Hernias Flashcards
Define Hernias
Protrusion of a viscus/organ through a defect of the wall containing cavity into an abnormal position
Describe the following hernias: Epigastric Umbilical Femoral Inguinal Incisional
Epigastric: passes through the lines alba, above the umbilicus
Umbilical: organ protrudes through the umbilicus (commonly paediatric)
Femoral: bowel enter the femoral canal and presents as a mass in the upper thigh/above inguinal ligament
Inguinal: Contents of the abdominal cavity protrude through the inguinal canal (Most common)
Incisional: contents herniate through a scar from a previous surgery
Aetiology of femoral hernias
Abdominal contents pass through the femoral canal (medial to the femoral vein, lateral to the lacunar ligament)
Can herniate through the femoral sheath
Border by the lacunar ligament - high risk of strangulation
INFERIOR and LATERAL to the pubic tubercle
Aetiology of Inguinal hernias
Most common in males (inguinal canal being larger and more prominent)
Often due to increased abdominal pressure e.g. coughing, heavy lifting
Indirect: assess through the internal/deep inguinal ring with herniation lateral to the inferior epigastric vessels
Direct: Passes directly through the posterior wall of the inguinal canal and through the external inguinal ring in HESSELBACH’S triangle with hesitation medial to the inferior epigastric vessels
SUPERIOR and MEDIAL to the pubic tubercle
What is hernial incarceration
Hernia cannot be reduced -> reduces venous and lymphatic flow -> swelling and oedema
Too much swelling -> strangulation (obstruction of arterial blood supply) -> ischaemia and tissue necrosis
Risk factors for hernias
Male (inguinal), female (femoral) Chronic cough Constipation Urinary obstruction Heavy lifting Ascites Past abdominal surgery
Epidemiology of hernias (femoral + Inguinal)
Femoral: uncommon, more common in middle aged and elderly females, incidence increases with age + association with pregnancy
Inguinal: Males,
Indirect - childhood + young adults
Direct - middle aged and elderly
Symptoms of hernias (femoral + Inguinal)
Femoral: asymptomatic, mass in upper medial thigh or above inguinal ligament ± abdominal pain
Inguinal: asymptomatic, abdominal pain, lump/mass in groin (intermittent/constant | painless/painful | uncomfortable | reducible/irreducible), constipation or change in bowel habit, scrotal swelling
Symptoms of hernial strangulation
Nausea and vomiting
Fever
Erythema
Signs of hernias (femoral + Inguinal)
Femoral: mass in upper medial thigh or above inguinal ligament
Hot, painful, irreducible (strangulated)
Inguinal: may extend to scrotum
Indirect: herniation LATERAL to inferior epigastric vessels, restrained once reduced and patient coughs with finger over deep ring
Direct: herniation MEDIAL to the inferior epigastric vessels, NOT restrained once reduced and patient asked to cough with fingers over the deep ring
Investigations for Hernias
Physical exam + clinical diagnosis
ABG: metabolic acidosis + raised lactate in strangulation
USS: visualise contents
CT/MRI: rule out other diagnoses
Management for Hernias that is incarcerated or strangulated
Prophylactic antibiotics e.g. cefazolin
Surgical repair
Management for Hernias
Small and asymptomatic: watchful waiting, Weight loss + smoking cessation
Large or symptomatic:
Prophylactic antibiotic e.g. cefazolin
Open mesh or lap. repair
What are the surgical options for hernia repair
Mesh technique e.g. Lichtenstein (mesh to reinforce the posterior wall)
Laparoscopic: Transabdominal pre-peritoneal (TAPP) = peritoneum entered + hernia repaired Totally extraperitoneal (TEP)
Complications of Hernias
Urinary retention Wound serum Inguinal wound haematoma Wound infection Division of the vas deferens Incisional hernia Ischaemic orchitis Bowel obstruction Dysejaculation Mesh infection
