Hernias Flashcards
what is the definition of a hernia?
the protrusion of an organ or part of an organ through a defect in the wall of the cavity containing it, into an abnormal position.
what is the structure of a hernia?
sac, contents, covering of sac
what are common contents of hernias?
o Omentum – omentocoel, epiplocele o Intestine - enterocoel o Bladder - cystocoel o Part of intestine – richters hernia o W type intestine – maydls hernia o Meckels diverticulum – littres hernia
what are the causes of hernias?
increased abdo pressure weakness of abdominal muscles excess fat muscle weakness following pregnancy surgical incisions familial
what are causes of increased abdominal pressure?
smoking, chronic cough, obesity, constipation with straining, pregnancy, prostatic enlargement, heavy lifting (precipitating factors)
what are the different types of hernias?
Inguinal Femoral Umbilical Incisional Epigastric Rare Hernias: Lumbar, Spegilian, Obturator
what are the two types of inguinal hernia?
indirect and direct?
where do indirect inguinal hernias occur?
at the opening of the inguinal canal
where do direct inguinal hernias occur?
near the opening of the inguinal canal
where do femoral hernias occur?
in femoral canal
where do umbilical hernias occur?
at the naval
where do incisional hernias occur?
site of previous surgical incision
where do epigastric hernias occur?
upper abdomen at the midline
what are reducible hernias?
contents can be replaced completely into the peritoneal cavity
why might a hernia be irreducible?
o adhesions of content to each other
o adhesions of content with the sac
o adhesions of one part of sac to other part
o narrowed neck of sac
o Occasionally, inspissated faeces within the loops of bowel in the hernia prevent reduction
what are obstructed hernias?
irreducibility + intestinal obstruction
what are the clinical features of a reducible hernia?
cough impulse
Lump that may disappear on lying down and is usually not painful, discomfort
what are the clinical features of an irreducible hernia?
painless?
what are the clinical features of obstructed hernias?
Vomiting/pain/distension/bowel movement/dehydration
what are strangulated hernias?
irreducibility + obstruction + arrest of blood supply
what is the pathophysiology of strangulated hernias?
contents of the hernia are constricted by the neck of the sac causing cut off of circulation. Can cause gangrene and bowel perforation.
what are the clinical features of strangulated hernias?
o Tender, tense hernia, non reducible, no cough impulse, overlying skin is inflamed and oedematous
o Signs of intestinal obstruction – abdominal tenderness, noisy bowel sounds
inguinal hernias tend to occur in
males
indirect inguinal hernias are
most common in women
what is the structure of the inguinal canal?
- Deep ring is ‘U’ shaped in fascia transversalis
* Superficial / External ring is in external oblique aponeurosis
where is the inguinal canal located?
4 cm in length from deep to superficial ring, 1.25 cm above mid inguinal point
what are the boundaries of the inguinal canal?
o Anterior: external oblique aponeurosis and few fibers of internal oblique laterally
o Posterior: fascia transversalis
o Superior: arched fibers of the conjoined tendon
o Inferior: inguinal ligament
what are the superficial landmarks of the inguinal canal?
o Epigastric vessels – mid inguinal point = midway bet. Symphysis pubis and ASIS
what are the contents of the inguinal canal in males?
Spermatic cords and it’s coverings -
Ilioinguinal nerve Genital br. of genitofemoral n. → cremasteric m. and scrotal skin
Iliohypogastric nerve
Remnant of process vaginalis
what are the contents of the inguinal canal in females?
Round ligament
Ilioinguinal nerve
Remnant of process vaginalis
what is the route of direct inguinal hernias?
Pass through posterior wall of inguinal canal, medial to inferior epigastric vessels?
what is the route of indirect inguinal hernias?
Pass through the internal ring, lateral to the inferior epigastric vessels
are indirect hernias congenital or acquried?
may be congenital
are direct inguinal hernias congenital or acquired?
always acquired
are indirect inguinal hernias controlled by pressure over the internal ring?
Yes
are direct inguinal hernias controlled by pressure over the internal ring?
No
Do indirect inguinal hernias tend to strangulate?
commonly because of narrow neck
do direct inguinal hernias strangulate?
rarely
do indirect inguinal hernias extend down into scrotum?
often
do direct inguinal hernias extend down into scrotum?
rarely
are indirect inguinal hernias reducible on lying?
not readily
are direct inguinal hernias reducible on lying?
spontaneously
do indirect inguinal hernias reoccur after surgery?
uncommon
do direct inguinal hernias reoccur after surgery?
more common
what are the clinical features of inguinal hernias?
- Swelling
- Dragging pain
- Features of constipation
- H/O increased abdo pressure
- Symptomless discovered accidently
what are the examination features of inguinal hernias?
• Inguino scrotal swelling • Expansile cough • Cannot get above the swelling • Reducibility • Finger invagination test • Deep ring occlusion test • Enterocoel vs Omentocoel o Visible peristalsis, consistency, reduction of contents, percussion note, bowel sounds
what are the differentials of an inguinal hernia?
- Inguinoscrotal swelling – Hydrocele, Testicular tumour, Varicocele, Hydrocoele of the cord, Abscess, Testicular torsion
- Groin swelling - Ectopic testis could be mistaken for a hernia, Saphena varix, femoral hernia, aneurysm, Enlarged lymph node, psoas abscess, lipoma
what aspects are included in the history of inguinal hernias?
how long, other hernia, precipitating factors, reducible vs irreducible, symptoms of obstruction, pain, symptoms of strangulation
what imaging can be done for hernia diagnosis?
US, CT, Herniography
where is the superficial location of femoral hernia?
above and medial to the pubic tubercle
where is the superficial location of inguinal hernia?
below and lateral to the pubic tubercle
what is the management of inguinal hernias?
watch and wait
hernia surgery
TRUSS
what are the different types of hernia repair surgery for inguinal hernias?
Herniotomy
Herniorrhaphy
Hernioplasty
Laparoscopic Repair (TEP/TAPP)
What is a herniotomy?
Excision of hernia sac, sufficient in children
what are the different kinds of herniorrhaphy?
Bassinis
Shouldice Repair
McVay
Preperitoneal
What are the different types of hernioplasty?
Lichtenstein
Mesh graft application
What are the further types of inguinal hernias?
- Sliding Hernia (Hernia en glissade)
- Richter Hernia: Part of Bowel
- Littre’s hernia: Meckel’s diverticulum
- Pantaloon Hernia: Both Direct and Indirect Hernia
- Maydl’s hernia: a few segment of bowel
- Amiand’s hernia: hernia contains the appendix
what is a spigelian hernia?
Lateral ventral hernia - Junction of vertical semilunar line + horizontal semicircular line
where do spigelian hernias occur?
occurs along the edge of the rectus abdominus muscle, which is several inches to the side of the middle of the abdomen.
where are spigelian hernias located?
• 90% located 0 - 6 cm above anterior superior iliac spine
what are the clinical features of spigelian hernias?
o Sharp pain, swelling, easily reducible o 20% present with incarceration o median age = 50 years o more common in males and on (R) o Rare
how are spigelian hernias diagnosed?
US or CT
how are spigelian hernias managed?
repair primarily or with mesh
what are the different causes of lumbar hernia?
Congenital, spontaneous or traumatic
what is Grynfelts triangle
associated with lumbar hernias
12th rib, internal oblique and sacrospinalis muscle
Covered by latissimus dorsi
what is Petits triangle?
o Latissimus dorsi,
o external oblique and iliac crest
o Covered by superficial fascia
what are the different kinds of pelvic hernia?
- Obturator hernia - Most commonly in women
- Sciatic hernia
- Perineal hernia
what is a parastomal hernia?
a variant of incisional hernia
what are the causes of parastomal hernias?
Paracolostomy > paraileostomy
what is the management of parastomal hernias?
- Traditionally relocate stoma, repair defect
- Concern for mesh erosion
- Laparoscopic/open repair
what are the risk factor for incisional hernias?
technical, wound infection, smoking, hypoxia/ischemia, tension, obesity, malnutrition
how are incisional hernias repaired?
Laparoscopic vs open repair
what is an epigatsric hernia?
Pre-peritoneal fat protrusion through decussating fibres at linea alba
what is the covering of a femoral hernia?
Skin, superficial fascia, cribriform fascia, anterior layer of femoral sheath, fatty contents of femoral canal, femoral septum, peritoneum
what are the borders of the femoral canal?
• Oval opening ½” in diameter bounded
o Anteriorly- Inguinal ligament
o Posteriorly- Iliopectineal ligament, pubic bone and fascia, over pectineus muscle
• Medially - Lacunar ligament
• Laterally - Septum separating form femoral vein
what is the path of the femoral canal?
femoral ring to sephanous opening below
what are the clinical features of femoral hernias?
- Globular swelling below and lateral to the pubic tubercle
- Enlarges on standing and coughing, may disappear when patient lies down
- May project above inguinal canal
do femoral hernias strangulate?
yes - neck is narrow
what is the differentials of a femoral hernia?
• Inguinal hernia, sephano varix, lymph node, lipoma, Aneurysm, Psoas abscess, psoas bursa, Ruptured adductor longus
what is the low management of femoral hernias?
Lockwood - Inguinal ligament to Ileopectineal line
what is the high management of femoral hernias?
McEvedy - conjoint tendon to ileopectineal line. For strangulated hernia
what is the lotheissen management of femoral hernias?
(Through inguinal canal) conjoint tendon or inguinal ligament to pectineal ligament
what are the contents of umbilical hernias?
• Contents are usually omentum / small bowel / Transverse colon
are umbilical hernias reducible?
rarely
what are the clinical features of femoral hernias?
Mostly in females, obesity, usually >40 years, flabby abdominal muscles, repeated pregnancy
• Pain, swelling, GI symptoms
what is the management of umbilical hernias?
surgery - Mayo’s op. Transverse elliptical incision. Double breasting of linea alba
