ veins
- nerves (genital branch of the genitofemoral nerve + sympathetic nerves)
- lymphatics
What can be damaged in an inguinal hernia repair surgery?
- in an inguinal hernia the contents of the spermatic cord protrude
- ileoinguinal nerve is not in the cord but could be damaged during repair
- if damaged get pain and decreased sensation in groin
What is the Hasselbach’s triangle?
surface of inguinal region where direct inguinal hernias typically poke through
- Medial border: Lateral margin of the rectus sheath, also called linea semilunaris
- Superolateral border: Inferior epigastric vessels
- Inferior border: Inguinal ligament
What is the femoral triangle? (scarpa’s triangle)
area just below the groin containing:
Superiorly – inguinal ligament
Medically - medial border of the adductor longus muscle
Laterally – medial border of Sartorius muscle
What is a hernia?
Hernia is a general term used to describe a bulge or protrusion of an organ through the structure or muscle that usually contains it.
Protrusion of viscus from one compartment to another
Causes of hernias
Some hernias have no apparent cause
Congenital (eg umbilical - abdo wall not closing well)
Increased abdominal pressure
A pre-existing weak spot in the abdominal wall (eg previous surgery or injury)
Straining (prostrate problem, constipation)
Strenuous activity
Pregnancy
Chronic cough
Hernias - risk factors
A patent processus vaginalis (congenital) Male – 8:1 (M/F) White Older Family history –weak association COPD Pregnancy Obesity Enlarged prostate Premature birth and low birth weight Previous hernia repair Marfan syndrome, Ehlers-Danlos syndrome
Inguinal hernia - features
Patients experience groin discomfort (often described as dull, heaviness, dragging, and sometimes burning) or pain in association with a bulging hernia; groin discomfort or pain is alleviated when the hernia is not bulging. Occasionally pain radiate to testicle
Visible and/or palpable mass or bulge in the groin that may or may not be reducible. Bulge more obvious when upright and on straining
Indirect inguinal hernia
- hernia goes through the deep inguinal ring and inguinal canal into the scrotum
- Congenital due to processus vaginalis persisting
- Superior and medial to pubic tubercle and can travel into the scrotum
- protrusion of omentum and bowel
Direct inguinal hernia
- hernia pokes through weak spot in inguinal area (usually hesselbach triangle)
- one third of all inguinal hernias are direct
- Usually acquired due to raised intra- abdominal pressure.
- usually Retroperitoneal fat
- Common in elderly population + other RFs
Pantaloon hernia
Pantaloon hernia (Saddle Bag hernia) is a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels in inguinal region
Femoral hernia
- More common in women but can occur in men
- weakness in femoral canal, a space near the femoral vein that carries blood from the leg
- More prone to develop incarceration or strangulation than inguinal hernias. Hence, early repair is advised
- inguinal is higher up and medial, while femoral is usually lower down and more lateral
Umbilical hernias
- natural weakness due to the blood vessels of the umbilical cord.
- Often occur in infants and can resolve by 3-4 yrs. - - -
- However, the weakness can persist throughout life and can occur in men, women and children at any time
- In adults, it will not resolve and will get progressively worse.
- Sometimes caused by abdo pressure due to being overweight, coughing, pregnancy
Paraumbilical hernias
- Above or below the umbilicus through the linea alba
- At higher risk of strangulation that umbilical
- Small painful and tender
- Usually has a small neck and so can strangulate
Paraumbilical hernia vs Divarification of the rectus
Divarification = abdominal separation also called diastasis recti. The right and left sides of the rectus abdominis spread apart at the linea alba
- RF: pregnancy, obesity, chronic cough
- Pt bends or sits up in bend and everything bulges
- not a/w pain like paraumbilical or epigastric hernias
Epigastric hernias
- through the linea alba in the epigastrium midline from xiphoid process to umbilicus
- may trap fat and other tissues inside the opening of the hernia, causing pain and tissue damage
- RF: obesity, pregnancy
Incisional hernias
A hernia that appears in the abdomen at the site of previous surgery through scar tissue
eg appendectomy, c-section, previous hernia repair
Spigelian hernias
- weakness through spigelian fascia inferior and lateral to umbilicus
- Often no obvious swelling or lump present, therefore it can be almost impossible to detect and often presents acutely (strangulated)
- Often develops later in life when abdominal muscles have become weaker >40yrs, and commonly obese
- Causes include sport, chronic cough, obesity, straining during urination/defecation, heavy-lifting, injury
- Symptoms include poor bowel function or constipation, a dull ache in the abdomen, pain when bending/stretching, a small swelling
Richters hernia
- Only part of the hernia material herniates through the defect
- The bowel is not fully in the hernia sac, so it is not obstructed, however the hernia sac can get strangulated to cause a tender mass
- can be easy to miss and presents when necrotic
DEFINE
- sliding hernia
- littre hernia
- amyand hernia
- maydl hernia
- Sliding = Protrusion through the abdominal wall of a retroperitoneal organ
- Littre hernia = Failure of vitelline sac to close leads to the formation of the Meckel diverticulum
- Amyand hernia = Appendix included in the hernial sac and becomes incarcerated
- Maydl hernia = Hernial sac contains two loops of bowel with another loop being inta-abdominal. “W”
Hernias - complications
- Incarcerated hernia (Non-reducible hernia with normal blood supply)
- Strangulation (The arterial blood supply to the contents of the sac is compromised)
- Obstruction (hollow viscus is trapped within the sac causing obstruction. The blood supply remains intact – common cause of small bowel obstruction)
- Incisional hernia
Reducible hernia vs Incarceration vs Strangulation
- Reducible = bulge can be pushed back and it bulges on coughing and straining (+ve cough impulse). More prominent on standing and no signs of obstruction
- Incarcerated hernia occurs when herniated tissue becomes trapped and cannot easily be moved back into place. An incarcerated hernia can lead to a bowel obstruction or strangulation
- Strangulated = N+V, inability to move bowels (obstruction) or pass gas, fever, tachycardia, sudden pain that quickly intensifies, hernia bulge can turn red, purple or dark, bloody stools, peritonitis
Hernia - diagnosis
- Clinical Dx
- Diagnostic Laparoscopy – patients with groin pain but no obvious hernia
Hernia - management approach
- Reducible asymptomatic
- Conservative (wait and watch) - Reducible symptomatic
- Surgery (if fit)
- Truss (if unfit) (eg severely obese - suggest they lose weight first) - Non-reducible hernia
- Surgery (may require bowel resection)
Hernia surgery
- Unilateral hernia
- Open hernia repair (push it back in) with mesh - Bilateral hernia
- Laparoscopic bilateral inguinal hernia repair with mesh - Recurrent hernia
- Laparoscopic hernia repair with mesh
Hernia surgery - benefits of laparoscopy vs open
- Less chronic pain after operation because the cuts are smaller
- Less muscle damage
- Less blood loss
- Less risk of infection
- Less side effects of analgesia as less analgesia is used
- Shorter hospital stay
Emergency hernia incarceration/strangulation and peritonitis - management
- analgesia
- anti-emetics for vomiting
- NBM
- NG tube inserted for decompression of the bowel
- consider IV fluids
- IV Abx for peritonitis
- surgery (hernia repair +/- bowel resection)
