Hernias

Question 1

What is a hiatus hernia?

Answer 1

Herniation of elements of abdo cavity through esophageal hiatus of diaphragm

Question 2

How can you classify hiatus hernias?

Answer 2

Sliding (type 1)

Paraesophageal (type 2, 3 + 4)

Question 3

What is a sliding hernia?

Answer 3

Displacement of the gastroesophageal junction above diaphragm
Stomach remains in longitudinal alignment + fundus remains below GE junction

Question 4

What are paraesophageal hermias?

Answer 4

Upward dislocation of gastric fundus

Question 5

How common are sliding (type 1)
vs paraesophageal (type 2, 3 + 4)?

Answer 5

Sliding = 95%

Question 6

Causes of sliding hernias

Answer 6

Trauma, congenital malformation, iatrogenics

Question 7

Causes of paraesophageal hernias

Answer 7

Complication of surgical dissection of the hiatus

Question 8

Pathology of sliding hernia

Answer 8

Progressive disruption of the GE junction that allows gastric cardia to herniate ypwards

Question 9

Pathology of paraesophageal hernia

Answer 9

Abnormal laxity of gastrosplenic + gastrocolic ligaments allowing greater curvature of the stomach to roll into thorax

Question 10

S+S of sliding hernias

Answer 10

Asymptomatic if small

Symptoms of GORD if larger

Question 11

S+S of paraesophageal hernia

Answer 11

Asymptomatic

Vague, intermittent symptoms of epigastric or substernal pain or postprandial fullness, nausea + retching

Question 12

Investigations for hiatus hernias

Answer 12

CXR, CT, MRI - shows retrocardiac air-fluid level within hernia
Barium swallow is most sensitive test for paraesophageal hernia, sliding can be diagnosed on barium swallow or endoscopy
Usually found incidentally

Question 13

Management of hiatus hernias

Answer 13

Symptomatic sliding = management of GERD

Surgery only for symptomatic paraesophageal hernias + for management of complications

Question 14

What are the complications of hiatus hernias?

Answer 14

Gastric volvulus, bleeding, obstruction, strangulation, perforation, resporatory compromise

Question 15

What are the types of groin hernia + how are they classified?

Answer 15

Inguinal (direct or indirect)
Direct - protrudes medial to epigastric vessels through Hesselbach’s triangle
Indirect - protrudes lateral to epigastric vessels
Femoral - protrude through femoral canal

Question 16

RF for groin hernias

Answer 16

White males
Hx of hernias
Older age
Smoking 
AAA
Chronic stretching of abdo wall due to increased pressure - chronic cough, constipation, strenuous exercise

Question 17

Presentation of groin hernias

Answer 17

Painless bulge in groin
Sense of heaviness when straining/ lifting
Can present of bowel strangulation

Question 18

Diagnosis of groin hernia

Answer 18

Diagnosed on physical exam with pt standing

US 1st line

Question 19

Management of groin hernias

Answer 19

Surgery or watchful waiting

Question 20

Complications of groin hernias

Answer 20

Strangulation

Question 21

What is an incisional hernia?

Answer 21

Abdo contents protrude through incision from surgery

Question 22

RF for incisional hernia

Answer 22

Surgical site infection
Obesity
Smoking
Malnutrition

Question 23

What is a ventral hernia?

Answer 23

Occur in anterior abdo wall:

Epigastric, umbilical, spigelian, parastomal, incisional

Question 24

Management of ventral hernias

Answer 24

Mesh (ideal) or sutures

Question 25

What is the pathology of umbilical hernias?

Answer 25

Due to opening of umbilical ring which should spontaneously close

Question 26

What is the natural history of closure of the umbilical ring?

Answer 26

Fascial opening exists to allow passage of umbilical vessels Complete closure occurs with fusion of peritoneal + fascial layers, occuring by 5

Question 27

What other conditions are associated with umbilical hernias?

Answer 27

``` Ehlers Danlos Beckwith-Wiedemann Downs Hypothyroidism Trisomy 18 ```

Question 28

Management of umbilical hernias

Answer 28

Watchful waiting | Surgery if incarcerated or strangulated

Question 29

Pathology of epigastric hernia

Answer 29

Defects in abdo midline between umbilicus + xiphoid process | Due to weakness of linea alba, forceful diaphragmatic contractions + perforation of linea alba

Question 30

RF for epigastric hernia

Answer 30

Physical training or coughing, obesity, smoking, chronic steroid use, diabetes, old age, males

Question 31

S+S of epigastric hernias

Answer 31

Asymptomatic | Lump between umbilicus + xihpoid

Question 32

What is a true vs false hernia?

Answer 32

True - involve peritoneal sac | False - without peritoneal sac

Question 33

Management of epigastric hernia

Answer 33

Surgery for symptomatic pts