Hernias Flashcards
1
Q
Complications (the big three)
A
- Incarceration
- An incarcerated hernia is when the hernia cannot be reduced back
- The bowel will be trapped in a herniated position
- It can lead to obstruction and strangulation
- Obstruction
- Hernia causes a blockage in the passage of faeces through the bowel
- Strangulation
- Hernia is non-reducible and the base of the hernia becomes so tight it cuts off blood supply
- Presents with significant pain and tenderness
- Surgical emergency - bowel will die within hours if not corrected
2
Q
Management of hernias
A
- Conservative
- Leave the hernia alone
- Appropriate in patients with broad based hernias who are not fit for surgery
- Tension repair
- Muscles and tissue on either side of the defect are sutured back together
- Hernia is held closed by sutures applying tension
- Can cause pain
- High recurrence rates
- Tension free repair
- Mesh is placed over the defect
- Mesh is sutured to the muscles and tissues either side of the defect
- Mesh covers the defect and holds the muscles and tissues closed
- Lower recurrence rates
3
Q
Inguinal canal (Hesselbach’s triangle) boundaries (remember RIP)
A
- Rectus abdominis (medial border)
- Inferior epigastric vessels (superior/lateral border)
- Poipart’s ligament aka inguinal ligament (inferior border)
4
Q
Femoral triangle boundaries (remember SAIL)
A
- Sartorius (lateral border)
- Adductor longus (medial border)
- Inguinal Ligament (superior border)
5
Q
Inguinal hernia
A
- Indirect inguinal hernia
- Normally after testes descend through the inguinal canal, the internal inguinal ring closes and the processus vaginalis is obliterated
- In some patients the inguinal ring remains patent and the processus vaginalis remains intact
- This leaves a tract or tunnel from the abdominal contents, through the internal inguinal ring, along the inguinal canal and into the scrotum
- If the hernia is reduced and pressure is applied to the internal inguinal ring (at the midway point from the ASIS to the pubic tubercle) the hernia will remain reduced
- Direct inguinal hernia
- Due to weakness in the abdominal wall around Hasselbach’s triangle
- Hernia protrudes directly through the abdominal wall
- Pressure over the internal ring will do nothing to stop the herniation
6
Q
Surface anatomy of the groin (remember NAVY)
A
- From lateral to medial
- Nerve
- Artery
- Vein
- Y-fronts (and femoral canal)
7
Q
Borders of the femoral canal (remember FLIP)
A
- Femoral vein laterally
- Lacunar ligament medially
- Inguinal ligament superiorly
- Pectineal ligament posteriorly
8
Q
Femoral hernia
A
- Occurs below the inguinal ligament
- Weakness around the opening of the femoral canal
- Abdominal contents therefore protrude through the femoral canal
- Has a narrow base to the hernia (higher risk of complcations)
9
Q
Incisional hernia
A
- Occurs at site of an incision from previous surgery
- The bigger the incision the higher the risk
- Difficult to repair with high rate of recurrence
- If large with a broad base often left along and low risk of complications in patients with multiple co-morbidities
10
Q
Umbilical hernia
A
- Due to defect in the muscle around the umbilicus
- Common in babies and can resolve spontaneously
- Can also occur in older adults
11
Q
Epigastric hernia
A
- Hernia in the epigastric region
12
Q
Spigelian hernia
A
- Through abdominal wall between lateral border of rectus abdominus and linea semilunaris
- Through spigelian fascia (aponeurotic layer)
- Diagnosed by US
- Often difficult to distinguish from inguinal hernias
13
Q
Diastasis recti
A
- AKA rectus abdominis diastasis and recti divarication
- Gap between the rectus abdominis muscle
- The linea alba is the aponeurosis of the two sides of the rectus abdominis muscle
- The gap is created because the linea alba is stretched and broad
- Most prominent when the patient lies on their back and lifts their head off (like a crunch)
- There is a protruding bulge along the middle of the abdomen
- This can be congenital (in newborns) or due to weakness, for example following pregnancy or in obese patients
- Generally treated conservatively but surgical repair is possible
14
Q
Obturator hernia
A
- The abdominal/ pelvic contents hernia through the obturator foramen due to a defect in the pelvic floor
- More common in women (particularly in older age after multiple pregnancies/vaginal deliveries)
- Often asymptomatic or presenting with irritation to the obturator nerve or complications of hernia
- Howship–Romberg sign - pain extending from the inner thigh to the knee when the hip is internally rotated due to compression of the obturator nerve
- Can be diagnosed by CT or MRI of the pelvis or incidentally during pelvic surgery
15
Q
Hiatus hernia
A
- Herniation of the stomach through the diaphragm
- Diaphragm opening should be at level of lower oesophageal sphincter and should be fixed
- Opening helps to maintain a narrow sphincter that stops acid and stomach contents refluxing into the oesophagus
- Herniation and broadening of the diaphragmopening allows contents to reflux up into the oesophagus
- Treatment is conservative (with GORD treatment) or surgical repair (Nissen fundoplication is most common)
