Hernias

Question 1

definition of a hernia?

Answer 1

protrusion of a viscus through the walls of its cavity into an abnormal position

Question 2

how are hernias classified?

Answer 2

• 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)

Question 3

example sites of hernias?

Answer 3

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

Question 4

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)

Answer 4

inguinal hernia

Question 5

Sx - patient presents with extreme pain and tenderness, bowel obstruction +/- sepsis?

Answer 5

strangulated hernia

Question 6

risk factors for hernias?

Answer 6

↑ intra-abdominal pressure:
• Chronic cough, C., urinary obstruction
• Ascites
• Heavy lifting

wall weakness:
• Obesity
• Smoking
• Previous surgery
• Connective tissue disorders

Question 7

commonest type of inguinal hernia?

which inguinal ring do they emerge through?

where are they in relation to pubic tubercle?

Answer 7

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)

Question 8

what is the kind of inguinal hernia that usually affects elderly pts?

Answer 8

direct (enters the inguinal canal DIRECTLY through a weakness /defect in the posterior wall)
(also emerges at superficial ring)
(but rarely extends into scrotum)

Question 9

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?

Answer 9

1) indirect

2) direct

Question 10

are indirect or direct inguinal hernias more prone to complications?

Answer 10

indirect

Question 11

where to find femoral hernias?

Answer 11

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

Question 12

femoral hernias more common in women or men?

Answer 12

women

Question 13

inguinal hernias more common in women or men?

Answer 13

men

Question 14

complications of femoral hernias?

Answer 14

1 in 3 present with strangulation or bowel obstruction

Question 15

ΔΔ groin lump?

Answer 15

• 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

Question 16

ΔΔ scrotal lump?

Answer 16

• 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

Question 17

small protrusion through linea alba above umbilicus, common in young and fit?

Answer 17

epigastric hernia

Question 18

congenital defect which usually closes spontaneously by 2, can be due to ascites in adults?

Answer 18

umbilical hernia

Question 19

usually affects elderly, risk factors ascites, obesity?

Answer 19

paraumbilical hernia

Tx: repair rectus sheath “Mayo” repair

Question 20

occurs in 15 percent of abdominal surgery. especially midline incisions?

Answer 20

incisional hernia

Question 21

Ix hernias?

Answer 21

• Clinical Ex *diagnostic

* US if suggestive Sx but no lump found (eg hiatus hernia)

Question 22

Tx hernias?

Answer 22

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)

Question 23

Tx strangulated hernias?

Answer 23

surgical emergency

Question 24

complications of surgery for hernia?

Answer 24

• recurrence (3 percent in 10 years)
• haematoma (7 percent)
• infection

Question 25

ΔΔ femoral hernia?

Answer 25

• inguinal
• saphena varix
• enlarged Cloquet’s lymph node
• lipoma
• femoral aneurysm
• psoas abscess

Question 26

Tx femoral hernia?

Answer 26

herniotomy (ligation and excision of sac)

Question 27

indirect vs direct inguinal hernia:

relation to inferior epigastric vessels?

Answer 27

direct - medial

indirect - lateral

Question 28

ΔΔ how to basically tell the difference between indirect/direct inguinal hernias and femoral hernias?

Answer 28

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