Hernias Flashcards
What is a femoral hernia?
Abdominal contents pass through the femoral canal, presenting as a mass in the upper medial thigh.
List 4 risk factors for femoral hernias
Female
Increasing age
Pregnancy: higher in multiparous
Increased intra-abdominal pressure e.g. heavy lifting, chronic constipation
Describe the epidemiology of femoral hernias
Less common than inguinal but more likely to get incarcerated as are situated in a tighter place
F > M (esp. in middle age + elderly)
Account for 5% of abdominal hernias
Describe presentation of a femoral hernia
Lump in the groin
Usually asymptomatic at presentation
~30% present as an emergency due to obstruction or strangulation
Describe physical examination of femoral hernias
Look for lump + compare both sides
Ask pt to reduce lump, ask pt to cough
Check if BELOW + LATERAL to pubic tubercle
If no lump visible, feel for a cough impulse
Likely to be irreducible + to strangulate due to rigidity of the canal’s borders
Repeat examination with pt standing
What investigation may be used for femoral hernias?
US
Describe the management of femoral hernias
Refer due to risk of strangulation
Repair urgently, as 50% risk of strangulation within a month.
Give 2 surgical treatment stages of femoral hernias
Herniotomy: ligation + excision of the sac
Herniorrhaphy: repair of the hernial defect
What is the most common type of hernia?
Inguinal
How are inguinal hernias diagnosed?
CLINICAL DIAGNOSIS
What is an inguinal hernia?
Abnormal protrusion of a peritoneal sac through a weakness of the abdo wall in the inguinal region
Both types can emerge at the superficial inguinal ring (indirect more commonly)
What is a direct inguinal hernia?
Protrusion through a weakness in the POSTERIOR WALL of the inguinal canal
Contents emerge in the canal MEDIAL to the DEEP ring + INFERIOR epigastric vessels
Appear through Hesselbach’s triangle
What is an indirect inguinal hernia?
Protrusion THROUGH the DEEP inguinal ring, following the path of the inguinal canal
usually congenital
Describe the aetiology of inguinal hernias
Congenital: abdo contents enter the inguinal canal through a patent processus vaginalis
Acquired: increased intra-abdo pressure + weakness of abdo muscles
List 11 risk factors for inguinal hernias
Male Prematurity Age Smoking: general defect in CT turnover in groin Obesity FHx AAA Prev RLQ incision (e.g. for appendectomy) Defective transversalis fascia Chronic cough e.g. COPD CT disorder: Marfan's, Ehlers-Danlos
Describe the epidemiology of inguinal hernias
COMMON
Peak age in adults: 55-85 yrs
M > F
How may inguinal hernias present?
Asymptomatic Pt notices a 'lump in the groin' Discomfort + pain Irreducible Increased in size Complications (e.g. bowel obstruction; N+V, constipation)
Describe physical examination of an inguinal hernia
Look for previous scars + check both sides; more common on R side
Can’t get above lump
Groin lump that extends to the scrotum or labia
If lump visible, ask pt to reduce it. If he can’t, make sure it is not a scrotal lump. If no lump visible, go straight to cough impulse.
Check for cough impulse
Auscultation: for bowel sounds over the hernia
Check for signs of complications
Repeat examination with pt standing
Give 2 signs of complications of inguinal hernias on examination
Bowel obstruction + systemic upset (pyrexia, tachycardia etc.)
Tenderness if strangulated
How do you distinguish between direct and indirect inguinal hernias?
Reduce the hernia + occlude the deep internal ring with 2 fingers.
Ask patient to cough/ stand.
If hernia is restrained= indirect.
If protrudes= direct
What is the management plan for small, asymptomatic inguinal hernias?
Watchful waiting
What investigations may be performed for inguinal hernias?
ABGs: may show lactic acidosis from bowel ischaemia
USS: exclude other causes of groin lump
Herniography (XR): rarely: requires intraperitoneal injection of non-ionic contrast admin beforehand
MRI: if unsure if there is herniation clinically
What is the management plan for symptomatic uncomplicated inguinal hernias?
Elective repair:
Mesh Repair (open preferred for unilateral hernia, Laproscopic preferred for bilateral hernias)
Hernia is surgically reduced + a mesh is inserted to reinforce the defect in the transversalis fascia
Advise diet, if overweight, + to stop smoking before pre-op
When is emergency surgery performed for inguinal hernias?
If obstructed or strangulated
Laparotomy with bowel resection may be indicated if the bowel is gangrenous
Abx prophylaxis e.g. single dose of a cephalosporin (e.g. cefazolin)
List 5 complications of inguinal hernias
Incarceration
Strangulation
Bowel obstruction
Maydl’s hernia (strangulated W-shaped loop of small bowel)
Richter’s hernia (strangulation of only part of the bowel circumference)
List 8 complications of surgery for inguinal hernias
Pain + numbness Wound infection Haematoma Penile/ scrotal oedema Mesh infection Urinary retention for 24hrs after Wound seroma for a week after (don't drain routinely as may introduce an infection) Osteitis pubis
What is the term used for presence of co-existing direct and indirect inguinal hernias?
pantaloon hernia
How do you differentiate between inguinal and femoral hernias?
Inguinal: superior + medial to pubic tubercle
Femoral: inferior + lateral to pubic tubercle (+ medial to femoral pulse)
Describe the anatomy of the inguinal ligament. What runs within the ligament?
Runs between ASIS + pubic tubercle.
Inguinal canal
What passes through the inguinal canal?
Ilioinguinal nerve
+
Males: spermatic cord
Females: round ligament
Describe the anatomy of the deep and superficial rings within the inguinal canal
Deep (entry): just above midpoint of inguinal ligament
Superficial (exit): just above + medial to pubic tubercle
What is an irreducible hernia?
Can’t be pushed back into place
What is a hernia?
protrusion of a viscus through a defect of the walls of its containing cavity into an abnormal space
What is an obstructed hernia?
Bowel contents can’t pass through the no longer patent, compressed bowel lumen
What is an incarcerated hernia?
contents of the hernial sac are stuck inside by adhesions
What is a strangulated hernia?
Compression around the hernia prevents blood flow into the hernial contents causing ischaemia to the tissues within
What is a reducible hernia?
Contents of hernia can be manipulated back into its original position through the defect from which it emerges
