Hernias

Question 1

Define hernia

Answer 1

Protrusion of a viscus through a defect in it containing compartment and its coverings into
an abnormal position

Strangulated–ischaemic due to restricted blood flow
Incarcerated – cannot reduce but blood supply remains intact
Obstructed – sac contains
trapped/blocked bowel

• Epigastric – at site of midline union of rectus muscles
• Umbilical – present in 3% at birth (normally resolves <3 years), transversalis fascia defect
• Inguinal – occur above the inguinal ligament, above and medial to the pubic tubercle
- Direct: through abdominal wall medial to inferior epigastric artery; weakness in the abdominal wall evolves into a localised hole or defect
- Indirect: through inguinal canal via deep inguinal ring lateral to inferior epigastric
artery; lax deep ring or patent processus vaginalis
• Femoral – occurs below inguinal ligament, below and lateral to the pubic tubercle

Question 2

What are the causes/risk factors of hernias?

Answer 2

• Pregnancy
• Obesity
• Ascites
• Chronic lung disease
• Heavy lifting
• Connective tissue disorders e.g. Marfan’s, Ehlers-Danlos

Question 3

What are the symptoms of hernias?

Answer 3

• Pain and tenderness (strangulated hernias)

* Nausea & vomiting (bowel obstruction)

Question 4

What are the signs of hernias?

Answer 4

• Visible or palpable bulge

Question 5

What investigations are carried out for hernias?

Answer 5

If ACUTE with painful irreducible hernia
• Bloods
- FBC 
- U&Es 
- CRP
- Clotting 
- Group and save (if operation is likely) 
- ABGs - may show lactic acidosis from bowel ischaemia 
• Imaging
- Erect CXR - check for perforation 
- USS - exclude other causes of groin lump 
- AXR - check for obstruction

Question 6

What is the management for hernias?

Answer 6

Inguial
Surgical
• Usually elective repair of uncomplicated hernias
• Mesh Repair
- The hernia is surgically reduced and a mesh is inserted to reinforce the defect in the transversalis fascia
• Laparoscopic Mesh Repair

EMERGENCY
•If obstructed or strangulated
• Laparotomy with bowel resection may be indicated if the bowel is gangrenous

Question 7

What are the complications of hernias?

Answer 7

Inguinal 
• Incarceration 
• Strangulation 
• Bowel obstruction 
• Maydl's hernia (image on the right - strangulated W-shaped loop of small bowel) 
• Richter's hernia (strangulation of only part of the bowel circumference) 
• Surgery Complications
- Pain 
- Wound infection 
- Haematoma