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General Surgery > Hernias > Flashcards

Hernias Flashcards

1
Q

what is the definition of a hernia?

A

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.

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2
Q

what is the structure of a hernia?

A

sac, contents, covering of sac

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3
Q

what are common contents of hernias?

A 
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
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4
Q

what are the causes of hernias?

A 
increased abdo pressure
weakness of abdominal muscles
excess fat
muscle weakness following pregnancy
surgical incisions
familial
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5
Q

what are causes of increased abdominal pressure?

A

smoking, chronic cough, obesity, constipation with straining, pregnancy, prostatic enlargement, heavy lifting (precipitating factors)

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6
Q

what are the different types of hernias?

A 
Inguinal
Femoral
Umbilical
Incisional 
Epigastric 
Rare Hernias: Lumbar, Spegilian, Obturator
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7
Q

what are the two types of inguinal hernia?

A

indirect and direct?

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8
Q

where do indirect inguinal hernias occur?

A

at the opening of the inguinal canal

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9
Q

where do direct inguinal hernias occur?

A

near the opening of the inguinal canal

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10
Q

where do femoral hernias occur?

A

in femoral canal

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11
Q

where do umbilical hernias occur?

A

at the naval

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12
Q

where do incisional hernias occur?

A

site of previous surgical incision

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13
Q

where do epigastric hernias occur?

A

upper abdomen at the midline

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14
Q

what are reducible hernias?

A

contents can be replaced completely into the peritoneal cavity

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15
Q

why might a hernia be irreducible?

A

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

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16
Q

what are obstructed hernias?

A

irreducibility + intestinal obstruction

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17
Q

what are the clinical features of a reducible hernia?

A

cough impulse

Lump that may disappear on lying down and is usually not painful, discomfort

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18
Q

what are the clinical features of an irreducible hernia?

A

painless?

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19
Q

what are the clinical features of obstructed hernias?

A

Vomiting/pain/distension/bowel movement/dehydration

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20
Q

what are strangulated hernias?

A

irreducibility + obstruction + arrest of blood supply

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21
Q

what is the pathophysiology of strangulated hernias?

A

contents of the hernia are constricted by the neck of the sac causing cut off of circulation. Can cause gangrene and bowel perforation.

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22
Q

what are the clinical features of strangulated hernias?

A

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

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23
Q

inguinal hernias tend to occur in

A

males

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24
Q

indirect inguinal hernias are

A

most common in women

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25
Q

what is the structure of the inguinal canal?

A
  • Deep ring is ‘U’ shaped in fascia transversalis

* Superficial / External ring is in external oblique aponeurosis

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26
Q

where is the inguinal canal located?

A

4 cm in length from deep to superficial ring, 1.25 cm above mid inguinal point

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27
Q

what are the boundaries of the inguinal canal?

A

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

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28
Q

what are the superficial landmarks of the inguinal canal?

A

o Epigastric vessels – mid inguinal point = midway bet. Symphysis pubis and ASIS

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29
Q

what are the contents of the inguinal canal in males?

A

Spermatic cords and it’s coverings -
Ilioinguinal nerve Genital br. of genitofemoral n. → cremasteric m. and scrotal skin
Iliohypogastric nerve
Remnant of process vaginalis

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30
Q

what are the contents of the inguinal canal in females?

A

Round ligament
Ilioinguinal nerve
Remnant of process vaginalis

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31
Q

what is the route of direct inguinal hernias?

A

Pass through posterior wall of inguinal canal, medial to inferior epigastric vessels?

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32
Q

what is the route of indirect inguinal hernias?

A

Pass through the internal ring, lateral to the inferior epigastric vessels

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33
Q

are indirect hernias congenital or acquried?

A

may be congenital

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34
Q

are direct inguinal hernias congenital or acquired?

A

always acquired

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35
Q

are indirect inguinal hernias controlled by pressure over the internal ring?

A

Yes

36
Q

are direct inguinal hernias controlled by pressure over the internal ring?

A

No

37
Q

Do indirect inguinal hernias tend to strangulate?

A

commonly because of narrow neck

38
Q

do direct inguinal hernias strangulate?

A

rarely

39
Q

do indirect inguinal hernias extend down into scrotum?

A

often

40
Q

do direct inguinal hernias extend down into scrotum?

A

rarely

41
Q

are indirect inguinal hernias reducible on lying?

A

not readily

42
Q

are direct inguinal hernias reducible on lying?

A

spontaneously

43
Q

do indirect inguinal hernias reoccur after surgery?

A

uncommon

44
Q

do direct inguinal hernias reoccur after surgery?

A

more common

45
Q

what are the clinical features of inguinal hernias?

A
  • Swelling
  • Dragging pain
  • Features of constipation
  • H/O increased abdo pressure
  • Symptomless discovered accidently
46
Q

what are the examination features of inguinal hernias?

A 
•	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
47
Q

what are the differentials of an inguinal hernia?

A
  • 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
48
Q

what aspects are included in the history of inguinal hernias?

A

how long, other hernia, precipitating factors, reducible vs irreducible, symptoms of obstruction, pain, symptoms of strangulation

49
Q

what imaging can be done for hernia diagnosis?

A

US, CT, Herniography

50
Q

where is the superficial location of femoral hernia?

A

above and medial to the pubic tubercle

51
Q

where is the superficial location of inguinal hernia?

A

below and lateral to the pubic tubercle

52
Q

what is the management of inguinal hernias?

A

watch and wait
hernia surgery
TRUSS

53
Q

what are the different types of hernia repair surgery for inguinal hernias?

A

Herniotomy
Herniorrhaphy
Hernioplasty
Laparoscopic Repair (TEP/TAPP)

54
Q

What is a herniotomy?

A

Excision of hernia sac, sufficient in children

55
Q

what are the different kinds of herniorrhaphy?

A

Bassinis
Shouldice Repair
McVay
Preperitoneal

56
Q

What are the different types of hernioplasty?

A

Lichtenstein

Mesh graft application

57
Q

What are the further types of inguinal hernias?

A
  • 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
58
Q

what is a spigelian hernia?

A

Lateral ventral hernia - Junction of vertical semilunar line + horizontal semicircular line

59
Q

where do spigelian hernias occur?

A

occurs along the edge of the rectus abdominus muscle, which is several inches to the side of the middle of the abdomen.

60
Q

where are spigelian hernias located?

A

• 90% located 0 - 6 cm above anterior superior iliac spine

61
Q

what are the clinical features of spigelian hernias?

A 
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
62
Q

how are spigelian hernias diagnosed?

A

US or CT

63
Q

how are spigelian hernias managed?

A

repair primarily or with mesh

64
Q

what are the different causes of lumbar hernia?

A

Congenital, spontaneous or traumatic

65
Q

what is Grynfelts triangle

A

associated with lumbar hernias
12th rib, internal oblique and sacrospinalis muscle
Covered by latissimus dorsi

66
Q

what is Petits triangle?

A

o Latissimus dorsi,
o external oblique and iliac crest
o Covered by superficial fascia

67
Q

what are the different kinds of pelvic hernia?

A
  • Obturator hernia - Most commonly in women
  • Sciatic hernia
  • Perineal hernia
68
Q

what is a parastomal hernia?

A

a variant of incisional hernia

69
Q

what are the causes of parastomal hernias?

A

Paracolostomy > paraileostomy

70
Q

what is the management of parastomal hernias?

A
  • Traditionally relocate stoma, repair defect
  • Concern for mesh erosion
  • Laparoscopic/open repair
71
Q

what are the risk factor for incisional hernias?

A

technical, wound infection, smoking, hypoxia/ischemia, tension, obesity, malnutrition

72
Q

how are incisional hernias repaired?

A

Laparoscopic vs open repair

73
Q

what is an epigatsric hernia?

A

Pre-peritoneal fat protrusion through decussating fibres at linea alba

74
Q

what is the covering of a femoral hernia?

A

Skin, superficial fascia, cribriform fascia, anterior layer of femoral sheath, fatty contents of femoral canal, femoral septum, peritoneum

75
Q

what are the borders of the femoral canal?

A

• 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

76
Q

what is the path of the femoral canal?

A

femoral ring to sephanous opening below

77
Q

what are the clinical features of femoral hernias?

A
  • 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
78
Q

do femoral hernias strangulate?

A

yes - neck is narrow

79
Q

what is the differentials of a femoral hernia?

A

• Inguinal hernia, sephano varix, lymph node, lipoma, Aneurysm, Psoas abscess, psoas bursa, Ruptured adductor longus

80
Q

what is the low management of femoral hernias?

A

Lockwood - Inguinal ligament to Ileopectineal line

81
Q

what is the high management of femoral hernias?

A

McEvedy - conjoint tendon to ileopectineal line. For strangulated hernia

82
Q

what is the lotheissen management of femoral hernias?

A

(Through inguinal canal) conjoint tendon or inguinal ligament to pectineal ligament

83
Q

what are the contents of umbilical hernias?

A

• Contents are usually omentum / small bowel / Transverse colon

84
Q

are umbilical hernias reducible?

A

rarely

85
Q

what are the clinical features of femoral hernias?

A

Mostly in females, obesity, usually >40 years, flabby abdominal muscles, repeated pregnancy
• Pain, swelling, GI symptoms

86
Q

what is the management of umbilical hernias?

A

surgery - Mayo’s op. Transverse elliptical incision. Double breasting of linea alba

General Surgery (14 decks)

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