Hernias Flashcards
definition of a hernia?
protrusion of a viscus through the walls of its cavity into an abnormal position
how are hernias classified?
- Reducible
- Irreducible (contents cannot be pushed back)
- Obstructed (bowel within is obstructed)
- Strangulated (ischaemic - surgery!)
- Incarcerated (contents of hernial sac are stuck inside by adhesions)
example sites of hernias?
Abdominal: • inguinal (75 percent) • femoral (8 percent) • epigastric (linea alba) • umbilical • paraumbilical • incisional • spigelian • lumbar • Richter's (bowel wall only) • Maydl's (double loop of bowel) • Littre's (Meckel's)
Internal:
• diaphragmatic (hiatus or congenital)
• mesenteric
• omental
Sx - patient presents with mild discomfort/pain, particularly when coughing or stooping, which may be heavy, dragging, +/- worse on straining?
+/- change in bowel habit, constipation, burning sensation in the groin, scrotal swelling (in males)
inguinal hernia
Sx - patient presents with extreme pain and tenderness, bowel obstruction +/- sepsis?
strangulated hernia
risk factors for hernias?
↑ intra-abdominal pressure:
• Chronic cough, C., urinary obstruction
• Ascites
• Heavy lifting
wall weakness: • Obesity • Smoking • Previous surgery • Connective tissue disorders
commonest type of inguinal hernia?
which inguinal ring do they emerge through?
where are they in relation to pubic tubercle?
indirect inguinal hernia (affect young as well as old)
they ENTER through deep ring alongside spermatic cord, and EMERGE at the superficial, extending into scrotum
above and medial to pubic tubercle (although if it has not fully emerged, it may be palpable lateral to the pubic tubercle)
what is the kind of inguinal hernia that usually affects elderly pts?
direct (enters the inguinal canal DIRECTLY through a weakness /defect in the posterior wall)
(also emerges at superficial ring)
(but rarely extends into scrotum)
which inguinal hernia:
1) enters in deep inguinal ring alongside spermatic cord, emerges above and medial to pubic tubercle, and often extends into the scrotum?
2) enters through posterior wall of inguinal canal, emerges at superficial ring, and doesn’t really extend into the scrotum?
1) indirect
2) direct
are indirect or direct inguinal hernias more prone to complications?
indirect
where to find femoral hernias?
through the femoral canal "FLIP" F - femoral vein (lateral) L - lacunar ligament (medial) I - inguinal ligament (anterior) P - pectineal ligament (posterior)
NAV Y
Nerve, then artery, then vein
femoral hernias more common in women or men?
women
inguinal hernias more common in women or men?
men
complications of femoral hernias?
1 in 3 present with strangulation or bowel obstruction
ΔΔ groin lump?
• Femoral/inguinal hernias
(can’t get above the lump, bowel sounds over it, reducible)
• Lymph nodes/abscesses
• Lipoma of spermatic cord
• Saphena varix (dilated varicose vein at sapheno-femoral junction which reduces on lying flat)
• Femoral artery aneurysm
ΔΔ scrotal lump?
• Femoral/inguinal hernias (can't get above the lump, bowel sounds over it, reducible) • Seperate from testes: - hydrocele, varicocele (reduces on lying flat) • Epididymal: - cyst - spermatocele - epididymo-orchitis • Incompletely descended testes • Tumour
small protrusion through linea alba above umbilicus, common in young and fit?
epigastric hernia
congenital defect which usually closes spontaneously by 2, can be due to ascites in adults?
umbilical hernia
usually affects elderly, risk factors ascites, obesity?
paraumbilical hernia
Tx: repair rectus sheath “Mayo” repair
occurs in 15 percent of abdominal surgery. especially midline incisions?
incisional hernia
Ix hernias?
- Clinical Ex *diagnostic
* US if suggestive Sx but no lump found (eg hiatus hernia)
Tx hernias?
Conservative:
• Watchful waiting (most eventually get surgery due to pain)
• Abdominal binders for elderly
Surgical:
• Reducible? usually repaired to ↓ strangulation risk and Sx
• Mesh repair (✓pain and recurrence) (open or laparoscopic)
• Laparoscopic repair
• Open repair
(both similar risk)
Tx strangulated hernias?
surgical emergency
complications of surgery for hernia?
- recurrence (3 percent in 10 years)
- haematoma (7 percent)
- infection
ΔΔ femoral hernia?
- inguinal
- saphena varix
- enlarged Cloquet’s lymph node
- lipoma
- femoral aneurysm
- psoas abscess
Tx femoral hernia?
herniotomy (ligation and excision of sac)
indirect vs direct inguinal hernia:
relation to inferior epigastric vessels?
direct - medial
indirect - lateral
ΔΔ how to basically tell the difference between indirect/direct inguinal hernias and femoral hernias?
indirect inguinal hernias and common and strangulate easily
direct are less common, and easily REDUCE (rarely strangulate)
femoral hernias, often in Females, strangulate and hard to reduce
