Hernias Flashcards
Define it
What does it consist of?
The protrusion of a viscus (organ of the body) or part of a viscus through the walls of its containing cavity into an abnormal position.
Hernial sac and neck
Define:
- Reducible
- Irreducible
- Obstructed
- Strangulated
- Incarceration
Content can be pushed back into place
Content cannot be pushed back into place
Bowel contents cannot pass - features of intestinal obstruction
Ischaemia occurs - the patient requires urgent surgery
Contents of the hernial sac are stuck inside by adhesions
Sliding hernia - define?
Sliding hiatal hernias are those in which the junction of the oesophagus and stomach, referred to as the gastro- oesophagal junction, and part of the stomach protrude into the chest. The junction may reside permanently in the chest, but often it juts into the chest only during a swallow.
Richter’s hernia - define?
Maydi’s hernia - define?
Only part of the hernia protrudes - you get strangulation without obstruction - look at pics
W-shaped loop (two adjacent loops) in the hernial sac with tight, strangulated neck - look at pics
6 types of abdominal wall hernias
Inguinal Femoral Epigastric Umbilical Paraumbilical Incisional
3 types of internal hernias
Diaphragmatic (hiatus or congenital)
Mesenteric
Omental
What is the most common?
Inguinal
Most are asymptomatic. You can get mild discomfort/pain.
What 2 ways is the pain described?
What makes the pain worse?
Heavy
Dragging
Worse on straining
What type of abdominal hernia is typically missed and should be checked in any acute abdomen case?
Femoral - 1 in 3 present with strangulation or bowel obstruction
One risk factor is increased intra-abdominal pressure. Give some causes of this?
Another risk factor is wall weakness.
Give some causes of this?
Chronic cough Constipation Urinary obstruction Ascites Heavy lifting --------- Obesity Smoking Previous surgery Connective tissue disorders
Inguinal hernias:
What sex is it commoner in?
What does the viscus pass through?
2 places it can be felt?
Male
Inguinal canal
Either medial to pubic tubercle (more common) or lateral when entering canal and not fully protruded.
Indirect inguinal hernias - commonest - effecting young as well as old:
Where does it enter into?
Cause?
What congenital problem may lead to this?
Deep inguinal ring and comes out at the superficial ring
A persistent opening that does not close during fetal development.
Patent processus vaginalis - look it up
Direct inguinal hernias:
Where does it enter into?
Cause?
What makes this better than indirect?
Protrudes through the abdo wall into the inguinal canal
Age-related stress and weakened muscles in the inguinal canal so there is a weakness in the abdo wall
They rarely extend into the scrotum so there are fewer complications
Femoral hernias:
Where is the protrusion through?
What are the canal borders?
What sex is it commoner in?
Femoral canal
Femoral vein (lat) Lacunar ligament (med) Inguinal ligament (ant) Pectineal ligament (post)
Women
Groin and scrotal lumps:
How can you distinguish between femoral and inguinal hernias and other causes of lumps? - 3
Can’t get above the lump - you can’t use a finger to sort of grasp it
Bowel sounds on auscultation
Able to reduce
Groin lumps:
- Inflammatory or infectious
- Type of tumour of the spermatic cord
- Where is there a dilated varicose vein?
- What vascular problem could you feel?
Lymph nodes
Abscess
Lipoma of spermatic cord
Sapheno-femoral junction
Femoral artery aneurysm
Scrotal lumps:
Testicles (reduced on lying flat)
- Define hydrocele and varicocele
Epididymal lumps? - 3
What may be noticed in the first few wks of life?
What is another thing that shouldn’t be missed?
H - A type of swelling in the scrotum that occurs when fluid collects in the thin sheath surrounding a testicle. Hydrocele is common in newborns and usually disappears without treatment by age 1.
V - An enlargement of the veins within the loose bag of skin that holds your testicles (scrotum). A varicocele is similar to a varicose vein you might see in your leg.
Cysts
Spermatocele
Epididymoorchitis
Incomplete descent of the testicle
Tumour
Epigastric hernia:
Where does the protrusion go through?
Who is it common in?
Through linea alba
Young and fit people
Umbilical hernia:
Cause in children
Cause in adults
Ascites in adults
A congenital defect in children - spontaneously closed by age 2
Paraumbilical hernia:
Who does it usually affect?
Elderly
Incisional hernia:
What percentage of abdo surgeries does it occur in?
What type of incision is it more common in?
15%
Midline incisions
Investigations - usually clinical:
What imaging is used when there are suggestive symptoms but not lump is found (e.g. hiatus hernia)?
USS
Management:
What is done with reducible hernias?
What is done in patients who are too unfit for surgery to help keep it reduced? - 2
Lifestyle - 2
Repaired to prevent risk of strangulation and reduce symptoms.
Truss or abdominal binders
Surgical options:
What is done in surgery?
Mesh is put in place laparoscopically. Suturing has increased post-op pain and hernia recurrence.
Weight loss and smoking cessation
Examination for inguinal hernias:
Where is the deep and superficial inguinal ring found?
D - the midpoint of the inguinal ligament - a few cms above the femoral pulse
S - Sup and med to the pubic tubercle
Examination for inguinal hernias - Lump visible:
Ask patient to reduce it. What should be done if they cannot?
What can you ask the patient to do to make the lump visible?
Make sure it is not a scrotal lump
Cough - appears above and medial to the pubic tubercle
Examination for inguinal hernias - Lump not visible:
What should be done if not visible?
Ask the patient to cough and repeat with them standing
Examination for inguinal hernias:
How do you distinguish between direct and indirect? - 3 steps
(1) Reduce the hernia
(2) Press down on the deep inguinal ring to occlude it
(3) Ask the patient to cough
If it comes back out, it is direct - finger not stopping it from coming back out.
If it doesn’t, it is indirect - finger stops it from coming back out.
