Hernias Flashcards
Define Hernia
protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position
What does ____ hernia mean?
a. Reducible
b. Irreducible
c. Incarcerated
d. Strangulated
e. Sliding
a. hernia can be pushed back into the abdomen with manual pressure
b. hernia cannot be pushed back into the abdomen with manual pressure - may be incarcerated or strangulated
c. hernia cannot be pushed back into the abdomen with manual pressure
d. hernia is tightly constricted so blood supply is cut off
e. hernias that move up and down, in and out of the cavity
How would you examine a lump?
site - relation to landmarks, can you get above it size - cough reflex? shape surface consistency - does it transilluminate? fixity - is it reducible? pulsatile?
How do femoral hernias develop?
bowel or abdominal contents slip under the inguinal ligament into the femoral canal
since the femoral canal is small, hernias here are at high risk of strangulation
lumps will appear inferior-lateral to the pubic tubercle
What are the boundaries of the femoral canal?
What is its function?
anterior = inguinal lig posterior = pectineal lig medial = lacunar lig lateral = femoral vein
To allow for the femoral vein to swell due to increased venous return during exercise
contains lymphatics inc lacunar node, empty space + loose connective tissue
What are the RFs and causes of femoral hernias?
enlarged femoral ring - lacuna varosum increases in size as you age whilst lacuna musculorum decreases
increased intra-abdominal pressure eg straining, heavy lifting, excessive coughing, ascites etc
stretching of aponeurotic tissue
Describe _____ hernia
a. inguinal
b. femoral
c. umbilical
d. paraumbilical
e. epigastric
f. incisional
g. parastomal
Give a cause for each
a. protrusion of abdominal-cavity contents through the inguinal canal - supermedial to pubic tubercle - muscle weakness or congenital defect
b. bowel enters femoral canal - inferolateral to pubic tubercle - increased abdominal pressure (IAP)
c. herniation of bowel or omentum through umbilicus - congenital or IAP
d. herniation of bowel or omentum above or below umbilicus (seen especially in ascites and obesity) - congenital or IAP or omphalocele
e. through linea alba above umbilicus
f. through incompletely-healed surgical wound - incompletely healed surgical wound or IAP
g. through abdominal wall defect created during ostomy formation - size of stoma, obesity, malnutrition, age, IAP
What some of the symptoms of complicated hernias?
lump is tender or painful abdominal pain abdominal swelling/tighter-fitting clothes back pain vomiting/nausea loss of appetite urethral discharge +/- dysuria constipation +/- change in bowel habit PR bleed SoB weight loss night sweats fever
What is the difference between direct and indirect hernias? How can you tell the difference on examination?
Direct = herniation through the posterior wall of the inguinal canal
only herniates through the superficial inguinal ring
cannot descend into the scrotum
medial to inferior epigastric vessels
the defect may be palpable
to reduce; up and in
cannot be controlled by placing pressure over the DIR
common in old age
Indirect = herniation through both deep and superficial inguinal rings due to a defect (often processus vaginalis)
can descend into the scrotum
lateral to inferior epigastric vessels
the defect is not palpable
to reduce; up, lateral, and in
can be controlled by placing pressure on DIR
common in babies (<1yr), children and YA
Describe Hasselbach’s triangle
the lateral border of RA
inguinal canal
medial aspect of inferior epigastric vessels
What are the different types of indirect inguinal hernia?
congenital = patent processus vaginalus –> hernia descend into scrotum
OR
Acquired
What is a pantaloon inguinal hernia?
simultaneous direct and indirect hernias on the same side
How will a direct inguinal hernia differ from an indirect inguinal hernia on examination?
place pressure on DIR
ask the patient to cough
if it bulges against your hand –> probably an indirect hernia
if the bulge occurs elsewhere –> direct hernia
Where do you find the deep inguinal ring?
midway between ASIS and pubic tubercle = midpoint of the inguinal ligament
What additional examinations would you perform even though hernias are a clinical diagnosis?
Abdo exam Testicular exam assessment of inguinal lymph nodes USS CT
