Hernias Flashcards
Define hernia and hernia sac
A hernia is an abnormal protrusion of a part or whole of a viscus through a defect, which may be congenital or acquired
A hernia sac is the peritoneal lining of the hernia. Within it are the contents of the hernia (usually intestine or omentum). However, you can have a hernia sac without a hernia
What is the definition and epidemiology of an inguinal hernia?
An inguinal hernia is the abnormal protrusion of a peritoneal sac into the inguinal canal through the deep inguinal ring (indirect inguinal hernia) or through the weakened posterior wall of the inguinal canal (direct hernia).
Affects males more than females (9:1), with the majority presenting in their 50s.
Describe the anatomical features of inguinal hernias
What is the aetiology of inguinal hernias?
Indirect hernias are much more common and typically occur due to a persistent processus vaginalis (congenital). This leaves an empty peritoneal sac lying in the inguinal canal. The hernia becomes clinically evident when bowel or other abdominal contents fills and enlarges the empty sac, creating a visible bulge. These are common (in approximately 4% of male births).
Direct hernias are always acquired and therefore unusual before the age of 25. Occurs due to degenerative and fatty changes in the aponeurosis of the transversalis fascia.
- Increased intra-abdominal pressure from chronic cough, constipation, BOO, ascites is a risk factor for developing a direct hernia.
What are the clinical features of inguinal hernias?
Can be asymptomatic, or presenting with groin discomfort with a bulge or mass.
Inguinal hernias are more likely to affect right side, as right testes descent after left.
If incarcerated, the hernia may be irreducible. If strangulated, will be very painful and tender and may be associated with signs of complications (bowel obstruction), tachycardia etc.
How can inguinal hernias be investigated?
A reducible hernia tends to be a clinical diagnosis, detectible with examination and history.
ABGs may be useful for indicating the presence of bowel ischaemia within the hernia (metabolic acidosis due to lactic acid build-up).
Imaging such as ultrasound may be useful when the diagnosis is unclear, but also detects clinically insignificant hernias. CT and MRI may be used in obese patients.
What is the management of inguinal hernias?
A small or asymptomatic inguinal hernia is not treated; a watchful waiting approach is taken.
A large or symptomatic hernia is treated with either an open mesh repair or laparoscopically. Those with high surgical risk may be treated without surgery, using a truss.
An irreducible or strangulated hernia requires an urgent open repair (non-mesh).
Inguinal hernias in infants need an urgent repair due to high incidence of strangulation.
What is the definition and epidemiology of femoral hernias?
A femoral hernia is the abnormal protrusion of a peritoneal sac, often with abdominal contents, into the femoral canal. Affects females more as they have a wider angle between the inguinal ligament and pectineal part of the pelvic bone, and wider femoral canal.
Describe the anatomical features of femoral hernias
What are the clinical features of femoral hernias?
As femoral hernias are often small, they are asymptomatic until they become strangulated or obstructed, presenting as a surgical emergency (up to 80%).
Patients therefore present with significant pain, abdominal distention, nausea, vomiting, and absolute constipation.
Without complications, patients may present with lower abdominal discomfort, or lump/bulge in the groin region.
On Examination
Careful inspection will show a swelling in the groin below and lateral to the pubic tubercle.
How can femoral hernias be investigated?
Bloods may show signs of metabolic acidosis (in bowel ischaemia)
AXR may show small bowel obstruction. Ultrasound if a different diagnosis is suspected, but should not delay surgery if an incarcerated hernia is suspected.
Describe the management of femoral hernias
Resuscitation is very important, with attention to rehydration and correction of electrolyte imbalances. Placement of NG tube if vomiting. Antibiotics should be administered if there are signs of sepsis, and surgical repair as definite treatment.
As they often present strangulated or incarcerated, emergency surgery is necessary, even if asymptomatic, should be scheduled for repair. Surgical treatment involves dissection of the sac, observing and reducing the contents, excising the sac and repairing the defect.
What are the indications for a hernia repair?
Indications:
- Symptomatic inguinal hernias
- Asymptomatic inguinal hernias as an elective surgery
- All femoral hernias
What are the borders of Hasslebach’s triangle?
Borders of Hasslebach’s triangle:
- Lateral border: Rectus abdominis muscle
- Medial border: Inferior epigastric vessels
- Inferior border: Inguinal ligament
