Hernias

Question 1

Pathophysiology

Answer 1

• Hernias consist of weakness and discontinuity in a cavity wall, usually of the muscle or fascia
• This allows a body organ (e.g. bowel) to pass through that cavity wall where it normally would be contained

Question 2

Hernia presentation

Answer 2

• A soft lump
• They may be able to reduce (put back) the lump (hernia)
• The lump may protrude on coughing (raising intraabdominal pressure) or standing (pulled out by gravity)
• Aching or dragging sensation

Question 3

What are the three complications of hernias?

Answer 3

• Incarceration
• Obstruction
• Strangulation

Question 4

Describe incarceration

Answer 4

◦An incarcerated (irreducible) hernia is when the hernia cannot be reduced back
◦The bowel will be trapped in the herniated position
◦It can lead to obstruction and strangulation

Question 5

Describe obstruction

Answer 5

◦This is where a hernia causes a blockage in the passage of faeces through the bowel
◦Will present with signs of obstruction (vomiting, absolute constipation, abdominal pain)

Question 6

Describe strangulation

Answer 6

◦This is where a hernia is non-reducible (it is trapped with the bowel protruding) and the base of the hernia becomes so tight it cuts off the blood supply
◦This will present with significant pain, tenderness at the hernia site
◦This is a surgical emergency, and the bowel will die quickly (within hours) if not corrected with surgery
◦There will be a mechanical obstruction

Question 7

Management options

Answer 7

•Conservative
◦Leave the hernia alone
◦Appropriate in patients with broad based hernias (low risk of complications) who are not fit for surgery

•Tension repair
◦The muscles and tissue either side of defect are sutured back together
◦The hernia is held closed (to heal there) by sutures applying tension
◦Can cause pain
◦Has high recurrence rates

•Tension Free Repair
◦A mesh is placed over the defect (covering the hernia)
◦The mesh is sutured to the muscles and tissues either side of the defect
◦The mesh covers the defect and holds the muscles and tissues closed
◦Lower recurrence rate

Question 8

What are the examination findings

Answer 8

weak spot
reducible
cough impulse

Question 9

What can be within the sac?

Answer 9

bowel

• see peristalsis
• bowel sounds

omentum
- doughy sensation (fat)

Question 10

Where to find the deep inguinal ring

Answer 10

Locate the ASIS and pubic tubercle

mid point is deep inguinal ring

Question 11

ASIS and pubic symphysis mid point is

Answer 11

femoral pulse location

Question 12

How to distinguish between a direct and indirect hernia?

Answer 12

Direct
- posterior wall defect

Indirect
- follows testicular descent

Locate deep ring and reduce hernia
Ask patient to cough, if it comes medially towards its indirect

Question 13

How to distinguish between a femoral and inguinal hernia?

Answer 13

Inguinal is above and medial to the pubic tubercle

Femoral in below and lateral (look for neck site)