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Surgery - 3rd year > Hernias > Flashcards

Hernias Flashcards

1
Q

What forms the walls of the inguinal canal? (anterior, posterior, superior, inferior)

A
  • 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

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2
Q

What are the contents of the spermatic cord?

A
  • vas deferens
  • pampiniform plexus
  • testicular and cremasteric arteries/ veins
  • nerves (genital branch of the genitofemoral nerve + sympathetic nerves)
  • lymphatics
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3
Q

What can be damaged in an inguinal hernia repair surgery?

A
  • 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
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4
Q

What is the Hasselbach’s triangle?

A

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
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5
Q

What is the femoral triangle? (scarpa’s triangle)

A

area just below the groin containing:

Superiorly – inguinal ligament
Medically - medial border of the adductor longus muscle
Laterally – medial border of Sartorius muscle

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6
Q

What is a hernia?

A

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

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7
Q

Causes of hernias

A

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

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8
Q

Hernias - risk factors

A 
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
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9
Q

Inguinal hernia - features

A

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

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10
Q

Indirect inguinal hernia

A
  • 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
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11
Q

Direct inguinal hernia

A
  • 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
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12
Q

Pantaloon hernia

A

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

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13
Q

Femoral hernia

A
  • 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
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14
Q

Umbilical hernias

A
  • 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
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15
Q

Paraumbilical hernias

A
  • 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
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16
Q

Paraumbilical hernia vs Divarification of the rectus

A

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
17
Q

Epigastric hernias

A
  • 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
18
Q

Incisional hernias

A

A hernia that appears in the abdomen at the site of previous surgery through scar tissue
eg appendectomy, c-section, previous hernia repair

19
Q

Spigelian hernias

A
  • 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
20
Q

Richters hernia

A
  • 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
21
Q

DEFINE

  • sliding hernia
  • littre hernia
  • amyand hernia
  • maydl hernia
A
  • 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”
22
Q

Hernias - complications

A
  • 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
23
Q

Reducible hernia vs Incarceration vs Strangulation

A
  • 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
24
Q

Hernia - diagnosis

A
  • Clinical Dx

- Diagnostic Laparoscopy – patients with groin pain but no obvious hernia

25
Q

Hernia - management approach

A
  1. Reducible asymptomatic
    - Conservative (wait and watch)
  2. Reducible symptomatic
    - Surgery (if fit)
    - Truss (if unfit) (eg severely obese - suggest they lose weight first)
  3. Non-reducible hernia
    - Surgery (may require bowel resection)
26
Q

Hernia surgery

A
  1. Unilateral hernia
    - Open hernia repair (push it back in) with mesh
  2. Bilateral hernia
    - Laparoscopic bilateral inguinal hernia repair with mesh
  3. Recurrent hernia
    - Laparoscopic hernia repair with mesh
27
Q

Hernia surgery - benefits of laparoscopy vs open

A
  • 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
28
Q

Emergency hernia incarceration/strangulation and peritonitis - management

A
  • 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)

Surgery - 3rd year (10 decks)

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